Hawkshead Medical Practice is a small rural practice in the central Lake District. The practice comprises two partners on a job share, providing general medical services including a minor injury and minor surgery service to a resident population of 1,150 patients. Our practice area covers 50 square miles within the Lake District National Park.
Also on the practice team are a nurse (eight hours per week) and two part-time receptionists. Practice management is provided by a manager from another practice, for three hours per month. The practice does not dispense, and works in conjunction with the local pharmacy to provide medical services to the residents but also to the significant influx of tourists over the year. Second home-ownership in the area is high.
The practice has never had high funding levels. It has been sustained by the dedication of the staff and the support of its patient group. Despite this, its ratings remain high achieving the highest scores in England for patient satisfaction in the 2013 national surveys.
Whilst the practice will not lose instantly from the current GMS contract changes it does suffer from already insufficient and reducing resources to manage the increasing workload in general practice both from patients and from organisational change. Seniority payments are now not paid to one GP as her income has fallen to levels where the payment is no longer available.
The practice has to deal with a high number of temporary residents, the funding of which has been frozen since 2004 and no longer represents the costs of providing the service.
One of the GPs was hired to the practice as an ‘associate’, a particular GP job-sharing arrangement from the old GP contract for rural areas that has not been available since 2004. The practice is therefore no longer sustainable beyond the working lives of the current GPs. Another local practice at Coniston is also under threat of closure.
If both of these practices close then the patients will have difficulty accessing primary care as travel in the area is difficult with limited public transport availability. Access to secondary care already involves significant journeys.
What we have done
Over the past year the practice has attempted to get NHS England to look at the funding.
The patient participation group and many other patients of the practice have written individually and as a body to the head of NHS England and the Cumbria, Northumbria, Tyne and Wear area team.
We have always actively engaged in discussion at locality and CCG level and will continue to do so. We involved Tim Farron, our local MP and chairman of the Liberal Party, who has lobbied Parliament on our behalf. we have had two meetings now with David Geddes (NHS England head of primary care commissioning) and one with Earl Howe.
We wrote on the practice’s behalf to the GMC, the BMA, the GPC, the CCG and NHS England on numerous occasions outlining the plight of small rural practices and trying to discuss constructively what could realistically be done to ensure longevity of practices like ours. We have messages of support from the GPC and the BMA is happy to organise a campaign for us if we want.
The CCG remains supportive of the practice but was limited in what they can do given the current restrictions on commissioning budgets.
The outcomes so far
The area team said it had no money available to resolve this issue and the NHS Executive believes it’s a local issue to resolve. So the practice has been pushed from one meeting to the next with plenty of sympathy on offer but no solution.
However, the practice was able to obtain a meeting with Earl Howe and David Geddes (NHSE) at the Department of Health on 22 July. The practice was represented by its local MP, Tim Farron who has actively campaigned for it, and the accountant.
They put the case that there are a number of small unique practices whose funding does not fit the normal mould of GMS and PMS practices. The failure of the practices to survive would have significant impacts on the local communities and NHS England needs to look differently at these practices. The numbers across England are small and the overall impact on NHS funding would be negligible to ensure these practices can continue.
Earl Howe agreed that a sustainable solution was needed and tasked David Geddes to look at this with the practices concerned, and the CCG.
Secondly a local benefactor has offered to build new small premises in the village that would be used by the practice and other community services. The benefactor wants nothing in return, apart from the transfer of the existing funding for rent on its current premises, to the new premises. Again the scheme has the full support of the CCG, but still needs NHS England’s approval before any change can happen.
We proposed the following five-point plan to NHS England:
1 The partnership asks the area team to consider revising the amount of funding available to cover care for temporary residents.
2 We asked the DH to consider restoring seniority flexibility to low-earners. Under the GMS contract you are entitled to receive a seniority payment if your income is above a third of the national average for the year. However, the average is defined retrospectively once pension returns have been processed for the year in question, which can take three years. If a GP earns less than a third of the average income he or she is note entitled to seniority.
3 We ask NHS England Cumbria, Northumbria, Tyne and Wear to provide the necessary support for the surgery development.
4 We ask that NHS England considers establishing an grant for rural practices, similar to the Essential Services funds in the pharmacy and education sectors, and recognises that for some practices the capitation funding model simply doesn’t work.
5 The partnership continues to work locally with the CCG and other partner organisations to develop more sustainable funding for the local area.
David Geddes has now taken a personal interest in the problem and has agreed to meet again with the practices late in the summer to progress discussions. He has accepted that time is not a luxury the practice have.
Until someone actually says why they are saying no to what we are asking (which is not a lot) then we will continue to ask the question and provide them with solutions. Being persistent, coming up with workable ideas and being well-supported is key.
Will these initiatives be enough to secure a long term GP presence for residents and visitors to Hawkshead? We sincerely hope so, and we hope to finally have some good news to tell our patients at the next public meeting in September.
Dr Jane Rimington and Dr Kaye Ward are GPs in Hawkshead, Cumbria.