Written evidence submitted by Primary Care 24 (FGP0370)

 

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

  People are confused how to access general practice.

General practice is used disproportionately by frail elderly people, whose numbers are increasing disproportionately in the population. Their default was to either phone or attend their practice in person. New methods of access have been introduced piecemeal during the lockdown without any clear explanation. These include e-consultation as only access and access only via the practice website (with strong algorithmic defaults instructing patients to phone 111)

Digital access requires hardware and digital literacy

Econsult and website access require a reasonable level of functional literacy with numerous groups in society facing a ‘literacy test’ to access their GP. In addition, the most socially deprived groups have least access to high quality computers and phones.

Practices are locked

An established form of access (walking into the surgery) was removed as many practices are now locked with access via a doorbell and speaker phone. This shifted an accessible community resource where people felt welcome, to something with an actual physical barrier and the potential to be excluded. This is a paradigm shift in the public’s relationship with their general practice.

Solution Unlock all practices and re-establish phone access so there is are alternatives to econsult and website access. ‘Our practice has an open door’.

 

 

There is no evidence-based guidance on access to general practice which could inform commissioners and practices

National evidence-based guidance eg from RCGP on integration of different access methods within and across practices could support practices to adopt bespoke models adapted to the needs of their registered patients.

Solution evidence-based guidance developed at pace

Limited capacity of telephony systems

The capacity of many practice-based telephony systems cannot meet the increased demand. It is doubtful how well telephone capacity met demand pre-Covid. However, there is now increased demand (widespread agreement that demand is up 30%) and a larger percentage of patients are accessing care by phone as practices remain locked. The limitations in capacity are physical (cabling, number of phones), the capacity of call waiting systems and numbers of reception staff. Depletion of practice staff leads to longer response times with many patients giving up before redirecting themselves elsewhere in the system. Upgrading and enhancing telephony networks is needed. Many practices are too small for this to be cost-effective so practice merger and provision of general practice at scale is required

Solution upgrade and enhance telephony networks at scale

Lack of GP time

The state of the general practice workforce is well understood. However, less attention is being paid to what GPs are actually doing. Much work that GPs do could be done more effectively (and arguably more safely) by other healthcare professionals eg clinical pharmacists should deal with all medication issues.

This depends on multidisciplinary team working. The team is led by the GP expert generalist with patients being directed to the most appropriate MDT clinician. Although this model is established in some practices (mostly Vanguards) this model has not been widely implemented. GP time spent providing care that could be provided by another healthcare professional is an opportunity cost to the system and a significant barrier to accessing care by patients who need expert generalist medical skills.

It has become a truism that there are ‘not enough GPs’. However, system changes are needed to enable GPs to work at the top of their license and bring maximum value to the system. One effective model which we are introducing across the 7 ‘failing’ practices looked after by PC24 is developing a Clinical Hub.

Solution clinical hub and MDT working, right patient right clinician right time

 

 

 

Clinical Hub (currently being piloted by PC24 in Merseyside)

This model is driven by a clear analysis of the GPs working day. On average, GPs do 7 different jobs.

Categorisation of GP workstreams

Patient facing, GP most appropriate clinician

Serious illness, clinical assessment and diagnosis needed, deteriorating long term conditions, complex multiple co-morbidities especially co-existing severe physical and mental health illness

All requests to see a GP are dealt with initially by a GP or ANP phone consultation.

PC24 has a 20-year track record of delivering OOH services where all calls are assessed initially by phone, so we are confident in providing care remotely. Around 75% cases can be managed safely and effectively, with strong patient satisfaction, without seeing the patient. However, this confidence is not uniform across general practice.

 

For clarity, this is not triage, it is remote patient consultation. This model is the basis of successful services like Babylon but there has been inconsistent wider adoption. It is well received especially for younger and healthy people.

It needs high degree of expertise at the front of the system (GP or ANP) This allows clinical risk to be assessed and absorbed at first clinical contact.

By contrast, the 111 system is risk averse. It is underpinned by the NHS Pathways algorithms which are administered by non-clinicians. Also, algorithmic diagnosis is limited in its effectiveness as its fundamental yes/no approach does not replicate the clinical diagnostic approach used by doctors (largely complex pattern recognition approach with assessment of ‘human’ factors.) Lack of current access to GPs is leading to patients ‘wandering’ round the system, seeking the appropriate level of clinical expertise.

 

 

 

 

Patient facing, GP not most appropriate clinician

Most of minor illness, social problems, mild/moderate mental health problems, stable long-term conditions, musculoskeletal conditions most health screening forms.

Serious cases can be escalated to the GP.

These patients are best managed by other healthcare professionals eg ANPs, ACPs, social workers, social prescribers, practice nurses, sports therapists and physiotherapists, care coordinators, mental health practitioners. This reflects the high professional standards in the allied health professions.

Non patient facing, GP most appropriate clinician

Abnormal test results (the system flags abnormal results), tasks generated by other MDT members, referrals

Non patient facing, GP not most appropriate clinician

All medication related activity, normal test results, forms only requesting information from patient record

All non-patient facing work is generated through the NHS software systems (NHS spine) and therefore easily accessible to clinicians with NHS log in rights.

All non-patient facing work is done remotely and flexibly. This is popular with GPs and is coordinated centrally. The GPs seeing patients face-to-face do not do any other work, reducing stress and increasing job satisfaction.

The practice-based MDTs are supported by the PCN ARRS roles and provide a structure which allows for coordination across PCNs.

 

 

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

 

HMG plans are good.

Although PCNs are demonstrably successful, they remain immature and implementation is hampered by needing to work across many and varied individual general practices. GP Federations are variable in effectiveness.

 

 

The ARRs roles are excellent and welcome. However, ‘lifting and shifting’ people into general practice usually needs investment by GPs in mentoring. This lack of capacity to ‘sign off’ is slowing movement of allied health professionals into the ARRs roles. Primary care lacks access to the large education and training teams, and HR frameworks, which underpin secondary care.

There is also the significant risk of depleting secondary care of staff and HMG leadership is needed to ensure system collaboration.

 

 

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

Impact 1: Much demand is redirected to 111 and the CAS and increased demand in the OOH services

Although it is obvious that limited access to one area of the system will lead to increased pressure in other parts, it is difficult to accurately quantify where and when this occurs.

The biggest increase in 111 has been in hours. However, this effectively increases access to general practice (where general practices have collaborated) via direct booking. Patients may be choosing 111 over directly contacting their practice.

The increase in 111 activity in the OOH period is leading to increased demand in the OOH services. This is an area where patient demand and flow can be quantified and OOH services such as PC24 can evidence a 30% increase in demand compared to pre-pandemic activity.

Impact 2; potentially increased demand on walk in centres

There is a potentially increased demand on WICs although many WIC have a triage first model and actual evidence is hard to obtain.

 

 

 

 

Impact 3; potentially increased demand on A&E departments

           There is potentially increased A&E attendance although actual evidence of this is hard to get. Possibly, people choosing to go to A&E are iller (and therefore attendance is appropriate). However, this may not be true for children as there is anecdotal evidence that parents/carers have lost confidence and now have a lower threshold for seeking medical care.

Impact 4: There is an increase in anxiety in some patients

This is fuelled by unhelpful media coverage. In fact, the change to access is a good news story. Digital access gives people more choice about how they interact with their GP and a face-to-face consultation is always an option. There are more patient-GP interactions overall than pre-pandemic but demand is not being matched and individual patient preferences not factored in (see above relating to digital barriers and locked surgeries)

Impact 5: increased patient complaints

Overall people are more likely to complain about lack of access and to escalate their complaints.

Impact 6: people may be put off from seeking care, leading to delayed diagnosis

There is evidence that this occurred in lockdown eg cancer treatment rates declined. However, in many situations, it is difficult to quantify the relationship of when a person seeks medical care and the ultimate clinical outcome.

Impact 7: duplication of investigations as people try to access healthcare at different points in the system

When people are unable to access their GP, they often re-direct themselves elsewhere in the system eg A&E, OOH. The interaction there will often lead to an investigation or even the initiation of a care pathway. There is insufficient systems operability to enable all this care to be coordinated so there is the potential for suboptimal and inefficient care, with the GP being not being sufficiently involved and increasing patient anxiety.

 

 

 

 

 

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?

The value of continuity of care is greatest for people with severe illness and complex multi-morbidities and in fact is best served by an MDT lead by the expert generalist GP. The main beneficiaries are frail elderly (numbers increasing disproportionately), people needing end-of-life care and younger people with complex lives (including severe mental illness, substance misuse and disproportionately affecting men), chronic pain and other challenging medical and social problems.

Having continuity of care for the right patients improves the care delivered, builds important therapeutic relationships, reduces hospital admissions and provides GP professional satisfaction. It supports the patient, their family and the whole community.

A key new ARRS role in providing continuity of care is the care coordinator. This frees the GP to practice clinical medicine and acknowledges the complexity of the system for patients.

Continuity of care is a valuable resource and must be used in a proportionate and time limited way.

 

 

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

Challenge 1 increased clinical demand

There is an increased overall demand from the ‘baby boom’ generation but especially a disproportionate increase in the frail elderly with complex needs. This will continue to increase.

Additionally, there is increased demand related to covid. Unmet need has built up, (delayed cancer diagnosis, increased suicides (especially in men) and drug overdoses, worsening mental health, obesity and substance/alcohol misuse.)

The burden of long covid is yet to be quantified and the impact of future pandemics is unknown.

 

 

 

Challenge 2 increased demand related to climate change

There will be more asylum seekers as populations are displaced globally (in addition to effects of war). There will also be increased demand related to changes in temperature (extreme heat) and the more nebulous but real fear in people as we try to face the existential implications of climate change.

Challenge 3 Lack of recruitment of young doctors

There are numerous factors contributing to this

 

 

 

 

 

 

 

 

 

 

 

 

 

Challenge 4 the salaried model for GPs is weak

 

This is closely linked to recruitment (above).

Salaried GPs are employed by the GP partners (rather than an organisation like a trust) They are not protected by AfC which contributes to instability in the overall jobs market due to differences in terms and conditions between even neighbouring practices. Salaried GPs do not benefit from the professional support available to hospital doctors and often don’t feel ‘part of a team’. This is even more true for

 

nurses. Salaried GPs also don’t benefit from having HR support (available in Trusts), their only source of support being the BMA.

Strengthening the overall salaried offer would be a positive step but it is difficult to see how this can be achieved within the current GMS contract.

 

Challenge 5 not enough medical graduates want to be GPs

 

Over the last 40 years both new medical schools have been established and there has been a massive increase in the numbers of medical undergraduates in the established schools. This has not translated into increased numbers of GPs. Data on what medical graduates do is extremely hard to find. However, it seems that there is both a significant drop out of medical graduates who don’t continue to registration and then a further significant drop out of registered doctors who don’t go on to any specialist training. It is also unclear what proportion of registered doctors choose general practice.

 

This is compounded by a lack of NHS clinical workforce planning which looks across the whole system and specifically, lack of planning for primary care.

 

An additional factor is that training practices are more attractive as places of employment for new GPs than non-training practices. This means that recruitment challenges in general practice are not uniform with training practices (and now HEE training Hubs) proactively recruiting their own trainees. There is no current system wide approach to rebalance this situation.

Challenge 6 the practice nursing workforce is in decline

There is no clear training pathway for practice nurses/HCAs with individual areas being left to develop piecemeal solutions. The lack of primary care workforce planning impacts particularly the nursing workforce as it is unclear how evolving roles eg HCAs and nursing associates fit in to primary care. A major barrier is that primary care does not match AfC terms and conditions (although we have done this in PC24).

 

Challenge 7 limitations of IT

Despite massive investment, IT capacity in primary care is inadequate. Internet access, system interoperability and resilience of the IT teams are all limited.

EMIS data capture is poor and does not allow for good patient data, help future modelling or integrated working.

Challenge 8 what purposes does society want general practice to address?

Overall, society and general practice itself are unclear what is the purpose of general practice in 2021. Although it seems to be about ‘seeing the doctor’ in fact general practices function more like a community resource providing healthcare, social care, administrative and social support.

General practice could be reshaped to embrace this holistic purpose as has been done in some Vanguard sites eg opening a café, having a herb garden, offering other treatments as well as providing clinical care. This would mean a paradigm shift in what a general practice looks like but would also potentially re-purpose and re-invigorate general practice and primary care. These community focused centres would advance inclusion and integration at all levels of society.

Challenge 9 adapting to working at scale

General practice has a culture of independent contractors working within but separate from the NHS system. General practice risks being left behind in the ICS development and becoming a silo if there are insufficient leaders who can advocate for general practice. Primary care lacks the overall structures to give a strong mandate or corporate teams support the GP representatives.

Challenge 10 Brexit

The effect of Brexit in terms of staffing is already observable with European GPs leaving the UK. The effect on supply chains is unclear.

 

 

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

The inverse care law continues to play out with areas of social deprivation and poor education continuing to have fewer resources overall than their more affluent neighbours. This includes infrastructure like public transport but also access to secondary and tertiary care.

 

There is significant variation even within adjacent urban areas as practices are individual businesses who have evolved differently over the last 60 years. This lack of uniformity contributes to unwarranted variation in care.

This is playing out with PCNs but to a lesser degree as they are more integrated parts of the whole system. To a large degree inequality in PCN development reflects the pre-existing inequalities in general practice capacity.

Estate is very variable in size and quality, even within one city region and much general practice is being provided from legacy estate with no realistic prospect of change soon. This limits the scope of services. In addition, there is often unhelpful ‘competition’ for space.

IT support also varies considerably even across neighbouring CCGs. It is possible that the ICSs can address some of these local unwarranted variations.

The overall effect is exacerbation of existing health inequalities, already worsened by the pandemic.

 

 

What part should general practice play in the prevention agenda?

Potentially general practice can play a significant part in the prevention agenda especially in relation to obesity, alcohol (and substance misuse more widely) and smoking. If every person with type 2 diabetes reduced their BMI by 10%, there would be significant positive health outcomes and reduced NHS costs. It is useful to look at all three of these problems through an addiction medicine lens.

A successful model of substance misuse here on Merseyside is our shared care system which involves over 30 Liverpool practices caring for heroin users with keyworkers from a specialist agency. This model can be adapted for weight loss and alcohol dependency. Bringing specialist expertise into primary care is an effective model which upskills primary care clinicians and provides holistic care for patients in their own community. It also enables other services to be ‘anchored’ to the point where patients reliably access the system eg having mental health practitioners, literacy workers, social prescribers and exercise therapists working alongside the smoking cessation, alcohol and weight loss teams.

Addressing these 3 issues will have a positive impact on all long-term conditions (cardiorespiratory, mental health, stroke and type 2 diabetes and reducing A&E attendance (substance misusers and alcoholics attend A&E disproportionately)

 

 

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

Solution1 embrace GPs into the wider system

Overall, GPs need to feel part of the wider system and the primary-secondary care silo needs to be challenged. This can only be done at scale with GPs working as part of much bigger organisations. This integration (either horizontal or vertical) would enable GPs to feel valued and ‘heard’

Solution2 strengthen primary care clinical leadership to reach across the NHS-GMS divide

General practice needs additional leadership with is neither academic nor political. This would appeal particularly to younger GPs.

Solution3 establish a system which ensures GPs see only the patients who need the expert-generalist level of skill (see above for Clinical Hub model)

GPs don’t control who they see, they are dependent on the system they work in (be it a practice, OOH service etc). By leaving GPs to see people with clinical conditions (and many non-clinical conditions) which do not require the expertise of an expert generalist, the underlying message is that the overall system does not value GP skills. No one would expect a neurosurgeon to remove a splinter.

Solution 4 develop the GP with special interest model

Many GPs reach a point in their careers when they are looking for something different. The overall system doesn’t support GPs with career development but GPwSI allows development of new clinical skills and exposure to the wider system. This includes primary care clinical leadership training, an area which suffers from chronic underinvestment. These roles are already well established in some clinical areas eg substance misuse, diabetes, sports medicine but there is considerable potential to develop this model both in terms of scale and clinical areas.

Solution5 widespread support to promote general practice and expert generalist care as the intellectually challenging and exciting area of clinical practice which it is

Support from the RCGP and GMC to explain general practice and expert generalist care as being as intellectually challenging and of equal value to specialist care. This needs to be supported by strong NHSe and HEE primary care leadership

 

 

 

 

Solution 6 ensure developments in primary care are perceived as equally relevant and exciting as disease-specific breakthroughs

Increasing research investment in primary care and getting it the same ‘airtime’ as developments in secondary care would change the perception of general practice to be a cutting-edge clinical area

Solution7 build on the success of Covid vaccination programme

This success is a unique opportunity to demonstrate the scale and strength of what general practice can achieve.

Solution8 increased vertical and horizontal integration

Although politically controversial in some quarters, increasing vertical integration with acute trusts running some general practices would be attractive for some GPs. Alternatively at scale horizontal integration can deliver increased capacity and new models of working.

Solution9 challenge scapegoating of GPs in the media, and support zero tolerance for patient abuse

Both address the wider relationship between GPs and society. Many GPs are unhappy with the adversarial approach of the BMA (a trades union) but there is no coherent alternative voice. However, negative media campaigns are unhelpful and undermine the overall positive relationship between society and GPs.

 

 

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

 

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

The traditional partnership model is based on the GMS contract (independent contractor status).

There has been an equilibrium in the system simply because the GMS contract has been in place since 1948. However, in the last 30 years it has become increasingly unattractive. This is despite the contract having no end date, generating a guaranteed minimum income and GPs having no actual competition.

 

Most GPs are not GMS contract holders (probably about 45% hold a GMS contract but accurate figures are hard to obtain) and having a GMS contract is strongly correlated with age. In younger age groups it is exceptional to hold a GMS contract and there is little appetite to take on existing contracts.

There is also increasing anecdotal evidence that Gen Z values are not aligned to the profit-making partnership model.

GP practices are not sustainable as small list size practices. However, the current contractual model doesn’t enable mergers and acquisitions where there is a different contract type eg APMS and PMS. This not only limits the ability of general practice to develop organisationally (it is largely ‘stuck’ with the GMS model) but also limits the ability of general practice to develop creative and adaptive responses to providing patient care, with onward negative effects on recruitment (see above).

 

One solution is a move to all being APMS. However, these APMS contracts would have to have equivalent income, long term contracts and a simplified procurement process (all possible).

 

The GMS contract is strongly defended by the BMA and the local LMCs. It is debatable how representative the GPC is of the wider general practice community with salaried and locum GPs being poorly represented by comparison to the GMS contract holders.

 

A key plank in the BMAs defence is that other contacts would ‘lead to privatisation’. This position has struggled to accommodate the partnership profit making (and bonus paying) aspect of the GMS partnership model of running a business.

The partnership model forces GP partners to prioritise the practice profit and much innovation costs the practice money. This means that there is on going tension with the demands of the wider system, developing innovative models of patient care and the GMS contract is therefore a barrier to integrated systems working.

Most practices are small organisations which have not needed to develop corporate functions. This especially includes HR. GP partners are employing salaried GPs without the protection of AfC and this is leading to many salaried GPs resigning to become locums. Although the remuneration is higher, the individual doctor is more separate from the whole system and our experience is that many are interested in salaried or hybrid models of working if they feel adequately supported.

An additional factor will be how IR35 legislation impacts the locum GP market.

GP partners are now working to maintain basic services with diminishing support from salaried GPs and increased reliance on locum GPs. It is doubtful whether this can continue and GP partners are increasingly looking isolated in the whole system.

 

 

Many GP partners are privately accepting that the future of the GMS contract is uncertain. The workload is increasing in amount and complexity. However, the current demand of GPC to ‘limit work’ is in tension with a self-employed contract. The only viable GMS model is a very large practice with a few managing partners and many salaried GPs. However, without adequate HR systems (and AfC) these may also not be sustainable.

Practice premises

The GMS partnership model often (although not always) includes ownership of the practice premises and profit from the cost-rent scheme. This embeds inequality within the overall system and is a significant underlying reason why the GMS contract is defended so strongly. A move away from this system to all general practice being delivered from NHS owned estate would be a powerful driver to physical and systems integration.

Considering all factors, the GMS contract is unsustainable. GPs should be aligned to the rest of the NHS medical workforce, not working in separate for-profit businesses where integration and collaboration is continually undermined by the necessity to maximise profit.

Role of not-for-profit organisations

PC24 is unusual in being a not-for-profit social enterprise providing a wide range of primary care including general practices and the out-of-hours service across north Mersey. In this model, all our surplus is reinvested in patient care and this enables us to develop innovative and develop adaptive responses to the challenges facing general practice (and wider primary care). We are currently ‘turning round’ 7 small failing practices in south Sefton (list 21000) even within the limits of the APMS contract and challenging estate (merging the list, new telephony, new clinical model) However, we can do this whereas a GMS contract cannot address the increasing problem of practices who have failed under the GMS system.

 

 

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

The current systems encourage proactive and personalised care for the named LTCs and public health programmes eg vaccination. They disincentivise care of any LTC outside this eg long covid where a new service has had to be commissioned. They don’t address coordination and integration. This is a legacy of the Red Book item of service approach.

 

 

There is a strong argument that this reductionist approach to clinical care is inimical to integration and coordination. It has reinforced a clinical and admin approach which is focused on detail rather than looking taking a holistic view of care.

It has also undermined clinical judgement by straight jacketing clinical decision making. Even within evidence-based care (mostly developed in secondary care) but widely supported and adopted in primary care, there should be the scope for an individualised approach to decision making. This is reflected in the NHS thinking around values based healthcare and shared decision making.

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

Its too early to say. However, there are a few reasons to be cheerful. PCNs have the potential to employ a general practice workforce which can provide flexible clinical and non-clinical services at scale. There are already successes in the Covid vaccine programmes, clinical pharmacists, social prescribers and the other ARRS roles and in improving care home and visiting services.

PCNs must get to the next stage (become incorporated) and establish robust corporate infrastructures. This involves an understanding of how organisations work which is challenging for many in general practice simply because most general practices are not sufficiently large. In addition, local relationship issues may block development. However, many PCNs will succeed but on-going leadership from NHSe/I will be key.

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?

Effective partnerships with other professions are limited within the GMS contract as other professions are employed by the GP. However, within this contractual arrangement, there are examples of good co-working but this is at practice level and there hasn’t been a process to scale this up.

Employing other professionals reduces practice profit so GPs generally want the other professionals to be employed within the wider NHS. This disconnect between NHS employment (generally by a Trust) and working in an independent practice also limits the effectiveness of ‘partnership’ working.

 

 

 

 

PCNs have addressed this by getting direct funding into primary care and providing the structure for delivery at scale and our own experience has largely been very positive.

 

 

An overlooked aspect of digital access and the development of PCNs is the positive contribution to sustainability and the aspirations of the NHS to become carbon neutral as digital access reduces carbon footprint.

There is also the opportunity to support people to be more confidant to self-care. The NHS site (plus many others) is excellent and could be promoted more as the place to get reliable healthcare advice.

Abbreviations

Primary Care 24 PC24

General practitioner GP

MDT multidisciplinary team

ANP advanced nurse practitioner

ACP advanced clinical practitioner (includes paramedics)

PCN primary care network

ARR additional roles reimbursement scheme

HR human resources

CAS clinical assessment service

OOH out-of-hours

WIC walk in centre

A&E accident and emergency

AfC agenda for change

BMA British Medical Association

HCA health care assistant

ICS integrated care system

BMI body mass index

GPwSI GP with special interest

RCGP Royal College of General Practitioners

GMC General Medical Council

 

HEE Health Education England

GMS General Medical Services (contract)

APMS alternative provider of medical services

PMS personal medical services

LMC local medical committee

GPC general practitioners committee

LTC long term condition     

  END

 

Dec 2021