Written evidence submitted by the BMA (FGP0366)

 

About the BMA

 

The BMA is a professional association and trade union representing and negotiating on behalf of all doctors and medical students in the UK. It is a leading voice advocating for outstanding health care and a healthy population. It is an association providing members with excellent individual services and support throughout their lives.

 

Overview

We are submitting evidence to this inquiry to address the following key components, highlighted below. If addressed, they will have a positive impact on workforce, workload, creating time to care, improving patient access, and creating a sustainable future for general practice through the continued delivery of high quality, safe, and effective patient care.

 

Regulation - Instead of focussing on what a safe working day should look like and holding the system to account for failing to deliver, existing regulatory frameworks seek to reprimand and penalise clinicians operating within workforce and workload constraints outside of their control. 

 

 

 

 

  1. Summary

1.1   General practice delivers continuity of care through a partnership model which improves patient satisfaction, reduces hospital attendance, and reduces health costs[2].

1.2   Over the last decade the service has faced increasing demands which have not been met by a corresponding increase in workforce or funding.[3] This is the root cause of current access challenges. We are calling for the Government to urgently work with us to develop and publish a comprehensive plan for the recruitment and retention of GPs which includes what a safe working day should look like.

1.3   Increasing disease burden; the evolution of medicine; patient complexity including comorbidities; and population rise are all factors contributing to this increasing demand, impacting access.

1.4   The pivotal role general practice has played, and continues to play, in the COVID-19 vaccination programme showcases its strengths, agility, creativity, and problem solving, alongside its unique role in the community. We believe learning should be taken from the success of the vaccine programme and these strengths applied to other areas of general practice care.

1.5   General practice has a strong role to play in the prevention of ill health, which we support, however, we require a clear operational plan that factors in how time to care will be incorporated into prevention strategies.

1.6   General practice works with everyone in the NHS, due to its unparalleled connection to local communities. It is imperative that when considering the future of general practice access, its role and representation within ICSs (Integrated Care Systems) and ICBs (Integrated Care Boards) is sufficient. We have campaigned for the Health and Care Bill to reflect this, by ensuring ICSs and ICBs appoint further GP representatives onto their boards, including formal roles for local LMCs (Local Medical Committees).

1.7   GPs are the cornerstone of extended access, out of hours care, urgent primary care in UTC settings, 111, and A&Es. The artificial separation of these elements at NHSEI and government level means that general practice is not recognised for the wide-reaching role it plays. Often, it is the same workforce that stretches itself to deliver care across these different settings. The role of GPs in this wider context should be recognised and celebrated, but the assumption that individuals will be able to continue to work such long hours cannot be taken for granted.

1.8   Healthcare partners such as the pharmacy sector, optometry, dentistry, and other community-based services have the potential to play a transformative role but continue to be held back by disinvestment and unnecessary bureaucracy.

 

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

2.1   Demand is outstripping capacity across general practice. This has arisen as a direct result of workforce, workload, and premises infrastructure pressures[4]. Capacity is being limited due to insufficient recurrent funding to train and retain clinical and clerical staff.

2.2   Despite a growing number of ways to contact a GP practice, there remains only a limited number of staff members available to respond to these requests.

2.3   The overall number of GPs has seen little growth since 2015, latest data shows we have the equivalent of 1,744 fewer fully qualified full-time GPs compared to 2015. Over the last year alone, between October 2020 and October 2021, the NHS lost 906 GP partners and 233 salaried and locum GPs.[5] A previous government target to recruit 5,000 more GPs by 2020 was unsuccessful and in February 2020, the Government announced a further drive to recruit an additional 6,000 GPs by 2024. Furthermore, the UK is falling behind many other European countries with just 2.8 doctors per 1,000 people, in comparison to an EU average of 3[6].

2.4   These  statistics coupled with the acknowledgement on 2nd November 2021, by the Secretary of State, Rt Hon Sajid Javid MP, that the Government will not hit its target of 6,000 more GPs[7] suggests patient safety will be compromised. The average number of patients each GP is responsible for has increased by around 300 or 16% since 2015[8]. We are calling for the Government to work with us to develop and publish a comprehensive plan for recruitment and the retention of GPs which also seeks to address what a safe working day should look like.

2.5   Access to care should be on the basis of clinical need, rather than the assumption a GP is always the most appropriate healthcare professional to see. The Government should do more to publicise the benefit of a multidisciplinary workforce in general practice and other system partners.

2.6   This is compounded by the amount of contractual and non-contractual work that GPs and practice staff have to undertake that is not directly relevant to patients or their care. The number of bureaucratic processes involved with regulation, non-healthcare related patient queries, financial processing for funding and transfer of workload from elsewhere in the NHS takes GPs and staff away from their patients. This has become much more acute over the pandemic period, where services transformed because practices were tasked with delivering the COVID-19 vaccination programme.

2.7   The wider central focus on increasing the number of appointments can have the direct consequence of suppressing the duration of appointments. The impact of this is that the same patient requires multiple appointments where a single, longer one would have been more effective and efficient. We continue to call for support to practices to enable them to increase the average appointment time from 10 to 15 minutes or more, to better meet patient need[9].

2.8   A 2019 BMA survey revealed that many general practice buildings in England are too small to meet patient demand, with eight in 10 saying that their practice was not suitable to meet future needs or anticipated population growth[10]. The situation has worsened since the pandemic as it becomes crucial for GP premises to be well ventilated and appropriately sized to minimise the risk of viral transmission. Further detail on the constraints of premises is included under point six.

 

  1. To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?

3.1   The current plan to invest £250m over the winter period does not address all of the barriers highlighted in this submission. We note that while the plan was published in October, by mid-December, little of the fund has been spent due to restrictions and bureaucracy surrounding its use. 

3.2   93% of members surveyed by the BMA responded that the access package is an unacceptable response to the current crisis[11]. GPs have reported to us that the package could increase workload and bureaucracy on GPs and their colleagues, reduce the number of appointments available, and impact the quality of patient care, while threatening to name-and-shame and penalise practices that need the most help[12].

3.3   The package does not provide a solution to the current crisis in general practice, as it does not seek to address, understand, or provide workable short or long-term solutions for workforce support or workload reduction. The document was not written in collaboration with profession representatives and did not consider fundamental historic problems nor the current pressures.

3.4   Our analysis of the plan shows the impact it will have on practices, and how it does not offer the necessary support for practices to deliver the care that their patients expect and deserve[13]. There is not enough staff to continue delivering all that is being asked of them. Those left working are exhausted, demoralised and have little left to give.

3.5   Following the announcement of the speeding-up of the booster campaign[14], there has been some emphasis on reducing contractual requirements to release time for care, something the BMA had been calling for at the time the access plan was released. We consider it a missed opportunity that the access package is outside the scope of these discussions and believe there is more that can be done to create time to care.

 

  1. What are the impacts when patients are unable to access general practice using their preferred method?

4.1   Where patients are unable to access care via their GP, they will seek help from elsewhere. There is currently no reliable published data to show exactly where patients choose to go for help. Common sense may suggest self-care, internet searches, or family advice. 111, pharmacies, and minor illness walk-in services are readily available options, followed by presentation at an A&E. This could result in burdening parts of the healthcare system with patients who should have accessed care elsewhere, such as patients unnecessarily attending A&E. The impact will be variable, some patients may successfully self-care and require no further treatment, whereas others may not receive the appropriate assessment and care, resulting in wasted resources, and delays in diagnosis and treatment.

4.2   To release system efficiencies and ensure better outcomes for patients, effective triage is an important tool. It means the right care by the right staff type at the right time. Defaulting to general practice increasingly omits the benefits of the wider team and reduces general practice capacity to manage the most complex cases that cannot be managed by other staff. Support is needed to enable the infrastructure to support different access points and effective triage. 

4.3   Despite the challenges, 83% of patients reported in the 2021 national GP Patient Survey that their overall experience of general practice was good.  The service continues to deliver high standards of primary care for the population[15]. In October, GP practices in England delivered more than 4 million more appointments than they did in September, a total of 33.9 million in October, and more than 3 million more than they did in the same month pre-pandemic in 2019[16]. This is not sustainable and is mentally and physically detrimental to the workforce.

 

  1. What role does having a named GP—and being able to see that GP—play in providing patients with the continuity of care they need?

5.1   While the premise of having  a named GP could be reassuring for patients, evidence has demonstrated that it does not result in improvements in continuity of care or unplanned hospitalisation[17]. However, there is a strong association between higher continuity of care and reduced mortality rate, complication risks, treatment concordance and health service utilisation across several disease areas. We suggest that it is the continuity of care that is important, not necessarily continuity of care with a specific GP. We advocate for continuity of care to be prioritised across the NHS. Many doctors report that they value continuity of care and if they were able to focus on this rather than wider bureaucratic and contractual requirements, they would stay in the profession for longer. In our view, the emerging model of general practice does not appear to value continuity, and instead prioritises access. Our recommendation referenced earlier in this submission -that GPs be supported to increase consultation times from 10 minutes to 15 minutes or more - would help in this regard.

 

  1. What are the main challenges facing general practice in the next 5 years?

6.1   Immediate pressures will arise from handling further waves of COVID-19 and managing the resulting medical illness, ranging from Long COVID to mental illness. Exhaustion and emotional toll, from working under mounting pressure whilst dealing with significant case load through a pandemic, is clearly felt by the workforce. Participating in an extended booster programme for COVID-19 whilst trying to support the NHS with its COVID-19 recovery programme is also a significant factor. This is coupled with additional patient need resulting from backlogs, late presentations, and unmet need.

6.2   Being a GP has become an untenable job for many due to the demands placed upon the profession, which some believe, are resulting in an inability to safely care for patients. As such, qualified GPs are leaving the profession or reducing their sessions. Shortages are also being felt across all practice staff from nursing staff to practice managers. These shortages coupled with unsafe and inadequate GP premises and uncertainty over NHS structural changes to ICS/ICPs, ongoing contractual reform, a punitive and counterproductive pension taxation system, and rising levels of abuse against staff is making general practice unappealing as a profession.

6.3   A key element of the challenges facing general practice is the prevalent culture, which does not seek to value, understand pressures, or support the workforce. This can be addressed through a collective effort and joint working and will require trusting the workforce and moving away from undeliverable performance management metrics.

6.4   Management of gaps in commissioned services, and patients at the interface between primary and secondary care, without the staff and resources to deliver care is a challenge. This includes increased expectations of tests and investigations in the community - often at the request of other bodies - oversight of secondary care clinical management plans delivered in the community, and decreasing outpatient appointments by 30%, whilst trying to diagnose and manage conditions with limited access to expert support and diagnostics. Specialist services such as for gender dysphoria, ADHD and other conditions are often lacking meaning that the default is to expect general practice to support and manage these patients. Further, there are bureaucratic barriers to referrals and a lack of access to mental health and therapies of the right level to meet need, which adds to the pressure on general practice.

6.5   One area where we believe change could be enacted is to extend the successful Electronic Prescription Service (EPS) to hospital clinicians enabling them to access electronic prescribing so that patients can collect their prescription directly from a local pharmacy and reduce the bureaucracy of requiring the prescription to be  issued by their GP practice.

6.6   GP premises are in urgent need of investment. Our survey showed that half of GP practice buildings are not fit for purpose, and only two in every 10 practices were fit for the future[18]. These results informed the General Practice Premises Policy Review, led by NHS England, and agreed by the DHSC and the General Practitioners Committee of the BMA. The review reported in June 2019, with a recommendation that ‘capital is required both to bring up the standard of current estate and to transform primary care estates across England, to deliver what is required for the clinical and service vision of the Long-Term Plan in purpose-built premises’. In the meantime, the COVID-19 pandemic has placed more urgent demands on GP premises, resulting in many being unequipped to meet the challenges of a highly infectious disease; namely by allowing practices to take additional measures such as social distancing, isolation rooms and ventilation in order to ensure patient and staff safety. GP premises are bursting at the seams, and unable to staff additional members of the team to cater to growing patient need.

6.7   GPs are also being faced with huge pension taxation bills, and in particular the Lifetime Allowance is acting as a trigger for early retirement. A recent BMA survey indicated that two-thirds of doctors over 55, and one in eight aged between 35 and 54 are considering retiring within three years.[19] Furthermore, the average retirement age has fallen from 61 in 2007/08 to 59 in 2018/19. There has also been a four-fold increase in the number of voluntary early retirements (VER) since 2008, with 54.7% of GP retirements in 2020 being VER.[20] This situation clearly cannot continue, and we are calling for an increase in the Life Time Allowance and the introduction of a tax unregistered defined benefit pension schemes across the UK for those affected in the NHS, to mitigate the current pension taxation system.

 

7         How does regional variation shape the challenges facing general practice in different parts of England, including rural areas?

7.1   Not all services are universally available across England, and even when services are available, they are not always easily accessible when travel is involved. Urban settings can have specific needs where there are more transient and diverse populations, while telecommunication infrastructure is not always present and reliable in rural England to allow for technological solutions. This presents a clear problem in the form of a postcode lottery, but also raises wider issues from a socioeconomic perspective. The well-documented socioeconomic determinants, including implementation of the Marmot 10 year on review[21], also need to be considered in the context of addressing variation. Any approach to improving access needs to be flexible to allow local decisions that are reflective of local limitations and their populations. It is also clearly important to recognise that difficulties of social deprivation exist regardless of geography and must be considered. 

7.2   Regional demographic variations in the patient population are not adequately reflected by the Carr-Hill formula. In 2019, a study in the British Journal of General Practice, found that for every 10% increase in a practice’s Index of Multiple Deprivation score, payments only increased by 0.06% under the Carr-Hill formula, suggesting the current formula is very unlikely to lead to a more equitable allocation of NHS practice funding. The study also concluded that the formula worked ‘less than optimally to reflect practice population health needs[22]. This should be addressed by increasing funding, but also ensuring a more effective method of a recognising the impact of deprivation.

7.3   It is also not uncommon for practices to struggle to recruit in some areas, which will also have a knock-on effect on their ability to offer urgent care and extended access. Solutions could include new medical schools, targeted training grants and international recruitment. The most crucial change will be a wider shift in recognising the contribution that GPs make and improving working conditions and morale amongst the existing workforce.

7.4   While the BMA is clear that shortages of doctors exist across England, some regions are particularly impacted. Regions of the country, other than London, with a large population do not have a proportionate number of doctors, for example,  3.5 million more people live in the Midlands than the North West, but they have 4,000 fewer doctors to treat them[23].

7.5   Since the 2012 Health and Social Care Act, there has been inadequate workforce planning. Government has inadequate information to know whether there are enough doctors within each grade/specialty or if the steady overall annual increase in secondary care doctors is keeping pace with patient need. We strongly suspect it is not, given that activity growth far exceeds workforce growth[24]. This has an impact on health outcomes within a community. For this reason, we are working as part of a coalition to propose an amendment to the Health and Care Bill which would require the Secretary of State to publish regular, independently verified assessments of the workforce numbers needed now and in the future, to meet the growing needs of the population. We were disappointed this amendment was not accepted in the Commons despite compelling cross-party support, but we will continue to push for it during the Lords’ scrutiny of the Bill. .

 

8         What part should general practice play in the prevention agenda?

8.1   General practice, working alongside its system partners, has a unique role to play in the prevention agenda. When supported with the right tools, including digital infrastructure, general practice can drive significant population health improvements. Prevention is not currently part of general practice core services, and this needs to change. Please see our response to the Government’s green paper ‘Advancing our Health: Prevention in the 2020s’ for further detail[25]. The new Office for Health Improvement and Disparities (OHID) is also a clear opportunity to revisit the prevention agenda, to ensure infrastructure is put in place.

8.2   When adequately supported, GPs and their teams would have sufficient time to care for their patients, enabling a greater focus on preventing ill health, including time to better support the health needs of any patients that are living in poorer communities. Issues like combating poverty, supporting loneliness, raising price of alcohol, improving access to fitness and dietary advice are outside the scope of day to day to general practice, however, they have a significant impact on patients health. We believe that GPs should be included in the planning of preventative strategies.

8.3   For general practice to play a greater role in the prevention agenda, vital public services supporting prevention must be sufficiently funded and reflect the needs of their communities, so that there is adequate provision to refer patients on to. The public health grant has been cut by 24% on a real-terms per capita basis since 2015/16[26]. This chronic underfunding has led to a reduction in vital services such as  smoking cessation, and alcohol, drug and obesity services, which have all seen a reduction in their funding over the last three years. Not adequately resourcing these services puts more pressure on general practice.

8.4   Cuts to the public health grant have often been greater in more deprived areas. Investment should be targeted at areas with higher levels of poverty, aiming to tackle health inequalities. Investment should be focussed on extending health literacy programmes, increasing the uptake of health screenings, tackling alcohol, tobacco and illicit drug harm, and programmes which support patients in managing their long-term conditions.

8.5   Health and well-being coaches are a new staff type that PCNs can recruit and could have a very positive role to play. However, like GPs, without adequate resourcing to move from responding to acute need towards the prevention agenda, the impact will remain limited.

8.6   There should be efforts to increase registration rates in general practices for those with low access to healthcare to help improve the health of those living in poorer communities or excluded groups, including people sleeping rough, offenders, sex workers and vulnerable migrants.

8.7   It is also crucial to include PCNs and GPs in prevention strategic planning, to ensure benefit from valuable insight into local communities, rather than expecting GPs to deliver strategies they were not included in making. ICSs will play an important role in the prevention agenda and in population health management, and therefore we would like to see strong primary care leadership within ICSs.

 

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

9.1   GPs and their teams need time to look after their patients, trainees, each other, and themselves. The most important commodity to do this, is time. To create time, we need to minimise inefficiencies and deploy trained and reliable staff where capacity is needed most.

9.2   The risk of disillusionment and burnout amongst GPs is higher than ever. Our survey from 2019 found that nearly nine out of 10 GP partners are at high or very high risk of burnout. While a 2021 report from the GMC showed that 42.8% of GPs reported burnout as a reason for leaving[27]. Meaning that even before the pandemic, a huge proportion of GPs were in danger of overwhelming exhaustion, depersonalisation and reduced personal efficiency.

9.3   The most important measures to reducing burnout and increasing morale is to have a workforce which is adequately staffed, with a manageable workload that is treated with respect and feels valued. Whilst we cannot achieve increased workforce numbers immediately, we can stop morale and workload getting worse now. Our wider submission makes recommendations as to how these shortfalls can  be addressed. We also support the recommendation from the Health and Social Care Committee’s report on workforce, burnout and resilience that continuous and transparent assessments of workforce shortages and future staffing requirements should be made.[28] As previously referenced, we are also calling for an amendment to the Health and Care Bill requiring transparent reporting of workforce shortages every two years.

9.4   In the short term, we have called for a suspension of performance management metrics, releasing time to care for patients. This includes QOF and IIF. While the Government announced in December 2021 that it has temporarily suspended some of these arrangements, we believe there is scope to go further to free up time to prioritise patients. CQC inspections, annual regulatory reviews and provider registration management contribute to the stressful and pressured working environment, divert time and resources away from patient care, and duplicate much of the performance management role of CCGs. We believe CQC resource could be better focussed towards supporting patients if they identified system solutions for the wider system pressures that are impacting on all parts of the NHS. This should include an end to CCG or other external demands for various mandatory training, often expected to be done within inappropriately rigid timeframes, and a return to GPs identifying their own training needs as part of their medical appraisal. The changes made to appraisal as a result of the COVID-19 pandemic have been widely welcomed and these reduced requirements should be retained. We also believe there may be scope in the long term to make some of the temporary changes permanent.

9.5   The primary secondary care interface could also operate more effectively through a reduction in bureaucracy. 73% of BMA members, from a recent survey, said that that traditional barriers between organisations, teams and funding streams result in increased bureaucracy and administrative costs. Areas to be addressed include increased investment in digital infrastructure, join prescribing budgets and a revision of how treatment pathways are designed and funded to support better collaboration between primary and secondary care. Further information on these recommendations is included in our report, Supporting effective collaboration between primary, secondary and community care in England in the wake of Covid-19[29].

9.6   We have long held concerns about the Government’s introduction of regulations that will compel GPs, and GPs only, to publicly declare NHS earnings above £150,000. We welcome the delay to next year for publication of these figures, however this continues to remain a source for anxiety for many and will inevitably result in fewer GP sessions. With this in mind, we are asking for the plans to publish earnings for GPs to be scrapped entirely.

9.7   The wider NHS is slowly realising that a key tenet to retention is allowing staff to work in a way that supports their needs, for example around caring responsibilities. Expectations to adhere to traditional surgery times, reluctance to utilise digital tools and working in arbitrary blocks of 4 hours made up of ten minute appointments are limiting for many GPs and can act to further reduce morale and increase instances of GPs reducing hours or leaving the profession entirely.

9.8   There is a need to provide greater access to occupational health support for GPs and their staff, particularly enabling ARRS staff such as health and well-being coaches to support the clinical workforce. A policy framework standardising the commissioning of occupational health services was introduced in 2016, and while some aspects are funded by the NHS, other services need to be paid for by the user. Other forms of support at primary care level such as those provided by NHS Practitioner Health are only available to GPs, while the NHS in Scotland has provided full occupational health services to all staff working in primary care since the end of 2016 and the Welsh Government pledged as recently as last September to explore means by which all staff will have access to health board-provided occupational healthcare. England should follow these examples and extend this support to all staff.

9.9   The sustained negative media attention on General Practice has contributed greatly to the deterioration in our workforce’s morale and mental health.  Many of these stories are inaccurate depictions of the work undertaken by GP and mislead the public.  This damages the doctor-patient relationship resulting in negative consequences for patients, clinicians, and the health service as a whole.  Clinicians do not have the time or resources to address this problem, and so it perpetuates.  We call on the Government, including its arm’s length bodies, to help end the abuse of general practice and to promote a positive narrative that results in stronger relationships and better outcomes for patients.

 

10      How can the current model of general practice be improved to make it more sustainable in the long term?

 

Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care, and the shift towards salaried GP posts?

10.1     The GP partnership model can be sustainable if it is allowed to be, and we believe that given the right future steps it could be an effective and efficient model of delivering general practice in the future NHS. However, there is a need for general practice to evolve, particularly with a growing number of staff wanting to work in more flexible ways. This can only be achieved with support for deregulation, re-professionalisation and a shift in culture placing more trust in GPs to lead.  Maintaining and developing the partnership model provides a wide range of opportunities for GPs, including salaried and sessional roles. GPs may choose different roles at different stages of their career.

10.2     Evidence of the success of the partnership model can be seen in its responsiveness and adaptability during the pandemic. In a few short weeks practices rapidly moved both to protect patients and staff and supported social distancing, by introducing total triage arrangements; effectively moving to a ‘digital front door’ model overnight[30]. They also have a long history of developing new innovate services when enabled to do so.

10.3     The main improvements to sustain general practice are to increase the workforce, reduce workload, remove bureaucracy, and enable practices to make decisions. It is also important to consider and define what a safe day of care looks like. The Government commissioned independent review of the partnership model provided several recommendations to sustain the partnership model, including removing premises liability, and we ask that the committee reviews these recommendations.

10.4     We also see opportunity in the future for general practice to offer additional services, if funding and support are provided, including community-based specialist service delivery, such as diagnostic services, supporting self-care and reducing the burden on secondary services. Now is the time to invest in general practice, not to try and reinvent the wheel through a wholesale change to the model.

 

11      Do the current contracting and payment systems in general practice encourage proactive, personalised, coordinated and integrated care?

 

11.1     We do not believe the current GP contract and funding system is fit for purpose and have called for contractual reform. A resolution from GPC England passed in September 2021 called to negotiate a comprehensive new contract to replace the outdated, underfunded, unlimited, unsafe workload of the current GP contract. Additionally, the annual Conference of England LMCs held in November 2021 called for a review and change to the funding model of general practice, away from a block contract of funding irrespective of workload and toward a fee for service contract for core general practice work.

11.2     Contracting of general practice care has become increasingly outcome focussed and target-driven. This has increased the administrative burden and reduced time for an individualised and innovative approach. 

11.3     General practice is funded in many different ways . This has created a complex system of funding streams for different (or the same) aspects of care provision. We wish to begin discussions on the creation of a new contract for General Practice and new funding mechanisms.

 

12      Has the development of Primary Care Networks improved the delivery of proactive, personalised, coordinated, and integrated care and reduced the administrative burden on GPs?

12.1     While some elements of GP workload may transfer to other non-GP staff within the PCN, some practices have suggested that this is outweighed by the administrative burden and bureaucratic processes associated with being part of a PCN, such as holding employment responsibilities, line management, supervision, training, managing finances and reporting.

12.2     Without enough GPs, patient access to the clinical and medical care they require is being compromised. The PCN Network Directed Enhanced Service (DES) as originally designed provides guaranteed funding to support the recruitment of 26,000 additional non-medical workforce, however this is a rigid, highly bureaucratic system of recruitment and does not consider local challenges or need. Recruitment is patchy in many regions, and funding committed remains unspent. Once recruited, unless staff can help to reduce workload pressures, they will do nothing to increase the number of GP appointments freed up, or retention of GPs in the workforce. One additional factor is the rigidity of the Additional Roles Reimbursement Scheme (ARRS) funding which should be made more flexible in relation to eligible roles to allow GPs to hire the staff needed to meet the needs of their individual localities and patients.

12.3     PCNs have not yet fulfilled their potential to support general practice and GPs. The concept that they would reduce workload, provide a wider variety of service, and stabilise general practice is not yet evident in all areas. Recruitment problems, overly bureaucratic processes, un-resourced training burdens, and an overly proscriptive system have prevented ARRS staff from being able to bring their intended benefits to the system.

12.4     Practices can be encouraged to work collaboratively and to recruit extra staff without the constraints of the PCN DES by investing the resource direct into practices core contracts.

 

13      To what extent has general practice been able to work in effective partnerships with other professions within primary care and beyond to free more GP time for patient care?

13.1     The BMA and its members have encouraged the development of multidisciplinary teams and recognise that there is great value in this approach. As we have highlighted in this submission, premises funding must allow for wider teams to be employed where they will benefit their localities’ patient need. We have also called for measures to be put in place to ensure that GPs are not charged VAT on additional staff funding through a PCN. We believe this penalty is extremely counterproductive to improving patient access.

13.2     We recommend the Government/NHSEI work to promote to the pubic the benefits of being seen by other healthcare professionals and not just GPs, rather than focussing on a GP centric approach. Patients must be supported to understand how they can and benefit from other services in their communities.

13.3     We have seen positive impacts from establishing pharmacists in practices, which has improved the quality of prescribing and reduced some of the need for GPs to undertake medication reviews. Similarly, physio first schemes that enable patients to be directed directly to physios rather than a GP appointment are also helping to free up GP time and allow timely access to support services for patients. Bureaucracy unfortunately places limits on the usefulness of the Community Pharmacy referral scheme, in particularly the structure and time necessary to fill in a referral form.

13.4     The overly onerous demands of the PCN DES can discourage integration. This is due to the workload demands of meeting the DES and the proscriptive nature of the contract. Deregulation and investment in core funding would allow more effective collaboration across the whole health and social care system. Non-medical clinicians in general practice provide an excellent service to patients which is highly valued, but this is not reducing GP workload and thus not freeing up GPs. Indeed, the training requirements and the bureaucracy of the PCN DES takes GPs away from clinical care. With IIF requirement becoming increasingly burdensome, PCNs will need to recruit simply to service further parts of the contract with little patient benefit. Already crowded and ageing premises prevent sufficient recruitment as there is simply not enough room to place all the new non-medical clinician that are expected to be recruited by the DES.

 

Dec 2021

 

 

 


[1] BMA press release, 13 September 2021, https://www.bma.org.uk/bma-media-centre/nhs-short-of-50-000-doctors-heading-into-winter-bma-research-finds

[2] BMJ, 01 February 2017, https://www.bmj.com/content/356/bmj.j84

[3]NHS Digital, Appointments in General Practice, October 2021, https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice/october-2021

[4] NHS Digital, NHS workforce statistics, https://digital.nhs.uk/data-and-information/publications/statistical/nhs-workforce-statistics

[5] BMA, https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice

[6] BMA press release, 13 September 2021, https://www.bma.org.uk/bma-media-centre/nhs-short-of-50-000-doctors-heading-into-winter-bma-research-finds

[7] https://www.pulsetoday.co.uk/news/workforce/javid-admits-government-will-fail-to-fulfil-gp-workforce-election-pledge/

[8] BMA, Pressures in General Practice, 14 December 2021, https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice

[9] Pulse, 11 May 2021,https://www.pulsetoday.co.uk/news/lmcs-conferences/bma-urged-to-negotiate-for-standard-15-minute-face-to-face-gp-consultations/

[10] BMA premises survey, 2018, https://www.bma.org.uk/news-and-opinion/gp-premises-survey-results-2018

[11] BMA, 14 October 2021, https://www.bma.org.uk/bma-media-centre/government-s-rescue-package-for-gps-is-flawed-and-patient-care-will-suffer-as-result-warns-bma

[12] BMA analysis of the NSHEI access package, https://www.bma.org.uk/media/4702/bma-analysis-of-nhsei-package-for-general-practice-oct21.pdf

[13] Ibid

[14]BMA press release, 03 December 2021, https://www.bma.org.uk/bma-media-centre/bma-hopes-gp-booster-plan-can-free-up-time-for-staff-to-prioritise-patients-most-in-need

[15] 2021 National GP Patient Survey, https://www.gov.uk/government/statistics/gp-patient-survey-2021-results

[16] BMA press release, 14 December 2021, https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice

[17] BMJ, 24 September 2019, https://www.bmj.com/content/366/bmj.l5682

[18]BMA premises survey 2018, https://www.bma.org.uk/news-and-opinion/gp-premises-survey-results-2018

[19] BMA survey, Are you paying to go to work? https://questionnaires.bma.org.uk/news/payingtowork/index.html

[20]BMA evidence to DDRB, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/966692/DHSC-written-evidence-to-the-DDRB-for-2021-to-2022.pdf

[21] Marmot review, 10 years on, https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on

[22] British Journal of General Practice, 2019, https://bjgp.org/content/69/685/e546

[23] BMA report, Medical Staffing in England, https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/workforce/medical-staffing-in-england-report

[24] Ibid

[25] BMA response to ‘Advancing our health: Prevention in the 2020s’ https://www.bma.org.uk/media/1626/bma-consultation-response-prevention-green-paper-oct-2019.pdf

[26] The Health Foundation, 05 October 2021, https://www.health.org.uk/news-and-comment/news/cuts-to-public-health-run-counter-to-levelling-up-say-leading-health-organisations

[27] Pulse, https://www.pulsetoday.co.uk/news/workforce/gps-twice-as-likely-to-report-burnout-as-reason-for-leaving-nhs-report-shows/

[28] BMA press release, 08 June 2021, https://www.bma.org.uk/bma-media-centre/current-staff-burnout-and-stress-levels-presents-a-worrying-risk-to-safe-patient-care

[29] BMA report, https://www.bma.org.uk/media/3334/bma-supporting-effective-collaboration-between-primary-secondary-care-covid-19-oct-2020.pdf

[30] BMA report, Trust GPs to lead 2021, https://www.bma.org.uk/media/2652/bma-report-trust-gps-to-lead-june-2020.pdf