NHS England’s strategy to increase face-to-face appointments has rocked general practice. Rachel Carter reports on a tumultuous period for GPs
It felt to some that this whole year was leading up to this point. GPs have been under growing attack, starting with the odd column in the national media criticising a perceived lack of face-to-face access but intensifying to include newspaper campaigns, NHS England and ultimately the health secretary and the Prime Minister weighing in.
So it came as no surprise when Sajid Javid responded to the row with new measures last month. But the response went beyond most GPs’ worst fears.
His and NHS England’s plan, with its focus on ‘tackling underperformance’ and driving up the number of appointments in the system – with sanctions for practices that fail to improve – has left the profession reeling.
The BMA’s GP Committee called an emergency meeting, held the week after the plan was announced. Following the meeting, it told practices and LMCs to disengage with all parts of the plan. But it went even further, with a threat of potential industrial action, which would involve not complying with certain NHS contractual requirements. It has also called on practices to submit undated resignations from NHS England’s flagship Network DES.
GPC chair Dr Richard Vautrey said: ‘GPs have been left with no alternative but to take this action. All efforts to persuade the Government to introduce a workable plan that will bring immediate and longer-term improvement for doctors and their patients, have so far come to nought.
‘The Government has completely ignored our requests for a reduction in bureaucracy to allow us to focus more on patient care, and we are therefore encouraging doctors to withdraw from this bureaucracy themselves.’
There is support for further action too: a BMA survey of 6,000 GPs – held before the plan was announced – asked whether GPs would be prepared to leave the NHS in the absence of adequate support in the current crisis. More than half (54%) said they would. And a snap poll of 3,500 GPs taken after NHS England’s plan was announced left no one in any doubt about whether the plan constituted ‘support’ – 93% agreed it is an ‘unacceptable response’ to the crisis.
There was even support for GPs from an unlikely quarter. Former health secretary and current Commons health and social care committee chair Jeremy Hunt said GPs were ‘running on empty’ and the plan would ‘fail to turn the tide’.
It seems there is a lot of stick and very little carrot. The BMA’s analysis says that, of the 29 initiatives included in the package, only seven may provide some new support for general practice, with the rest either repackaged or offering no support or only potential support. It added: ‘When taken together, the support these seven initiatives will provide will be very little compared to the punitive approach being pursued.’
And the very first page of NHS England’s document made clear the extent of the media’s influence on this plan: ‘Some patients are experiencing unacceptably poor access to general practice, including an inability to contact practices – as witnessed by their stories and those reported in the media.’
What NHS England says
‘For the five months November to March, a new £250m Winter Access Fund will help patients with urgent care needs to get seen when they need to, on the same day, taking account of their preferences, instead of going to hospital.’
Is this new money?
Sajid Javid claims it is ‘extra’ money. In an interview on the BBC’s Today programme on 14 October, he said: ‘It’s all extra funding, every penny of it, this is money that I secured in the spending round discussions just a few weeks ago for the winter and this is money directly from that’. He claimed it is more than GPs would get in an ‘ordinary winter’.
But Pulse has not yet received a response from the DHSC confirming where the money is coming from.
How can GPs access the money?
The NHS England plan says local systems can ‘determine optimal use of the funding’ and commissioners will be able to set their ‘own local conditions’. But the money is not designed as a ‘pass-through’ payment to individual practices, it adds.
If there is no demonstrable progress by practices by mid-December, funding ‘could be reduced or discontinued’.
The amount given to local areas will depend on their being able to ‘demonstrate value’, including how much they can increase capacity and the expected impact. Funding will be released to lead CCGs within ICSs in early November, following NHS England approval of their plans.
But the BMA warns GPs may never see this money: ‘We fear [CCGs and ICSs] will simply direct funding elsewhere, away from general practice, or remove already planned funding intended for winter resilience.’
How we got here
In retrospect, the events of the past year make this outcome seem inevitable. It took root in 2020, when coverage of general practice was dominated by the false claim that surgeries were ‘closed’ – with GPs accused of being ‘lazy’ and ‘refusing to see patients’. This led to the first intervention from NHS England: a press-released letter ‘reminding’ practices to offer face-to-face appointments to patients when they need them.
And the negativity towards GPs has only intensified since then. The Mail on Sunday launched a campaign for GPs to see patients face to face, while Telegraph columnists selectively highlighted instances where patients felt they should have been seen in person. This further coverage brought a second major NHS England intervention in May: a change to the standard operating procedures that instructed GPs to ‘respect patient preferences for face-to-face care unless there are good clinical reasons to the contrary’. Practices were also told to re-open receptions to walk-ins – but that these should also continue to be triaged. This time, the BMA acted, voting to pause all meetings with NHS England until the dispute was resolved. Its GP Committee passed an emergency motion of ‘no confidence’ in NHS England’s executive directors. Talks have since resumed.
What NHS England says
‘Some patients are experiencing unacceptably poor access to general practice, including an inability to contact practices – as witnessed by their stories and those reported in the media… Healthwatch and the CQC record rising number of concerns and complaints, typically about appointment availability, waiting times, and in particular, the ability to see a GP, and specifically face to face.’
Identifying the practices
Practices with the lowest levels of face-to-face appointments face ‘immediate action’. ICSs are asked to submit a list of the 20% of practices with the lowest levels of face-to-face appointments (with a GP only) by 28 October.
ICSs must also identify practices with overall appointment numbers lower than in the equivalent pre-pandemic months, the 20% of practices with the most significant levels of 111 calls from their patients during GP hours, and the 20% with the most significant rates of A&E attendances.
All practices were to review whether they have ‘the right balance’ between remote and face-to-face consultations by the end of October. The RCGP has been asked to issue guidance to practices on gauging that balance – by the end of November. NHS England will work with the NIHR on a ‘big data’ analysis of remote versus face-to-face consultations.
Measures targeted at practices
The 200 GP practices with the worst access will be subject to the Access Improvement Programme, which involves ‘on site support’. Smaller practices could be forced to partner with other practices, federations or PCNs. Practices not engaging with support face contractual action.
The CQC is also developing an inspection methodology focusing on improving GP access. ‘Wherever appropriate’, it will conduct unannounced inspections, NHS England says.
The past couple of months has seen the pressure on GPs reach new levels, as ministers have jumped on the partisan bandwagon. Sajid Javid told MPs in September that it was ‘high time GPs started operating in the way that they did before the pandemic and offering face-to-face appointments to everyone who would like one’. Less than a week later, the Daily Mail launched a new campaign, demanding a ‘guarantee that face-to-face GP appointments are the default’. It also called for the Government to ‘ensure a greater proportion of GP appointments are in person, including by providing incentives or penalties for local surgeries if necessary’. It also claimed the support of the health secretary and Prime Minister.
So last month’s NHS England plan can be viewed as the inevitable result of this inexorable pressure on the profession.
‘Work more hours, open for longer’
What NHS England says
NHS England suggested GPs can boost their appointment numbers by using the money from its package to fund ‘more sessions from existing staff’, hire locums, or employ other physicians such as retired geriatricians.
The funding could also be used to expand extended hours capacity, or to employ extra administrative staff, ‘where commissioners agree that it is necessary’, it added.
In other words: work extra hours and stay open for longer.
Problems with this approach
However, there are numerous problems with this. Existing GPs do not have the capacity to carry out extra shifts; they are already at maximum capacity. And there aren’t enough GPs in the system – despite the plan’s claim that there are now 1,200 more FTE GPs than two years ago (the true figure is 101 fully trained GPs).
Meanwhile, many GPs are reporting that there are no extra locums available for practices to hire.
BMA sessional GPs committee chair Dr Ben Molyneux agrees, saying the suggestion the funding could be used to employ locum GPs to increase the number of appointments is ‘baffling’.
He adds: ‘GP locums are already working flat-out to support a failing system, and while new money may help, there aren’t enough of any kind of GP
to go around, so this announcement is unlikely to make a material change to many practices, out-of-hours services or urgent treatment centres.’
But the relentless assault on GPs is simply unfair. GPs moved to total triage at the start of the pandemic to help stop the spread of Covid, at the behest of NHS England. This was in keeping with the direction of travel at the time in any case – then health secretary Matt Hancock was the biggest proponent of remote consultations, and argued that they should comprise around 45% of appointments even after the pandemic.
The landscape has changed since the start of the pandemic, too. Patients have got used to e-consultations and quicker GP appointments. Indeed, a Pulse survey in September showed the average waiting time for both remote and face-to-face appointments was around a week, down from 15 days in 2019, in part as a result of adopting a hybrid model. A move back to face-to-face consultations as the default will inevitably increase waiting times – which, of course, will be published in the proposed league tables. On top of this, the UK Health Security Agency had continued to recommend social distancing in practices and remote consultations – this guidance only changed when the plan came out.
Most importantly, practices were moving back to face-to-face appointments as restrictions were lifted. Before the pandemic, some 80% of GP consultations were face to face – as expected, this fell in 2020 but it is already back up to 58%.
Increasing overall appointment numbers
Commissioners have been told to increase overall appointment volumes in general practice – and ensure all practices ‘achieve at least pre-pandemic activity levels’.
NHS England says this excludes appointments for Covid 19 vaccinations, which practices are currently managing. Even when Covid vaccinations are removed from the data, practices saw 500,000 more patients in August compared with August 2019, before the pandemic.
If the vaccinations are factored in, practices carried out two million more appointments than in August 2019.
But GPs are asking where the capacity to deliver more appointments will come from if they also have to fulfil the requirements for face-to-face consultations at the same time as providing Covid vaccinations.
NHS England offers no indication of how GPs can achieve this, other than stating that appointment levels should reflect ‘full deployment of ARRS staff’, while hinting that Covid vaccination work could simply be handed over to community pharmacies if it’s found to be impacting on access.
‘Participation by a practice in the Covid-19 vaccination programme can never be at the expense of providing reasonable patient access to core GP services,’ the document says.
It adds: ‘Where access to primary medical services is challenged, for example where levels of face-to-face appointments with GPs in the practice are inappropriately low, commissioners must put in place immediate solutions to resolve the position, including considering alternative provision for vaccination of the affected population, most likely through community pharmacy.’
Any practices that are not achieving pre-pandemic levels of appointments by November will get none of the £250m and will instead be offered ‘support’ to improve.
GPs under attack
Sadly, patient abuse has also increased, notably worsened by the interventions from NHS England. LMCs and GPs directly linked the May 2021 letter to a rise in abuse towards staff.
A Pulse survey of 1,000 GPs, carried out in September, found nearly three-quarters of GPs are experiencing higher levels of patient abuse compared with before the pandemic. This has also been linked to a spike in GPs seeking mental health counselling.
Recently, the abuse has taken an even more worrying turn. In August this year, Minister Medical Practice in Lincoln was targeted with a hoax bomb threat, while blood-soaked items were thrown at receptionists at May Lane Surgery in Dursley, Gloucestershire. In September, four staff members at Florence House Medical Practice in Openshaw, Manchester were attacked – two of whom were hospitalised. In October, a GP and two staff members at a practice in east London, were barricaded in their surgery for hours, waiting for police to respond to a violent patient. In the same month, a branch surgery of a Staffordshire practice had to close for two days after staff suffered relentless abuse.
Abuse against GPs
The NHS plan dedicates just five of 54 paragraphs to patient abuse.
It proposes ‘communication tools’ to help people understand how they can access ‘the care they need in general practice’ – but fails to say how these tools will be delivered – and a zero-tolerance campaign on abuse of NHS staff, to be launched by the Government and NHS England in partnership with trade unions and the Academy of Medical Royal Colleges.
NHS England also says it will ‘immediately establish’ a £5m fund to facilitate essential upgrades to practice security, distributed via NHS regional teams. The health secretary believes this could pay for measures GPs ‘think they might need’, such as CCTV or ‘panic buttons’.
Action is already being taken to protect and support staff through a ‘violence reduction programme’ and NHS England is working with the police and the Crown Prosecution Service to bring offenders to justice.
The Government is legislating to double the maximum prison sentence for common assault to two years if the victim is an NHS worker. The BMA says increased sentencing is something it asked for but it is ‘meaningless if the same Government refuses to address the crisis fuelling such abuse’.
The BMA has come out fighting. The motion passed at the emergency GPC meeting will have early repercussions. First, practices have been effectively told not to comply with the bureaucratic elements of the plan that involve data collection, which will be used to compile the league tables. Second, it is pushing for industrial action that would involve practices not complying with contractual requirements to declare their earnings of more than £150,000 a year, and the request to force GPs to oversee the Covid vaccination exemption process.
Perhaps the most powerful move is the call for practices to submit undated resignations from the Network DES to their LMCs. The BMA will send these resignations to NHS England when they receive them from more than 50% of eligible practices.
Sadly, though, many GPs might have already decided to vote with their feet. The ‘Parody RCGP’ Twitter account claimed it had been contacted by 24 GPs after the release of the plan, all saying they would be leaving the profession.
If this ill-advised plan by NHS England and the Government turns out to be the last straw for many GPs, the profession and patients will end up worse off.
Removal of bureaucracy
The plan states that secondary care providers must be ‘held to account’ for dumping work on practices that could ‘reasonably be arranged directly by that provider, for example phlebotomy, organising investigations and, in particular, prescribing of medications.’
The transfer of patient data from secondary care to GP practices will also be improved by ‘removing the need to send email attachments or paper letters requiring manual processing’, it adds.
The BMA’s analysis says these measures are ‘welcome’ but it has ‘little faith’ they will actually happen.
Other measures outlined in the plan include expanding the simplified DVLA process for renewing licenses to include other conditions, and embedding electronic fit notes in hospital systems.
Annual GP appraisals – which were ‘refocused’ and ‘simplified’ in October last year – will continue in their ‘less burdensome format’ for the rest of 2021.
The BMA says these measures are ‘nothing new’ and have been announced previously.
GPs in Scotland are expected to increase face-to-face appointments this winter, following the announcement of £28m of extra funding.
It’s part of a £300m funding package for health and social care, which includes up to £15m to employ 1,000 extra healthcare support staff to assist staff in hospitals and community health teams, and £4m
for staff wellbeing such as psychological support.
The Department of Health has committed up to £5.5m to support general practice over the winter: £3.8m to support additional patient care and £1.7m for telephony infrastructure and accessibility. The BMA NI has welcomed the package.
No funding has been announced but the Welsh Government is working to improve access. In a swipe at NHS England,
it says: ‘We’re working with GPC Wales to improve access
to services in a collaborative way, not driven through accusations of underperformance.’