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Written evidence submitted by Thurleigh Road Practice (FGP0371)

We are a GP surgery in South London consisting of seven partners (five GPs, one Advanced Nurse Practitioner Partner and one management Partner) and a team of salaried GPs, nurses and allied healthcare professionals serving a population of over 14000 patients. We would like to submit evidence from our perspective as ordinary, frontline GPs.
 

What are the main barriers to accessing general practice and how can these be
tackled?
 Demand hugely outstrips supply. Patients recourse to contacting primary care has
 vastly increased with average consultation levels increasing six-fold. Meanwhile, our
 workloads have changed with us managing increasing areas of secondary care and
 complex care work and an expectation that we are also managing emergency care
 alongside chronic disease management and routine demand. Primary care is not a
 limitless resource; spiralling demands and heavy workloads are taking their
 toll. Every other area of the NHS can manage its workload and as a result we
 are absorbing more and more with no acknowledgement of the impact on the
 service. No one measures the complexity of the cases we manage and there has been
 a subtle but overwhelming transfer of hospital work to primary care (eg menopause
 management and mental health support) without the staff, funding or time to do this.  In hospital, clinicians have an hour for new menopause cases and a clearly defined workload whereas we have ten minutes for this work and endless demand and case numbers. In A&E a clinician can spend an hour with an acutely unwell patient but GPs have ten minutes.   The ten minute consultation is no longer fit for purpose and the only reason this is not changed is the recognition that this would limit our work load which currently is
 endless. It is a short-sighted view, as the ability to properly manage cases would mean less impact further down the line. 

Another major challenge is staffing; a lack of reception/administrative staff to answer the phones and deal with queries. Recruitment and retention is very poor and a lot of staff have left due to the levels of abuse they face from patients. It is very stressful.

To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?
It has sent mixed messages to patients; pitting patients and practices against each other when actually we are all on the same side. We are in the middle of a pandemic and to focus on patient preference rather than clinical need has caused a lot of issues and tensions and not helped the practice-patient relationship. It has unfortunately seemed to fuel a lot more frustration within our practice population which has often manifested into aggressive and/or verbal abuse to our staff. With the advance of the omicron variant now it just does not make sense to encourage more people to come for face to face consultations when many of these can be done remotely. Ofcourse if there is a clinical need or the patient insists they can be seen but we do not feel it is safe to have the same volumes of patients in the practice as pre pandemic levels. In terms of supporting general practice, as said above it has actually caused more tension. In our opinion, the threat of more punitive measures should a practice be deemed to be performing ‘poorly’ (e.g with the plans to expose the worst performing” practices) and the relentless media attacks on GPs constitute a moral injury to our profession. 

NHSE does not acknowledge the workforce issues that underpin the problems within primary care. We do not have clinician capacity to meet some of these expectations. Also we have issues in terms of physical space especially because of accommodating the ARRS (additional roles and reimbursement scheme) roles and even with hybrid ways of working (remote and in office) this remains a challenge.
 

What are the impacts when patients are unable to access general practice using their preferred method?
The best way to answer this is to qualify the purpose of the access. Currently work streams are not formally separated so GPs have to provide emergency access and care alongside routine access and chronic disease monitoring (learning difficulty, entire spectrum of chronic disease and illnesses, mental health, cardiovascular, neurological eg MS, epilepsy etc). Trying to satisfy all these work streams in the same queue is part of the problem and our roles and workload need to be redefined and clarified for practices and patients alike as currently the demand is unsustainable, yet the expectation that we will be all things to all people is fuelled and until the limitations are openly aired and addressed, workload will continue to soar and retention of staff decline. Work streams, roles and finite workloads need to be stabilised as a matter of urgency. It may be unpalatable politically but the current service nationally is not meeting patients needs and so the time is ripe for this discussion, before services collapse.

Usually when it is explained to patients that they will first have a telephone consultation to review their issue and then if necessary they can be seen face to face, they do understand this. It is about patient safety and reducing the risks to everyone but especially the vulnerable, that we cannot have everyone coming in for face to face reviews. We have an active patient group who are very supportive and helpful in disseminating information to patients. More collaboration between practices and patients is needed. We are not shirking work or refusing to see patients; we are having to adapt to a rapidly changing environment and with the emergence of new variants etc it is imperative that we get genuine support instead of criticism and veiled threats from NHSE.


 

 

 

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?
This is crucial for continuity of care and the preferred way of working for our team too. However due to levels of sickness and staff shortages it is not always possible to achieve this and that is where interprofessional communication is key so that patients do not lose out if they do see a different clinician from time to time.

Having a named GP in the context of chronic/ongoing issues is much more important than for acute consultations and it may be helpful to highlight this to patients where possible.
The reality is that NHSE has prioritised access over continuity yet placed a requirement for a named GP on surgeries. There is no longer the ability to provide continuity of care with limited routine appointments due to enormous and overwhelming demand. Unless the value of true continuity of care is recognised and prioritised this concept of having a named GP remains farcical and misleading for patients.

 What are the main challenges facing general practice in the next 5 years?
Retention and recruitment of GPs and nurses due to stress and burnout; we are seeing a lot of negative media coverage of GP and frankly this is putting off potential new recruits and also adding to the stress levels for those of us working in GP so that staff are considering leaving or retiring early. Also the mandatory vaccinations for staff (especially admin) means we have to let go of significant numbers of our team; this is very distressing and we would question the basis for this especially when vaccines do not prevent transmission and if staff are wearing PPE then we are mitigating against transmission. This will cause a crisis in our workforce.

Increase demand and expectation from patients; many people quite rightly expect a very high level of service but unfortunately we do not have the resources to meet that.
Increasing demands and expectations on GPs with no recognition of the same; we are taking on more specialised and complex work as secondary care turns down referrals.
We are for example managing;
1) High risk adolescent mental health cases in ten minute appointments and
2) We are expected to provide general menopause management and care equivalent to that
given in secondary care menopause clinics (with two year + waiting lists and a move to telephone consultations in hospital clinics, we are absorbing and taking on this work at time when we are already overwhelmed- with no additional time or funding for the work, or acknowledgement of the impact of this work load on other work).
3) Premature postnatal discharge with all the complications involved. A local hospital discharges patients one day post caesarian section with no information regarding feeding support and only remote health visitor input. So postnatal depression, physical complications etc have all increased and we are having to manage that. 
4) Increasing secondary care workload absorption via a subtle but enormous shift as we have no capacity to turn down requests for appointments (unlike secondary care) and no defined workload limits so are expected to absorb endless demand. There is also pressure to reduce referrals to secondary care in general.  The whole purpose for us referring to secondary care is that we feel that the patient is in need of specialist input and assessment. It is unsafe and unfair for patients and for us to have to ‘hold them’ in primary care when we have clearly made the decision that the help they needs has gone beyond our expertise and capabilities.
This is further stoked politically so that the expectations of patients for their care are unrealistic but there is no open acknowledgment of limitations of the NATIONAL health service - no differentiation between urgent and routine (same day access encouraged for all), no recognition of limitations of wider services. There needs to be an open, honest, wider national debate about what the NHS can and cannot provide as there definitely is rationing but this is not openly acknowledged.

Physical space/ventilation issues; with the era of covid and the fact that we will have to learn to live with this virus we need an urgent review into long term strategies to make our buildings safer eg a review on ventilation and air quality. The WHO has published a roadmap on ventilation and we have repeatedly asked NHS estates but not heard back from them. Schools have been given (quite rightly) CO2 monitors to check air quality but GPs have not been offered this. Furthermore even with CO2 monitors one needs to know what measures to take to improve ventilation eg structural issues around windows and ventilation systems.  We feel that this is being brushed under the carpet as there will be a cost associated with this. 

Funding/finances (as detailed in the question on contracting/payment systems below). 

How does regional variation shape the challenges facing general practice in different parts of England, including rural areas?
We are a suburban GP surgery so cannot really comment on what happens in rural areas. However, we would say that although the Carr Hill equation is used to calculate levels of deprivation and need, for a practice such as ours, which is in a relatively well to do area that does not cover certain needs”, we feel unfairly treated.  We have a high population of new mums and levels of postnatal depression, anxiety and women’s health issues eg perimenopausal women and we do not have the resources to deal with these needs. Given the relatively affluent patient population that we have, a lot of our needs are often underestimated (e.g. our need for drug and alcohol liaison support). Our practice population’s needs may be different to a more deprived area but that does not diminish the impact of those needs on quality of life, health and illness.
 

What part should general practice play in the prevention agenda?
It has an important part to play but all we can do for the foreseeable future is firefight and the workforce is exhausted and demoralised.

What can be done to reduce bureaucracy and burnout, and improve morale, in general practice?
End farcical CQC investigations which are punitive and draining in terms of time and finances; there are other truly supportive ways of doing these checks and the work is duplicated by CCG teams. Every member of GP teams across the country have uniformly complained about this but are all ignored.

Appraisals and revalidation - there has been some improvement with the new “appraisal light” system but if these work streams can be deferred for a year it is clear they are not helpful or essential and the work is duplicated in house.

Please listen to and work with GPs. The constant media attacks/playing politics does not help and has made things a lot worse. It is important to be transparent about the issues within the NHS throughout (e.g. backlogs in secondary care, the issues with community services, the problems within the social care sector that has an impact on the NHS). This is not about blaming others however it is imperative to try and help the public understand that the issues lie beyond the GPs who it seems are often scapegoated for the failings of the system as a whole. Genuine support is needed for practices to be resilient and more patient education on self management.

We need support in dealing with an avalanche of patient complaints; in spite of the fact that we are in the midst of a global pandemic and are trying to do our best to keep everyone safe, we have been receiving a barrage of complaints and this is extremely demoralising and time consuming to deal with

 

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?
Yes we think the partnership model is key to GP. It engenders a sense of ownership, autonomy and authority which many GPs aspire to, though this has been eroded over recent years with the loss of our ability to create local work streams and services specific to our population and a wider aim to create “equal services” (which is impossible) which effectively means dumbing down to the lowest common denominator eg we are not able to provide a minor injuries service for our patients as other surgeries in the borough could not offer the same service to their patients – this to us does not make sense. 

We love being the gatekeepers for our patients’ health and want to take responsibility for doing that. It is more than a job for us and we do not want the partnership model to be diluted or abolished. It gives GPs a sense of something to work towards professionally. There is a role for salaried posts too but not as a replacement for partnerships. The two go hand in hand. We work in a multi- disciplinary partnership which has advantages too.


Do the current contracting and payment systems in general practice encourage proactive, personalised, coordinated and integrated care?
No.  The issue of weighted versus actual patient population and what is paid for in the core funding is huge. In our practice 2904 patients (20% of practice population) are unfunded. This discrepancy is widening, unsustainable and unfair.  It does not reflect the huge and complex workload and the numbers of consultations we are carrying out. There is overwhelming evidence that consultation rates have dramatically increased yet with fewer GPs we are expected to provide a workload on average four times greater than normal. This is unsustainable.

The ever-changing goalposts in terms of the different enhanced services, contracts and targets that we are supposed to be providing/meeting is very chaotic and does not allow us to plan for the long term. It is very short term thinking.  A lot of our income comes from these enhanced services.  When systems have been put in place to provide a certain level of care for our patients in response to such services/contracts, it is likely that in the next year this will be completely scrapped and we are back to square one. This creates an unnecessary workload burden on practices whereby their efforts then ultimately go to waste and does not allow for adequate financial planning.


Has the development of Primary Care Networks improved the delivery of proactive, personalised, coordinated and integrated care and reduced the administrative burden on GPs?
PCNs have not been demonstrated to improve patient care at all and are proving to be another layer of bureaucracy, micro management and monitoring for NHSE. The ARRS roles can be helpful but the terms are very rigid and there is virtually no flexibility. Apart from the pharmacist role, we were not able to be involved in the recruitment process for the other posts. Given that they would be working closely with us and our patient population, it would be helpful for us to be able to give our input into recruitment. We have experienced enormous variation in the quality of staff recruited to roles. The opportunity to employ an adolescent or younger adults psychologist would have been more useful for us.

We do not want to lose our individuality as practices. Although we have provided covid vaccines via the PCN model, local practices were already working closely together and PCNs were not needed to facilitate this and in fact this took staff away from day-to-day work.


 

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?
Unfortunately in our experience it has not freed up more time. We have ever increasing expectations and many people still want to speak with a GP. Improving lines of communication with secondary care is key and also with community services which has been problematic.  CCGs are less localised and more distant. Options to provide private services in GP should be available (where services are not available on the NHS).

                                                                                                                                                          Dec 2021