Written evidence submitted by The King’s Fund (FGP0359)

 

Introduction

 

  1. The King’s Fund is an independent charitable organisation working to improve health and care in England. Our vision is that the best possible health and care is available to all. We aim to be a catalyst for change and to inspire improvements in health and care by:

 

 

  1. The King’s Fund has a longstanding interest in the development and reform of general practice and has been examining how to address pressures in general practice since we published an influential report on this issue in 2016 (Baird et al 2016). Alongside a growing body of research and policy work, we also provide organisational and leadership development support to primary care networks and work with GPs across the health system. Our submission focuses on the main barriers to accessing general practice, and the changes needed to the current model to tackle these and put general practice on a more sustainable footing for the future.

 

  1. Effective primary care, including general practice, is the bedrock of a high-quality and cost-effective health system but general practice in England is under significant strain. These pressures pre-date the Covid-19 pandemic and reflect wider pressures across the health and care system but have significantly intensified over the past six months (NHS Digital 2021a; The King’s Fund 2020).

 

  1. General practice has been facing significant workforce pressures for a number of years with projections suggesting a significant shortfall of GPs over the coming decade, despite the increased numbers of GPs in training and the deployment of additional roles (Beech et al 2019). Burnout and attrition as a consequence of the Covid-19 pandemic are likely to have a heavy impact on the already strained general practice workforce over the next year and exacerbate these issues (House of Commons Health and Social Care Select Committee 2021a).

 

  1. Despite these challenges the most recent GP Patient Survey results, appointment data and the coronavirus vaccine roll-out show that public satisfaction with GP services has remained high throughout the pandemic, that general practice continues to deliver a very high volume of appointments and is playing a significant role in supporting vaccine roll out (GP Patient Survey 2021; NHS Digital 2021a; NHS England 2021). However, it is clear that pressures have, and continue, to affect patients’ experience of general practice, with the previous GP Patient Survey and British Social Attitudes survey showing satisfaction has been declining in recent years, driven by problems accessing appointments (GP Patient Survey 2019; Robertson et al 2019). General practice has been and remains under unprecedented strain and in need of support.

 

The immediate issue: tackling barriers to access in general practice

  1. The issues around access to appointments in general practice pre-date the pandemic but have significantly intensified in recent months. Simply put, demand for services is outstripping the available supply, resulting in frustration for patients, unsustainable workload for staff, and inevitably, unmet need. Our research indicates that a combination of rising demand, growing complexity, higher expectations, increased administrative burden and rising thresholds for referral to other parts of the system have all contributed to the pressures on general practice over a number of years (Baird et al 2016). This has been exacerbated by the impact of Covid-19 on the health and care system and the elective backlog which means that general practice is being required to manage more complex needs while unable to unlock access to other services (National Audit Office 2021).

 

  1. The additional funding announced in Our plan for improving access for patients and supporting general practice is welcome, as is the ambition to train more GPs and invest in additional roles, but they will only be effective if the growing number of GPs leaving the profession can be reduced (NHS England and NHS Improvement 2021). Our experience suggests that many practices already have vacancies that they are unable to fill, and in some areas even locum GPs are hard to find.

 

  1. The emphasis on access in both policy and media narratives around general practice has focused on speed over other dimensions of access. Past experience has shown that this focus on ‘transactional’ models that aim to ease access demands by providing quicker access to a GP – such as via walk-in centres or instant online GP access – can have unintended consequences. Our research found that these models can lead experienced GPs to be diverted to delivering rapid access clinics, leaving them less time to spend on longer appointments or multidisciplinary team meetings for complex patients (Baird et al 2018). This means that the patients who need the most care may find themselves with care that doesn’t fully meet their needs, in turn generating further demand.

 

  1. There is no single solution – improving access is complex and will take a sustained effort over time. There is no lack of guidance, national programmes and case studies on how to unlock additional capacity, including Future NHS, Time for Care and the London-wide access project. These approaches aim to alleviate pressure on GPs and can have a beneficial impact on burnout, which in turn can improve retention. However, while they can make a real contribution, they will not compensate for a lack of GPs and primary care staff.

 

  1. Furthermore, the issue is often not what model to choose, or how to adapt systems and processes, but about how practices can be supported to make the necessary changes when GPs have little headroom or indeed expertise to redesign services and undertake the change management needed. It is critical that integrated care systems and their partners consider how they will provide support to general practice to improve access in the short term. However, many of the issues having an impact on patients’ ability to access care will also require longer-term actions some of which we outline below.

 

Tackling the main challenges facing general practice in the next five years – a longer-term plan

  1. There has been clear commitment to improving access over in recent years with national policy focus through the General Practice Forward View, reiterated by the NHS Long Term Plan, and while there has been some progress, the pressures on general practice have not been alleviated and it is clear that a more transformative vision is needed to help general practice tackle the challenges facing it.

 

  1. In our work we have examined models of primary care from around the world, as well as England and the other UK health systems. This suggests a future model of general practice is required that:

 

In order to achieve this the following actions are key.

 

Attracting and retaining sufficient workforce

  1. Increasing the numbers of staff in general practice is critical, and that will mean both recruiting new staff and retaining existing staff. While more GPs are being trained than ever before, there is still currently a shortage of GPs, with fewer GPs choosing to undertake full-time clinical work in general practice, while large numbers are retiring and leaving the profession – with burnout playing a role in these decisions (NHS Digital 2021b; Sutton et al 2019). The significant growth in workload, compounded by the increasing complexity and intensity of that work, has led to challenges in recruiting and retaining GPs who want to do full-time, patient-facing clinical work (NHS Digital 2021a). Instead, portfolio careers – where GPs work in a general practice for part of their week but also spend other time working in a different context or organisation – have become an increasingly popular option with a growing proportion of trainees stating that they intend to do this (Bharmal 2021).

 

  1. National efforts to increase the number of GPs need to continue, but the stark reality is that even with a major focus on training more GPs, the number of GPs in the NHS will fall substantially short of demand. Data shows that the number of GPs in permanent roles fell by 6.6 per cent between March 2016 and March 2021 (NHS Digital 2021c), while the Secretary of State recently admitted that the government’s 2019 manifesto pledge to deliver 6,000 more GPs by 2024/25 is not on track (House of Commons Health and Social Care Committee 2021b). There are also shortages among other primary care staff, especially nurses, but also paramedics and mental health practitioners, leaving general practice unable to meet the demand for appointments. The distribution of staff across the country is also unequal, leaving some areas under-doctored – an issue that will be covered in greater detail by The Health Foundation’s submission which draws on our joint publication, Closing the gap (Beech et al 2019).

 

  1. NHS England and NHS Improvement and the government must urgently design a workforce strategy which considers long-term supply, recruitment and retention, training and development for the general practice workforce and crucially supports sustainable careers for GPs and their fellow team members. It must recognise that supporting hard-pressed staff to provide care more effectively is as important as recruiting additional staff to address the growing recruitment crisis. This will mean not just increasing the overall workforce but also implementing effective team-based models of care and redesigning processes and workflow, supported by expert service improvement support and investment in technology and buildings. 

 

Access to improved system support

  1. The fact that general practice is seen as a ‘contractor profession’ tends to result in its interactions with the wider health system being seen through the prism of national contract negotiations, with general practice often not benefiting from the development and support offered within local systems, and subject to an arms-length contract management arrangement rather than development and support.

 

  1. The demise of primary care trusts saw a loss of local expertise to support primary care, as clinical commissioning groups (CCGs) no longer had that remit and there was no equivalent to the support available for NHS trusts (for example, through NHS Improvement) to support primary care improvement. Our work has found while some GP federations, CCGs and local medical committees have provided some support, this is not consistent (Baird et al 2018). There is currently no guidance about the role of integrated care systems to support the delivery of care in general practice, or a commitment to do so, and this is a gap that must be addressed.

 

  1. National bodies and ICSs need to address the route by which they will support GPs and their team members to take on the task of redesigning services to better co-ordinate care for their population, by providing them with the right resources, including organisational development support, data analytics and change management. Our research shows that while general practice has potentially more freedom to ‘get on and do’ than in the past, it often has less access to the financial or human resources needed to undertake the kinds of change needed for the future than statutory NHS organisations (Baird et al 2018).

 

  1. The reforms introduced by the Health and Care Bill mean that general practice also now has to find its place within integrated care systems and navigate new place-based models of partnership working. It is critical that system leaders understand the centrality of effective, high-quality general practice in delivering system-wide change. Investment in new models of care has system-wide benefits as well as securing a strong primary care base and system leaders should actively engage general practice at all levels of planning and delivery. They should also ensure that the voice of general practice is heard and acted on in the systemwide plans being developed by the ICS and through its position on the integrated care board.

 

 

Implementation of effective teamworking

 

  1. Evidence shows that team-based care – where a range of professionals work together to provide proactive, person-centred care – can support improved access, more efficient co-ordination and improved continuity (Baird et al 2020). Many international models of general practice focus on building stronger, more proactive and continuous relationships with patients by moving away from the traditional one-to-one patient–practitioner interaction to a team-based approach. It is positive therefore that the government has committed to funding 26,000 additional roles in general practice, including clinical pharmacists, physician associates and paramedic practitioners – and primary care networks are in the process of developing the appropriate skill-mix in their teams to meet the needs of their populations.

 

  1. However, effective implementation of these teamworking models is key: primary care networks and individual practices need a clear understanding of the needs of the patient population and how the skills and knowledge of team members map against those needs. They also need a clear and shared vision of how the roles will be integrated within the teams: our current research into the implementation of the additional roles in general practice has found that, in many cases, general practices are not ready to implement a multidisciplinary model of care either within or across practices that embraces these roles, leaving some staff isolated and demoralised (Baird et al, forthcoming).

 

 

Thoughtful and evidence-based implementation of digital models

 

  1. The pandemic has led to a huge expansion in the use of telephone and video consultations and the almost universal adoption of digital triage, going far beyond the digital offer to patients available in 2019 (Baird and Maguire 2021). The move to remote triage and telephone/video consultations has the potential to unlock a number of benefits for both patients and GPs. However, digital technology in general practice is not just about patients being able to access care in different ways; it can also allow GPs to access support that allows them to provide an enhanced level of care.

 

  1. However, a small but significant proportion of the population in England is digitally excluded or have needs that make digital access less appropriate for them (Healthwatch 2021). Looking ahead, the task for national bodies and local leaders is to embed, evaluate and refine the rapid measures taken during the pandemic to ensure they meet both staff and patient need, and to make lasting changes to policy and practice that create a more supportive environment for digital health innovations that improve patient care. This means adopting digital models that go beyond just improving access to how they can promote self-care, shared decision-making and the co-ordination of care. Technologies to support sharing clinical information and improving communication between practices and with the wider system are also needed so professionals are able to access and share information easily, including while working out of hours and on home visits. Better communication between general practice and specialists in secondary care could be facilitated by enhancing the advice and guidance system that allows clinicians to seek advice on their patient before or instead of referral. Again, system support for the effective implementation of these models is key.

 

 

Coherent investment, contracting and funding

 

  1. The complex and piecemeal nature of funding for general practice is a significant burden and acts as a barrier to transformation (Baird et al 2016). An adversarial approach to commissioning and contracting has resulted in a ‘shopping list’ of tasks required of GPs from commissioners and politicians, and a protectionist response from general practice, with a lack of trust on both sides and a sense that each side is being taken for granted (Beech and Baird 2020). The capitated global sum payment forms only about half of a practice’s income. Therefore, partners and practice managers face the challenge of seeking out many small sources of funding, each with their own reporting requirements, which adds to the bureaucratic burden on general practice. Easy access to funding for general practices to invest in the activities required for transformation, including leadership and organisational development support, project management expertise and capital funding is lacking.

 

  1. Programmes designed to increase productivity in secondary care and move care closer to home for patients have transferred activity previously undertaken in secondary care to primary care without concurrent adjustment to the division of funding and investment. The approach to commissioning and contracting general practice needs to move away from over-specification of individual actions and services towards an approach based on outcomes for the local population, that rewards the development of integrated care and enables resources to be re-invested and deployed outside acute settings.

 

Effective delivery models

  1. The traditional partnership model of general practice will need to change to continue to enable high- quality care for patients. Increasingly, GPs want to work in salaried and locum roles rather than taking on partnerships. This continues a long-term trend in which fewer doctors aspire to become partners in their practices (Baird et al 2016). Therefore, bringing general practices together to work at scale can help to address this shortfall.

 

  1. Bringing practices together to work at scale and in partnership with other health and care providers within primary care networks potentially provides an opportunity to improve the management of population health by providing a wider range of primary care services to patients than would be available in an individual practice (Baird and Beech 2020). However, in our experience most networks lack the capacity needed to reach their full potential and are funded to deliver against the defined service specifications set out in the contract extension, rather than to support individual practices to address variation in quality of care and performance. General practice needs to shift its focus towards proactive and planned care and play a more effective role on prevention but in many instances does not have the time or leadership capacity to make the fundamental changes needed.

 

 

  1. Larger practices and at-scale models of delivery of core general practice are becoming more common and can bring benefits of economies of scale, particularly in back-office support. But effective delivery models must be grounded in and responsive to local communities and provide holistic, continuing and co-ordinated care for patients, which is based on strong, trusting relationships with professionals who know them and their communities. Work at scale must not be at the expense of redesigning the way in which patients access care, building collaborative partnerships with local communities or improving the working lives of the professionals working within general practice.


References

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Baird B, Maguire D (2021). Understanding factors that enabled digital service change in general practice during the Covid-19 pandemic [online]. The King’s Fund website. Available at: www.kingsfund.org.uk/publications/digital-service-change-general-practice-during-covid-19 (accessed on 13 December 2021).

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