My alternative GP Forward View
Dr Jackie Applebee
There is no doubt that there is an unprecedented crisis in general practice. Eighty-four per cent of GPs report that unchecked and growing workload pressures are undermining their ability to provide safe and quality care.
The GP Forward View has been heralded by some as the solution, but in my view £2.4 billion is wholly inadequate to make the vision into a reality and opportunities have been missed to make a real difference to the working lives of GPs.
We are told that the NHS is unsustainable and that we must make efficiency savings, but we are a rich country with the most cost-effective healthcare system in the developed world.
Abolition of the NHS market would instantly save billions but this low hanging fruit is never contemplated by those in power. We can afford to fund the NHS properly, the Government just chooses not to.
The main thrust of the GP Forward View document is about transforming general practice, but is this really necessary?
Here’s what I think should have been in the GP Forward View instead.
I would abandon the hub model, and redirect resources back into practices
The workforce crisis must be urgently addressed. I would introduce an immediate moratorium on the threat to the immigration status of foreign GPs and nurses. The GPFV aims to recruit from overseas, but recent Government policy has meant that the reverse is happening and more than four in ten European doctors are considering leaving the NHS due to uncertainty about their continued residency after Brexit.
We desperately need to encourage more British medical students to choose general practice in the first place. The GP Forward View should have addressed this with a programme to enhance the status of general practice within medical schools. High quality GP student placements would give wide ranging clinical experience and show the rewards of family medicine, encouraging young doctors to embark on a career in general practice.
In addition, we need support for health professionals other than GPs. We are in desperate need of practice nurses, but since the abolition of the bursary last year applications to study nursing are down by ten thousand, so reintroducing the nurse’s bursary would have a massively beneficial effect for GPs. At the same time, I would end the physician associate project and divert the money to returner schemes to attract doctors and nurses back into practice – they are already trained and we know we need them, unlike physician associates.
GPs at the front of A&E departments, working with secondary care, not parallel to them as in urgent care centres, as the Government has suggested, could help to signpost patients back to more appropriate services should they arrive at A&E with a problem that really should be dealt with in primary care core hours.
I would rationalise the plethora of services that have sprung up in the name of extending GP access. Patients are often blamed for using services inappropriately but this is hardly surprising when there is such a confusing array to choose from. Hubs and urgent care centres divert GPs from surgeries and extended hours pilots at weekends have not been popular. I would abandon the hub model, and redirect resources back into practices, providing more appointments, improving job satisfaction and stemming the flow of GPs who are leaving the profession early. Continuity of care would flourish, taking the pressure off hard pressed A&E departments.
The GP Forward View also showed an obsession with working at scale, which NHS England believes is one way to improve access. However, practices can work at scale without joining the MCP contracts and super-partnerships that the Forward View proposes. In Tower Hamlets we have collaborated in networks for years with excellent outcomes. It is possible to pool some functions while maintaining valuable, individual practice autonomy. The Forward View should have shown support for these models, which support individual practices rather than create a one size fits all approach.
The GP Forward View promises money for practice infrastructure but that hasn’t reached practices. Premises need urgent capital investment. Too many GP surgeries have been waiting for years to be developed to an acceptable standard. The poor state of some buildings acts as a barrier to recruitment. The antics of NHS Property Services have caused immense stress and unnecessary work for practices. Instead of another scheme that practices have to bid for, I would bring the work of NHS Property Services back in house and adopt a transparent national formula for the setting of rents and service charges.
Similarly, other outsourced services to companies such as Capita have been a shambles. I would bring them back within the NHS to save hours of staff time.
If practices come up for tender I would allow bids for GMS contracts. Too many local GPs are forced into APMS contracts because of competition law. Exposing them to costly and time consuming procurement processes every ten to fifteen years and leaving them at risk of being taken over by private providers.
Many of my ideas are not new and have worked well in the past. We are being forced to change our model of general practice, not because the old system doesn’t work, but because it doesn’t fit with Government ideology. Continuous political interference, underfunding and fragmentation of care have led to confusion for patients and sapped the morale of doctors and nurses. General practice is the cornerstone of the NHS my alternative GPFV would keep it that way.
Dr Jackie Applebee is chair of Tower Hamlets LMC and a GP in east London