Written evidence submitted by Dr Kate Jenkins (FGP0360)

 

I am a GP partner working in an 11,500 patient practice in the Southwest of England, partly urban and partly rural, partly middle class but also covering some deprived areas of Bath. I have been a partern for 10 years but have been qualified as a GP for 21 years and I worked on a salaried basis in 2 other practices before I joined my partnership.

I’ve written this in a hurry, as we only had 2 weeks’ notice of the consultation deadline and I was unwell with a cold (not covid) which has prevented me from being able to spend any time on this before tonight.

What are the main barriers to accessing general practice and how can these be tackled?

Capacity does not currently meet demand. Resources (financial and/or staffing ) can’t meet current demand.

Most practices still use telephone access though some have moved to online triage. My friend’s practice in Somerset has done that but she complains that it’s too easy for patients to access them via an online method, and they are inundated.

We switched back to almost all ‘advanced access’ at the beginning of covid as this was the best way to make sure all patients were phoned first. Now that things are changing (!) we are still mostly on the phone but have very low threshold for calling in patients.

It’s hard to find the headspace to redesign the appts system whilst we are facing such high demand recently. And now some of my partners are also heads down trying to ramp up our local PCN vaccination service.

Triage- we have different types of staff in our practice and so getting patients to the right person is key. We have trained our receptionist (multiple times due to turnover) to triage to NP/Dr/TRN  and now pharmacist and first contact physio, but it isn’t perfect and the default person to send the patient to whether its an appt or message via task (our internal patient specific message system) is to the doctor. This is daft as we are the most expensive resource but spend a lot of our time dealing with fairly minor complaints or administrative issues . but if we want some else to do these tasks we have to train them and set up protocols which we don’t have head space to do. More head space needed- or maybe external support?

If access is too easy this increases workload but sometimes the work that is being done can be of lower value- its less important for that patient to have advice but they got it easily because they were able to access it easily. The ‘eat all you can buffet’ mentality to general practice- it’s there so we’ll use it. (we won’t ask a friend/extended family/consult the internet)

It depends on the patient – for a young patient with an isolated or acute health problem, with no psychological issues, seeing any doctor is fine, but for older, more complex patients, a doctor who knows their history and how they usually present will have an advantage over someone who hasn’t met the patient before- it makes their job easier, and the patient will usually get better care and be happier. Also so many patients with anxiety, especially health related anxiety, or symptoms that are hard to diagnose, or who have had similar presentations in the past, will be better off seeing a doctor who knows them. It avoids unnecessary investigations, and may reduce escalation of heath anxieties.

I have this argument so often with my nephew who thinks that all patients are like him – and satisfied by a chat with some random online doctor .

Staffing levels and the ongoing increasing complexity of the medicine we are practising. More medications coming online for which there is more monitoring. More knowledge and skill needed in knowing when to prescribe or not, interactions etc, more potential side effects to manage.

Too many older GPs are going to retire, leaving a less experienced workforce. Experience really counts- medicine is all about pattern recognition – you don’t see every pattern in med school, or even in your training years- it builds up over time. And you (hopefully) get better at consulting so that patients are more satisfied with the outcome and less likely to bounce to another GP.

Older GPs get more tired though, and find the 11-13 hour days of non -stop brain activity completely draining!

Our staff costs are going up but the funding in primary care never seems to keep up with this.

Lack of headspace as were all too busy, our managers too

 

I am lucky- where I work GPs are recruitable (not easily recruitable, but recruitable) but I know in other areas it is almost impossible to recruit GPs. I have no idea how they are coping with the current workload without enough GPs.

I’m no expert in how regional variation would affect the challenges of GP- I suspect others can say a lot more about this. But off the top of my head- areas with high population of non -native speakers must be hard to look after- everything takes ages through a translator (if you can get one on the line!) and is just harder work.

We don’t have the capacity for the should in this sentence! But GP could play a role in prevention. This country doesn’t do enough in prevention. I’d like to get all the junk food out of our local supermarket, and have parenting classes including teaching cookery skills, healthy lifestyle education to include healthy psychology education easily accessible to every parent. Take a look at what the Finns do- they have it right.

What can be done to reduce bureaucracy and burnout, and improve morale, in general practice?

Help General practice to triage better. Perhaps provide more admin staff and make it easy to train them (ring fenced funding ) we haven’t yet got a care coordinator in our PCN .

Reduce the population’s expectation of what GP can or should do for them to something that is realistic for the approx. £100-120 per individual, per year we are funded to look after them. Or dramatically increase the funding so that there are more hours of GP or nurse time – but I don’t think there are the GPs for this. Some areas would just suck up all the GPs and that would leave the areas with difficulties in recruitment with nothing.

Invest in training up new treatment room nurses so that we can recruit them. Also invest in getting them, trained up as prescribers in their own specialist area – this is happening already but slowly. Increase funding so that we can hire more nurses and train them ourselves to be specialists in asthma /diabetes/ or to be a minor illness nurse. Why were nurses left out of the ARRS scheme??

But the PCNS are beginning to help - we have a great pharmacy team, they have reduced some of the prescribing and associated admin. We have just got a first contact physio. And are getting some physicians associates next year. It’s a start. We also are getting a care coordinator- but the pay rates are causing a problem as we will have staff in our practice paid by us (a lower rate ) than the PCN attached staff who are on a national scale.

Ancillary pay rates in GP are a problem, as in all care areas . Our receptionists are paid about £9.50-10.50 an hour- they can get more in a restaurant, or even cleaning people’s houses. The job is hard and stressful- it’s getting harder to recruit and retain staff. Likewise, our pay rates for secretaries, other admins, and nurses is not as good as in secondary care. You could suggest we just pay them more- but the staff budget expands massively with even small adjustments. We can almost never offer a pay rise that is close to or matches the national cost if living rise.

 

Address

 

This is a biggie! The advantages of the partnership model are multiple and so are the disadvantages. In a good partnership, the partners drive the practice, they motivate their staff, and they work together as a team to provide the best care they can for their patients within the finances available. The partnership model is why GP is such good value (aka earlier comment re 100 per patient).

In a bad partnership, the culture can affect staff morale and ultimately the service received, but that’s down to management and even in a salaried service you have managers. Ultimately a lot of doctors that become GPs do so because they like working in a team and they like the idea of being able to influence their working environment and the way their service is delivered. Losing the PM would risk losing this and I think less doctors would be interested in GP as a career.

There isn’t a move towards salaried posts- these have been with us at least since I qualified as a GP 21 years ago- my first job was as a salaried GP, then a salaried partner (really just a glorified salaried GP) and finally as a partner for the last 10 year. These have been the most satisfying of my career as I have worked with my partners every day and every week to ensure the smooth (ish) running of our practice.

Nope- they are far too complicated, with too many itty bitty contracts, and returns to fill in and boxes to tick to claim for things. Having said that there doesn’t need to be some bean counting to make sure that we are doing the work correctly. But it’s quite hard to keep track of all the monies, and make sure you getting everything you should – which ultimately enables you to pay your staff and keep  the show running. Also the contract varies across the nation in terms of what GP is paid for in some areas and what its not paid for (the old core vs non-core argument) and what local contract arrangements are in place. But- don’t throw the baby out…some aspects of the current contract are ok changes have been good;

So many words in one question, how do you expect an answer!!? All I can say is that I think they are a good start but may not have achieved that long list of objectives yet. But in our PCN we are all trying to work together more- and we are running a local vaccine centre in our PCN which has meant working together.

The ARRS scheme associated with the PCNS is great- it’s ring fenced money for additional staff which are badly needed for all the reasons above. I still think our PCN is in its infancy but will toddle then walk and then run. If you want to really help GP then maybe the next ARRS staff budget should be for project manager support to give headspace for redesign of local access but in tandem with recognition that GP and its team is a finite resource (just like the orthopaedic surgeon is a finite resource, and the cardiology team is etc etc)

Through the ARRS scheme we have been working with pharmacists, now a physio and will soon have a PA, and a care coordinator.

You haven’t asked about the elephant in the room – premises! –perhaps that’s for another time…..

 

Dr Kate Jenkins

 

Dec 2021