Written evidence submitted by Brenda Allan, Alan Morton & Rod Wells (FGP0377)

We are a group of patients  in north London, concerned about the crisis engulfing general practice, and have ideas about how this could be tackled.

  1. Barriers to access

The barriers are resource driven and attitudinal. The latter appears reflected in the Committee’s call for evidence. We worry that the short timescales, 16/11 to 14/12, and lack of publicity, or obligation to effectively inform organisations representing patients, local authorities, and other partners, will result in a narrower  response, less likely to deliver a patient orientated service. This is a lost opportunity,  and we hope that the deadline can be extended and publicised.

Effectiveness of NHSE’s plan

 

  1. Challenges for the next 5 years

These are long term underfunding, serious workforce shortages, coping with the continuing pandemic and its legacy of unmet need, escalating workloads, lack of capacity in allied services,  low morale, loss of influence, privatisation, and government policy.  Somehow the government must be persuaded that investment in the NHS and services impacting the social determinants of health,  is infrastructure investment, essential for the economy as well as health, providing immediate increases in employment and therefore tax revenues. It needs to publicly support General Practice rather than issuing threats, and rapidly contradicted instructions.

 

The crisis is now so bad with LMCs reporting in August that some practices might close because of staffing and workload pressures that the only option now is for the NHS to buy its way out of trouble, with a massive and sustained investment in workforce, premises, and equipment; the most urgent is workforce, and that means funding. Tackling the backlog will be one of the major challenges for the next 5 years

 

Funding: a year’s worth of GP care per patient, costs less than two trips to A&E, so increasing GP’s proportion of NHS spend makes economic sense. Of the extra £60b funds apparently allocated the NHS between 2019/20 and 2020/21, about £47b went to the Test and Trace and PPE provision, i.e. not to the NHS and general practice, which has misled patients into thinking general practice is better resourced, and should be able to see them

Workforce: The Number of FTE GPs per 1000 population has decreased, with recruitment initiatives to encourage doctors into general practice and post graduate practice-based training places insufficient to meet replacement demand, let alone an increase. The commitment  to 6000 more GPs and 26000 more other primary care staff is outstanding, and must be delivered within  an annually reviewed workforce strategy.

Workload: under capacity and cuts to other services generates massive workload burdens for General Practice. Spending on most services impacting the social determinants of health – housing, education, employment, income, and the environment, has fallen substantially  (3). The grant to Local Authorities, for Public Health  has fallen by 15% from 2013/4 to 2019/20, and the pressures on social care, also spill over into the General Practice workload.

 

Primary/secondary care interface: There is an over emphasis on symptoms and pathways, rather than the whole patient, with referred patients often returned to primary care with negative test results, but with the same problem, or returned with a host of new tasks for primary care, for which it is under -resourced to deliver. It is too early to assess whether the 2021/22 NHS Standard Contract stipulation, that secondary care providers must address certain processes  that generate avoidable administrative burdens for  GPs, will improve the situation.

 

The reduction in general and ICU hospital beds has led to pressure on discharges with the UK having far fewer beds per head of  population in 2021 than comparable countries, and all year-round winter pressures,  with no spare capacityTransition from hospital to home results in nearly 20% adverse incidents for patients, including avoidable symptoms, additional A&E visits, hospital readmissions and death. (4). Earlier discharge and recovery at home to GP care is enshrined in Discharge to Assess and  included in the Health and Care Bill, with no allowance made for the parlous state of primary and social care.

Privatisation: there is a danger with the growth of APMS contracts, of primary care becoming like social care, a failing market, with heavily leveraged private companies, seeking opportunities to make quick, low risk profits and using loss leader strategies, until profits are made, and they sell, or quit because they cannot generate  sufficient profit, resulting in poor quality care, and provision instability. (See Q8).

Private providers on APMS contracts are also offered more money for provision than the NHS GMS/PMS practices for the same service.

 

Influence: in the new ICS structure proposed in the Health & Care Bill,  GPs have only one seat on the ICS Board. They need to be given much greater representation on all the ICS committees to play  a major role in shaping local healthcare.

 

3. Regional variation challenges

4. Role in prevention

        Reducing workload is key to improving staff retention and  morale. More needs to be done urgently, and on a sustainable basis, to speed waiting times for GP appointments, either telephone or face to face, and reduce waiting times for secondary referrals. This requires increased capacity and workforce in primary and secondary care.

 

6. The future

There needs to be a major review of primary care, to ensure it has a far more central role, with an expanded remit, fully resourced and skilled up, to undertake a wider preventive role addressing health inequalities, some of the work now referred to secondary care, e.g. outpatients (tests, initial consultations), and that of  some of the services established to relieve pressures on A&E and provide instant access to a GP service. These resources should be (re)invested in primary care to provide a one-stop shop model, to deliver local, timely, joined up healthcare, greater job satisfaction and opportunities to specialise and collaborate for primary care staff, and a better use of resources.

 

The boundary between primary and secondary care should be blurred with more services e,g. dermatology and muscular skeletal, diagnostic test centres and specialist clinics  and treatment, currently undertaken in hospital, transferred to primary care. More  specialists would be co- located in GP clusters, with GP generalist clinics in hospital.  This would reduce weighting times and inefficiencies.

 

With the proposals on the preventive agenda (see Q4), this would be a game changer for general practice, popular with patients and primary care staff, freeing secondary care for more complex cases, genuinely beyond the scope of a well-resourced primary care service, and securing better health outcomes.

 

7. Partnership model

 

8. Contracting and payment systems

We consider that General Practice  is more cost effective when the NHS is the default provider with GP run practices on GMS or PMS contracts, or salaried options. The introduction of APMS contracts opened the door for the Centene type takeovers, and one of these practices, previously rated good, has already been judged unsafe by the CQC. One of the difficulties for GP partnerships or even GP Federations when bidding for contracts, is that large private corporations produce deceptively polished tenders, and threaten, or actually sue, if they fail to win contracts. (See Q2) Research suggests that patient satisfaction levels are lower for very large and private company practices, as compared with smaller ‘NHS’ practices, so the type of primary care contract matters to patients. (9)

 

 

9. Primary Care Networks

PCNs were still new and developing their role when the pandemic arrived, and were trying to support practices with the covid restrictions,  escalating workload and vaccination programme. They would need greatly increased resourcing to deliver for practices. (See Q5)

 

10. Partnership with other professions

GPs are so overwhelmed, that the time to nurture relationships with other professionals or community groups seems minimal, and other professions also experience high turnover levels. There is a lack of capacity in many practices to successfully recruit,  induct, support, and integrate other staff, or assess the skill and seniority level required for them to work relatively independently. This could be a role for PCNs.

 

References

1.Goyal, DK et al. Restricted access to the NHS during the Covid 19 pandemic: is it time to move away from a rationed clinical response? The Lancet regional health – Europe https://doi.org/10.1016/jlanepe.2021.100201

2.Pereira Gray DJ, et al, Continuity of care with doctors -a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 2018. 10.1136/bmjopen-2017-021161.

3 .Kings Fund Jan 2021. Spending on public health

4.Ola Markiewicz et  al.  Threats to safe transitions from hospital to home : NW London primary care. BJGP 2020;70 9690

5. Health Foundation 2021. Levelling up in general practice in England

6. Commonwealth Fund, 2021. Mirror, Mirror: reflecting poorly.

7 .Doctors in UNITE, 2020, Public health and primary care

8  Kings Fund 2019. A review of the West Suffolk Buurtzorg test and learn in 2017-18.

9. Cowling TE et al. Contract and ownership type of general practices and patient experience in England: multilevel analysis of a national cross-sectional survey. JR Soc Med 2017;110:440-51.                                                                                                                                                                                                                                                                                                                                                                                                                                                          

 

Feb 2022

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