Bringing general practice back from the brink
Pulse brought together a panel of GP leaders to discuss the crisis in general practice and how it can be tackled. This is what they had to say
Nigel Praities (NP) Pulse editor (chair)
Dr David Geddes (DG) Head of primary care commissioning, NHS England
Dr Chaand Nagpaul (CN) GPC chair
Professor Clare Gerada (CG) Former RCGP chair and chair of NHS England (London) clinical board for transforming primary care (speaking in a personal capacity)
Dr Naomi Beer (NB) Leader of east London’s ‘Save Our Surgeries’ campaign
Dr Amanda Doyle (AD) NHS Clinical Commissioners co-chair and chief clinical officer of NHS Blackpool CCG
NP: General practice is at a crossroads. Practices are coping with unprecedented levels of workload, and they are struggling. Morale is at rock-bottom and Pulse has also found scores of practices are considering closure. This is a disaster at a time when we should be increasing the capacity of general practice. What are the main issues that practices are facing in your view?
NB: For us locally, it is definitely a funding-related issue and it exists because deprivation and its difficulties are not currently recognised within core funding.
CG: If I could be provocative, one of the reasons we are seeing such a catastrophe at the moment is the way we are contracted with the NHS. We just have to keep taking on more, rather than actually having defined hours, numbers of patients we are meant to see, defined volume and staffing.
The demands have far outstripped the capacity to deliver. In the past 20 years, there has been no planned approach to expand general practice. In fact, we have seen the opposite. We have seen relative reductions in the numbers of GPs in the workforce and in the spend on general practice relative to other parts of the system. It is no surprise we now have a service simply unable to deliver the demands placed on it.
DG: I agree. There are stresses in both primary and secondary care. We are trying to provide 10-minute appointments with someone with three, four or five long-term conditions. It does not feel that we are providing a sustainable service for the kind of needs we need to be addressing.
AD: And we have a huge workforce issue: an increasingly high percentage of female GPs, who often want to work part time, and older GPs not wanting to work for as long. This is a vicious circle, with increasing demand and the stresses putting people off from committing themselves. We’re seeing young GPs who, 10 to 15 years ago, would have been automatically grabbed as partners into practices as they completed their training, but who are just not interested. They want to be locums, to travel, to take a salaried job. And that is causing increasing problems.
NB: There is a problem with a lack of vision for general practice. The people who are responsible for making decisions have not had a clear idea what they want from general practice, so it has been a very reactive response to what has been happening.
CG: We have been fiddled with too much. Instead of allowing GPs to find the solution, all these earnest people – think-tanks, politicians – are basically reinventing what general practice was 15 years ago. We need to restore our self-esteem as a profession and then move forward.
NP: What about the narrative around general practice in the national media? Do you think this is having an effect?
CN: We are now beginning to see the press pick up on the fact that there are pressures on general practice. A year ago, this was absent. We were considered to be the problem. We need to work with the public to highlight the huge knock-on effect the failure to support general practice is having on the rest of the system.
AD: That is really important, certainly as a commissioner. The interest CCGs are showing in involvement in primary care commissioning is purely for that reason, because primary care is the linchpin that the system sits on.
CG: It is only a 1% investment per year for about five to six years that we actually need. A 1% shift of resource is not a vast amount of money. It will not destabilise secondary care.
AD: At the moment, there is just no mechanism for anybody to increase the amount of core primary care that is available in a locality. Allowing CCGs more direct involvement in commissioning will allow that to happen and give us a mechanism for investing where we really think it is needed.
DG: Co-commissioning is the lever to make sure that clinicians are able to start reworking what primary care looks like. Although we are a ‘national’ health service, it does need to have a local sensitivity. There are very different challenges in Birmingham compared with Devon, in Manchester compared with Liverpool. We need to make sure that commissioners, who are key to integration between health and social care, have the opportunity to properly involve primary care, using the resource that we have got – to shift that 1% or 2% from secondary care, or mental health, into primary care.
CN: I am not sure it is all about having percentages. I could not even conceive of asking my local consultant or my local hospital to do twice as much without any more resource. It is not about special pleading. It is about being fair. The commissioning process has to ensure the resources match the service being delivered. It is not really about getting into a battle of just moving money for the sake of it.
CG: But, Chaand, it is actually the granularity. I processed 200 documents on Friday. I could have offered 20 more appointments that day if I was not being asked to do things on behalf of hospital doctors: initiate very complicated drug regimes; follow up a patient with Shigella for another stool test; do a whole series of blood tests; prescribe x, y and z. These would not come up in a commissioning framework. We need to document the excess work – these tiny little bits – that make our life impossible.
NB: Absolutely right. Providing evidence of what we do is definitely part of the process. Then it needs NHS England – or whoever is going to be responsible – to actually decide what level of primary care they are going to resource [to DG] because I am not convinced you actually have a handle on what it is that you want.
DG: I do not know if you can. We have got some interesting areas where secondary care is starting to provide primary care services and other areas where primary care is doing more of what you might consider traditional secondary care. I do worry that we end up thinking in binary terms about secondary and primary care.
CG: We can define primary care. I think we need to be taking stock and asking, what is not general practice? What is not primary care?
CN: But we have every government across the four UK nations saying they want to move care out of hospital. But one of the elephants in the room is premises. In my practice I cannot house an extra nurse. I cannot even house the care co-ordinator the CCG was willing to provide us. I cannot walk into my surgery on a Monday, because there is not the space. If you are going to talk about an out-of-hospital strategy, you need to have an out-of-hospital investment approach. Commissioners can do some immediate things. For instance, why does any hospital discharge a patient and ask them to make an appointment with their GP for a re-referral? Stop it. The commissioner should write in a service specification and say that is not right. For Med 3s, when hospital doctors can actually sign them off after an operation, why go to your GP?
DG: We need to be thinking about what services are currently being provided and why they are provided in hospital. It is not just about GPs. We should be getting pharmacists, local consultants and A&E attending consultants and doctors working differently in the community to sort more people out.
NB: You are not going to get any of it until you stabilise general practice – none of it. There is just no will out there. You know, the people are leaving…
DG: They are.
NB: …because they are fed up with being treated like…
CG: Children. And criminals.
DG: I agree, but we are not going to be in a situation where we can stabilise general practice alone – it is about trying to change a whole system in one go.
NB: Well, I am sorry. If you can find £3bn to go to bomb Iraq, there is money there if the will is there.
CN: A government has choices. Not achieving the four-hour target in hospital generated £500m for an A&E crisis. That was a choice. The £400m pilot fund for patients to see a GP over seven days was a choice. Whereas the whole cost to buy out MPIG is £100m. The Government could solve the pressures on general practice.
AD: But we cannot kid ourselves that money alone is the answer, because it is not.
CG: Money helps, though. At present, the profession is just holding together with goodwill and Sellotape. The big crisis actually is in our generation, the mid-50s and onwards, who will walk. If that generation goes, with all of their expertise, then that is the real catastrophe.
CN: I think so.
CG: I think we also now need to be pushing this agenda forward, because we have got 12 to 18 months if you do not sort it, I am afraid.
DG: Well, let us say what we are doing. You might think: ‘Oh, it is the Prime Minister’s Challenge Fund. It is political’, but that is delivering some changes.
AD: But we could never fund seven-day opening at that level across the country.
NB: And also it is focusing on access.
AD: But for a big chunk of the population, access trumps continuity.
DG: And we know that the answer is both, is it not?
CG: No, it is not both.
DG It is in different populations.
NB: This is our problem, David. Exactly what you have said is the problem. You do not actually understand.
DG: We do.
NB: You do not believe that we do actually need this investment in order to survive.
DG: We recognise that we do have to have investment. We do recognise absolutely the importance of having continuity of care. That is what the care programme is all about. It is trying to deliver…
CG: The care programme is not continuity.
DG: It is building…
NB: You are ‘yes’ men. You just…
NP: Let him speak.
DG: We do get it. There are huge pressures in primary care. Huge pressures in terms of premises. The workforce and how it is changing. But we know we do not have the answer nationally to be able to have a one-size fits…
CG: But where is the protest? Why is it that you are allowing your service – your people – to be cut by 15% when you cannot even deliver the services to general practice you are supposed to?
AD: I think one of the fundamental problems with NHS England and its area teams is that there is a very tiny number of people who are contracting with practices. And it is very difficult for them to do anything other than that, because they do not have the capacity. So there is nothing strategic going on.
CN: We still have this problem, when you talk about NHS England, of politics trumping common sense. We were told NHS England would be running the NHS, but it does not quite feel like that. If you have got £400m then actually give it to local areas and let them use it in the way they feel is most appropriate. Allow the politics to be removed, and put patient need as the driver of use of resources.
NP: If you could have an emergency package to help practices, what would it look like?
CG: I came up with some ideas when I was RCGP chair. Reducing the workload, through engaging secondary care, reducing the extraneous work preparing for CQC inspections – all the monitoring and regulation. We even suggested pausing the QOF for a year or so to reduce the amount of work.
NB: I think you have got a problem with confidence. There is a ridiculous level of nit-picking and all sorts of things not being dealt with. [to DG] It is Kafkaesque, actually, what you have been asked to do. But you need to stand up and say: ‘We have confidence in our GPs. We are going to do something. We are going to support primary care.’
NP: You are almost wanting a reset button? We start again from now.
DG: I accept your opinion, but we cannot just wave a wand. We need to work with our co-commissioning colleagues, with the GPC to look at doing things differently. It is about the kind of stuff coming from secondary care, the Department for Work and Pensions, and others. Some of that is NHS England. Some of it is CQC, to be honest. It is about making sure that we do not duplicate where we can, or about making sure that we are joined up. So if the CQC has got information from us, then they can use that, rather than actually going back and trying to find out again.
CN: We put to NHS England some specific, tangible suggestions that we think should be implemented. One is a short-term, immediate investment in infrastructure support. And that includes staffing. For many practices, just having two more receptionists and two more admin staff could make a huge difference. The second is premises. We did a survey where 50% of GPs said they could adapt their premises to provide more services. That is not a huge amount of money. Also, would it not be right for NHS England to say to the public: ‘Do the right thing. Do not misuse your GP’s time.’ That would be a powerful message. And finally, it would be great to have a policy where all public pronouncements are positive about general practice. We have given you these proposals, and I implore that something is actually done.
DG: I think those are good suggestions, but some are quite cost-intensive.
CN: But can you afford not to? If you do not pay for it, it is going to cause much bigger costs in the rest of the NHS.
CG: Our profession is at great risk. We are seeing doctors get terribly sick. The biggest group of doctors coming to the Practitioner Health Programme [which I run] is 29-year-olds who are burnt out and depressed. How tragic is that, at 29, to have had enough? You should be raring to go.
CN: We have sapped the energy from the system.
CG: What we should be doing is removing the culture of fear. I would ask you to remove NHS Choices. It is a heartache every day, when you get a negative comment. I do not even look at the positive ones any more. It just is hardwiring cruelty into our system.
CN: Can I agree with Clare there? The NHS Choices patient feedback is reducing us to some sort of absurd commodity. It should not be there. Rightly, you have a patient survey, which gives you information. At least that goes to a representative sample, but the NHS Choices feedback is purely self-selected.
CG: People who did not get what they wanted.
DG: In our practice we have had some recent bad comments on NHS Choices, and I accept it does actually take a lot of energy out of the system. There is an issue there, but it is about also making sure we have a system that is transparent. We have piloted the family and friends test and the comments about our practice receptionist, very directly, made a difference.
NB: We are not supermarkets. We have a motivation that is not about selling products. It is about delivering care. It is about compassion. And the way that we have been treated in the past 10 years has gone right against that, and has cut it completely from under us. And that is why doctors are so fed up.
DG: Primary care does feel hugely vulnerable at the moment. I think you will feel and see a change in what is being said, because NHS England does recognise this. Simon Stevens is absolutely clear this is a top priority that has to be delivered.
NP: Simon Stevens’s idea about ‘extended group practices’ employing consultants – is that a good idea?
CN: Having certain types of specialists moving into the community makes sense. There is no logical reason why rheumatology, ENT – perhaps some elements of gastroenterology and cardiology – cannot be done in the community. What I would say is the care must not be disjointed. There is no point having a system where you have got the care being delivered in the community, and you cannot even look at their blood results because it is done at the local hospital. But in theory, the idea of GPs and consultants working together is not a wrong thing. At the moment we are caught in the crossfire.
NB: I come from Tower Hamlets. They are very innovative. But the immediate problem we face is a shortfall of about £7m due to MPIG and APMS/PMS restructuring. You are not going to get huge amounts of healthy innovation while you have that level of disinvestment.
DG: We do not need to necessarily stay rigid to a primary/secondary care divide, but I do think we want to be able to see a list-based approach so we can actually have that sense of practice ownership of the problems for those patients, and that kind of long-term relationship, which I think is so important for primary care.
NP: If Jeremy Hunt was at the end of the table, what would you say to him?
CN: There has to be honesty that we have a real problem in general practice. If you want more care within the community, the resource must match that. There also needs to be honesty with the public about what general practice can provide within its current context. I do not believe there is an issue about unaffordability, because if you do not spend that money, the NHS will be far more unaffordable through the consequences of general practice not delivering.
DG: It is about alignment. It is about recognising demand and the priorities we need to be able to stick to. We need to make sure that is communicated and we are clear about what the offer is of primary care, and also what we cannot deliver.
AD: I think that it is important that we come up with some very immediate solutions. Then, we need a long-term strategy that looks at the whole system and how we resource it and how we move resource and activity around the system.
NB: If he was sitting here, I would tell him to get rid of Section 75. I would say there needs to be some immediate solutions, and in developing that strategy for the medium to long term, there needs to be collaboration, not just a telling down from above with so-called ‘bright ideas’ from politicians. And much more transparency and public debate as to what kind of NHS we want, what kind of primary care service we want and how to develop this for the future.
NP: Okay. Thank you.