DOCTORS IN UNITE SUBMISSION ON THE FUTURE OF GENERAL PRACTICE TO THE PARLIAMENTARY HEALTH AND SOCIAL CARE COMMITTEE

The Health and Social Care Committee has launched an enquiry into the future of general practice, “examining the key challenges facing general practice over the next five years as well as the biggest current and ongoing barriers to access to general practice.” Further information can be found here. This is the submission Doctors in Unite have made to the enquiry.

Main barriers to accessing general practice and how can these be tackled

General practice is not synonymous with primary care, the primary care team is essential to General Practitioners being able to concentrate on the areas where they are especially skilled.

The major barrier to accessing general practice is quite simply that the system has been massively under-resourced for the job it is being asked to do.

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

It goes nowhere near what is needed.

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

They do not get the help they need.

They attend Accident and Emergency departments.

Excess non-Covid deaths observed during the pandemic.

Inequality in health grows.

Some patients may be distressed by not being able to access general practice in person at a time of their choice. This is sometimes unavoidable as the general practice resource has to be effectively rationed, and distributed in a needs based way. With effective triage systems this should cause no harm.

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?

Reference Norway study

The ability to develop long term relationships in general practice is essential for the full benefits of this speciality. Continuity is not needed for everything, but the greater the complexity of someone’s problems, the greater the value of continuity. Access systems need to be flexible enough to provide continuity where it is going to add value.

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

Keeping the show on the road.

In one Vocational Training Scheme in London last year 26 GPs were trained, but only 2 took up permanent GP posts. Retention is a huge problem both for younger GPs not taking up work or leaving the profession, and for older GPs retiring early.

Serious firefighting is needed now, or the remaining GPs will not be able to deliver the service and it will collapse, to the detriment of the whole health service.

It will be years before enough GPs come on line to handle the workload well. GPs and their teams know what would help them survive – ask them (via Local Medical Committees) and fund what is needed without targets – the target is the survival of General Practice as a speciality within the NHS.

One third of GP premises are no longer fit for purpose and have no space for expanding teams. There needs to be significant investment in premises.

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

 Each team will have its own needs for survival, for example some may need more receptionists, with good training provided, some will need more secretarial and administrative staff, some will need new phone systems, all will need high quality IT systems including rapid IT support. The recruitment situation in each area will differ, some may have been unable to recruit nurses, but can recruit physiotherapists, others can recruit paramedics but not mental health workers.

What part should general practice play in the prevention agenda?

General Practice, within the primary care team, is just one cog in the big wheel of the wider societal promotion of good health, and prevention of ill health. Public health input is fundamental to the planning of services, and national policies that combat poverty, and loneliness, procure decent housing, reduce pollution, stop climate destruction, facilitate exercise and enable healthy diets are vital. General practice can not prevent mental ill health, or provide conditions in which those who are vulnerable, disabled or suffer from complex multi-morbidities can lead fulfilling lives whether in or out of work. If Governments are serious about the prevention agenda, then tackling the social determinants of ill-health is essential.

General Practice can work with others to the make the best use of local opportunities to provide help and support, but it is no good having a Social Prescriber when the support services that used to be provided by Local Authorities have been cut to destruction.

General Practitioners are well placed to pick up early problems of illnesses, and, in partnership with patients, help to prevent some of the complications of longterm illness, for example in Diabetes management.

General Practitioners can also protect patients from over-investigation and over-medicalisation of their problems, through judicious and personalised use of investigations, referrals and treatments.

The development of a National Occupational Health Service would potentially make a big difference to the ability of workplaces to be places that contribute to the health promotion and ill-health prevention agenda, and would have a reach beyond that available to general practice.

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

There would be a huge difference if QOF targets and incentive schemes and routine inspections were immediately suspended until a new contract can be agreed.

Pension taxation issues for General Practitioners approaching the lifetime allowance need to be sorted.

NHSE and Government messaging must switch to supporting the incredible work of GPs and the primary health care teams, instead of the current scapegoating.

Restoration of Local Authority cutbacks so support services could be reinstated.

Boosting NHS secondary care capacity for the long term, with investment to meet predicted needs, rather than short term funding of cherry picked private secondary care.

Significantly improve mental health resourcing.

Fund secretarial support for Consultant colleagues so that direct communication is easier (this is the sort of thing that makes a real difference to “integrated care” rather than a whole NHS reorganisation)

How can the current model of general practice be improved to make it more sustainable in the longterm 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 has become increasingly problematic as the available funding has been restricted, and increasingly tied to attaining targets that may not be relevant or achievable in some populations. It has had the great strengths of encouraging long-term commitment to a population, and innovation, although these do not depend on the contractual mechanism, but can be facilitated by appropriate organisational culture.

In the present climate we believe that the Independent Contractor option needs to remain, with a significantly improved contract offer, to prevent a huge loss of current GPs. In the longer term we believe that, in the right circumstances, a more attractive salaried service similar to that agreed by hospital Consultants, could be developed.

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

A preferable contractual system would be one in which GPs would have sufficient time allocated to do their work within a working day. Time should be built into the workplan for personal development, supervision and education, with the option of time for management work, research, training and public health work. Overstretched GPs cannot provide optimal care.

General Practitioners do not need to be the employers of other members of the primary health care team.

General Practitioners need to be relieved of the necessity of being the owners or leaseholders of the buildings within which they work, they should be offered a fairly priced buy-out or take over if they are current owners or leaseholders.

Any salaried General Practitioner Contract will require the Contract holder to be an NHS body, with National Terms and Conditions, working within an NHS which has been reinstated as a fully publicly funded and publicly provided service. By definition private providers have the profit motive as a demand on their service development, which will always be unhelpful in the context of the NHS.

 Line managers for GPs should be clinician peers, or those with extensive understanding of primary care teams.

There needs to be developed provision of comprehensive multidisciplinary primary care teams, with local health service management based on neighbourhoods, with local accountability driving bigger system planning and resource allocation decisions. General Practitioners would be amongst the team members, but not necessarily leading the team.

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

Unfortunately the development of Primary Care Networks has been significantly hampered by the centralised prescription of what the funds can be used for. The specified Additional Roles staff are often not available for recruitment, and the money cannot be used to meet alternative local needs. There is a pool of fully trained General Practitioners who are leaving the profession because they cannot find work that is attractive enough to retain them, while at the same time Primary Care Networks are prevented from creating bespoke posts that could keep their skills and cover unmet need.

The Networks have certainly not reduced any administrative burden on GPs, those involved in running them have been, to the contrary, heavily burdened and inadequately recompensed for the huge workload of recruitment and management.

The Networks need resources for structured training and induction for new staff, as well as ongoing supervision and mentoring.

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?

General Practitioners ability to work in effective partnership with other professions is constrained by the overall workload. Co-location of other professions massively improves effective partnerships, and the reduction of this over the years has been damaging. Conversations with co-located professionals can happen when they need to, when people are in the same building. Large multidisciplinary meetings have a very limited role. Problems of IT lack of interoperability reduce the potential for IT communication solutions. In the fast moving world of acute patient care there is no substitute for a timely care planning discussion which cannot wait for a routine scheduled meeting.

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