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Gerada: GP patient lists should be ‘pooled’ across PCNs


Professor Clare Gerada


GP patient lists should be pooled across PCNs as part of measures to address the GP workload crisis, former RCGP chair Professor Dame Clare Gerada has said.

In a British Journal of General Practice editorial, published last week, Professor Gerada reiterated that she has ‘never seen things so bad’ in general practice.

She set out a series of recommendations that must now be ‘put into action’ to protect GPs, including a ‘new service model’ to prevent ‘piecemeal’ care of complex patients.

She said: ‘Now more than ever the management of complex patients (including, I would suggest, those in nursing homes, frail elderly, those with complex comorbidities, and those with serious mental illness) must be moved outside the remit of day-to-day care of the GP and instead cared for through intermediate multidisciplinary teams, bridging the gap between hospital, general practice, and home, each adding complementary skills providing enhanced care to patients.’

Professor Gerada added that the partnership model is ‘outdated and holds us back’, instead advocating for the pooling of patient lists across networks alongside digital triage to direct patients appropriately.

She said: ‘The pandemic has shown the value of GPs working together — within primary care networks (PCNs). Patients and staff have benefited from the greater flexibility size gives. 

‘We should build on this and pool patient lists across PCNs; allowing for continuity provided through personal lists (adjusted in size to address numbers of clinical sessions GPs undertake).’ 

And the number of patients GPs routinely see per day and per week must be capped, she added.

She said: ‘The current situation is intolerable, unsustainable, unsafe, and leads to burn out, depression, and poorer quality care. We must look to split the GP’s working week into digital, face-to-face, continuity, and multidisciplinary contacts — each given the necessary time with appropriate limits.’

Meanwhile, primary care must stop being treated ‘as a “sink hole” absorbing unlimited work’ that hospital doctors ‘can’t or won’t do’, Professor Gerada said.

She added: ‘GPs now need to have a hard conversation: what are we not going to do? Without that realisation, without that acceptance, then we are without hope.’

Professor Gerada also said:

  • Secondary care colleagues should also take up a generalist ‘approach’ to stop the ongoing management of patients from flowing ‘unrelentingly’ to primary care;
  • GPs must have ‘parity of esteem and pay’ rather than being viewed as a ‘cheaper alternative to consultant care or fodder to fill service gaps’;
  • The planned extension to GP training from three to four years must be implemented;
  • All hospital doctors must undergo core training in general practice of at least six months and at minimum ST4 level.

Addressing renewed controversy over GP access, Professor Gerada said that GPs have ‘moved mountains’ to help their patients.

She added: ‘Rather than being lauded GPs have been reprimanded, unjustly, for not being ‘open’. This hurts. General practice is open. 

‘Our doors are so widely open that you can drive a coach and horses through them.’

It comes as the BMA’s GP Committee has paused all meetings with NHS England until the disagreement around face-to-face appointments in practices is resolved, saying it has ‘no confidence’ in NHS England’s executive directors.

Last week, health secretary Matt Hancock met with GPC to discuss the fallout. According to Mr Hancock, they discussed ‘what more we can do to strengthen access to GPs’, while the BMA said Mr Hancock ‘recognised’ the ‘extreme pressures currently facing general practice’.

In April, Professor Gerada told  Pulse that 22% more GPs are presenting to burnout service NHS Practitioner Health – where she is medical director – than before the Covid pandemic.

READERS' COMMENTS [20]

Turn out The Lights 1 June, 2021 3:15 pm

How will this make a difference when there is a shortage on practice nurses and GPs across the board and a massive increase in demand. Add to that morale that is at rock bottom and workload that has increased by 30% over the last 12 months and and already perfect storm become more deadly. Into this mix come a government ,patients and a right wing press which keep flogging the dead horse to do more.The Exodus will continue

Andrew Jackson 1 June, 2021 3:33 pm

I appreciate CGs approach to wellbeing but disagree with her solutions which are to take workload away by removing the interesting and challenging medicine from our day job.
What we need is to continue to have a varied day but just less of it ie a workload cap.
PCNs are a distraction to this. Everyone is hyping up PCNs due to their success in the pandemic but actually community vaccinations could have been delivered by groups of practices without needing to be in a formal PCN structure.
The original point of PCNs (2 years ago let us not forget) was to reduce GP workload and for me that is how I measure the value of them. They have not remotely made any meaningful difference to this in a way that is encouraging R and R and we still have no sustainable career offer for young GPs apart from P/T F2F work as that’s all you will be able to manage!
Everyone was dreading the tsunami that is a Tuesday after a BH which is no way to enjoy a career.
If secondary care want me to do some work for them they should have to find time in my diary and book this and if I haven’t got any then they need to find someone who has.

Patrufini Duffy 1 June, 2021 4:27 pm

That adds only more reason to opt out of a PCN.
I agree AJ – fair points on wellbeing. But, on the other hand this Tesco model and working at scale was pushed out, and I’m not sure has succeeded. The CQC and Professor Field obliterated the small practices – like Arvind Madan’s comments. Ms Gerada’s colleague at Hurley Practice. Perhaps an inside job that has got us to this point. He is also the co-founder of Econsult. That hardy generation of grassroot GPs will never be replaced in the UK with the new generation – they may try to import it from elsewhere, but it wont be the same, ever. The new GPs require a different portfolio and work-life balance. Anecdotally, it is not quite working for “pooled” Babylon patients (multiple sites, randomly spaced, random doctors) or maybe Hurley Group patient satisfaction. ***Pooling demoralises staff – as it breaks any sense of meaning, continuity or purpose in a days work. You just generate more fragmented medicine, under the perception of “safety in numbers” and “shared care” – but in fact, more goes missing and more can become negligent despite integrated IT systems – no one really knows what is going on. And ultimately no one cares – as you will employ more managers, pushing more onto salaried part-time workers. It is like a PCN factory of nothingness. And add in some care homes while you’re at – you seeing other care homes, you didn’t want to see. And the salaried, clock-in clock out churning of EMIS numbers continues. Yes, Partners will disappear – that is inevitable in this “on demand” country and evolution of the NHS crisis and the way the NHS Juggernaut has planned for their future. It sadly does not want to preserve the greatest leaders of community healthcare that it has ever had. Patients will gravitate to the “better” practice and demand that. And I think that will just burden and kill off smaller sites more, if you have an “appointment book controller” who is generically just swamping every practice. It is like a glorified Walk-in Centre with a PCN logo on it.
The bigger this “merges” and gets, the more generic and wasteful it will become. You are seeing it right in front of you. 50% of GP consultations are not required – deal with that at a Governer’s meeting – you can’t, because the Government won’t say no, and no one is paying for this, so healthcare means NOTHING. Start paying, then that pint at Weatherspoons, triple decker burger and prosecco, punch up on a Friday night and the trip to Magaluf with an ounce of cocaine will stop. Patients can yo-yo like headless chickens and find themselves with no one brave enough or knowledgeable enough, to say – there’s nothing wrong. Size does not correlate with anything currently.

John Graham Munro 1 June, 2021 4:40 pm

Television G.P.s are the answer——they sit and take queries from callers——this method of consultation is less stressful because they are becoming more famous by the minute as compensation

Michael Mullineux 1 June, 2021 5:44 pm

In our locality the PCN responses were directly driven by NHSE advice which was slow and always behind the curve from the onset of the pandemic. The assertion by Prof Gerada that PCN’s have somehow been at the forefront of all completely ignores this and the assertion that the Partnership model is outdated and needing replacement is a narrow view. The description she gives is that of a PCN mediated salaried service with all working to rule that will require massive workforce increases, something the PCN model has failed at thus far. The partnership model has allowed us to react quickly and introduce changes throughout the pandemic that NHSE mediated PCN’s only began to deliver months later. In the meanwhile not being part of a PCN has allowed us to manage our workload and simply say no to many of the more flaky poorly evidenced NHSE DES and LES without the distractions of an undeliverable PCN-contracted workload.

Bob Hodges 2 June, 2021 9:41 am

I disagree fundamentally. My practice resulted from a merger of 4 practices to hit the PCN threshold sixe in 2018. We are our own merged/pooled list and MDTs for complex care and frailty. We are a partnership….there’s nothing in CG’s proposed model that could not be done by a modernised partnership structure.

However, be careful what you wish for…..partnerships are the greatest force AGAINST inequality of provision due to our professional pride and friendly ‘co-opertition’ that drives and mainatians standards and professional self respect. We also know that when we go the extra mile for a patient, the ultimate benficiary isn’t a US owned ‘Healthcare corporation’.

Take that away, and you are left with either an NHS England dominated shambles, or a crony-capitalist kleptocracy. Either of which would see me moving twards the exist with laser-like focus and determination i.e. i’ll be out of the game 10 years earlier, taking my experience with me.

Chris Dixon 2 June, 2021 10:23 am

How about

‘Make the Job less overwhelmingly terrible’ to stop GPs leaving and attract young blood ?

IF number of doctors remains the same so does the workload. The ONLY way this will be dealt with is with more doctors ( not noctors).

Unless, maybe that’s the plan all along.

I’m not sure Dr Gerada with her unique model for providing primary care is really the person who should be asked what the profession wants or needs.

Clare Gerada 2 June, 2021 8:32 pm

Dear David. I am glad you no longer are in practice – what a nasty post. Calling me a ‘silly cow’ is sexist, rude and so upsetting. For what its worth, I am still in clinical practice – doing sessions unlike you, and trying to support our profession. And calling me a ‘c….n’ is even worse. I suggest you reflect on what you have written and the upset you have caused me. At least I am trying my best to find a solution. And at least I do not resort to such abuse language

RAMAN PRABU 2 June, 2021 8:35 pm

Seriously!
Does she even know what really happens in General practice! Or what gives the quality of care!

Clare Gerada 3 June, 2021 7:51 am

Raman. Not sure who long you have worked in GP. I have just completed my 32 continuous year – and the last clinic I did was yesterday and before that last week. I did out of hours (all nighters) till around 5 years ago and out of hours till 11pm until 12 months ago. So please dont ask me if I know what happens in general practice. I suspect I know a great deal more than most. Disagreed with my comments, but dont personalise them. I also understand what gives quality of care – and have been giving it for decades. I also know GPs are struggling and we need to change what, who, where, when and if you would do me the courtesy of reading the whole piece then comment on it. Thank you.

Clare Gerada 3 June, 2021 7:53 am

And by the way Raman, I am 61 years old. I dont know many 61 year old GPs – who are still in clinical practice. Maybe you do. Maybe you are one of them?

nasir hannan 3 June, 2021 9:41 am

The hurley group is also a partnership model. You were a partner in this and have benefitted from this. I am a partner now and have thoroughly enjoyed my career as a partner. I would not wish to remove the chance of young Gp’s of the future to be a part of this and maintain their stake in the future of primary care. The partnership model is the bedrock of general practice. Having a list that we care for is absolutely critical to its function. Yes it has its challenges, but also those challenges breed innovation.

I have been a locum and salaried to different organisations and for me personally there is no turning back. The more people that continue to breed innovation and growth the more different models of care will develop in primary care the stronger we will be as a profession and as a system.

We can and do successfully work together as pcn’s but this does not require that we sacrifice our identity. This is evidenced by the highly successful vaccine delivery work, extended access, development of Arrs roles across pcn’s.

Calls to disband primary care are highly premature. There are other problems in secondary care and community care but the focus seems to be how can we support them. However their challenges are actually much higher than ours. There are more cqc issues. They have major financial blackholes. Our problems are far easier to fix and arguably would have far greater benefit to the system.

I want my leadership to see how general practice can be supported. Please do not as a leadership attack the partnership model. You have been in this for your entire career and it is not fair on our future colleagues. We should not pull up ladders we should throw down ropes.

James Cuthbertson 3 June, 2021 1:39 pm

GPs need to stop adapting. Let the government and public adapt to the service that can safely and realistically be offered, not the other way round.

Shibley Rahman 3 June, 2021 4:41 pm

I think it’s fair and reasonable to discuss openly how organisations adapt to changing environments. I am here talking about organisations rather than individual doctors.

Patients’ complex needs can be only addressed optimally by a diverse and well-resourced workforce. It happens that, whatever the history of the GP partnership (and few lawyers I think would want to shoo-horn the legal structure within the Partnerships Act 1890), and whatever one’s own political beliefs, there is a concern from all of us as to how best to address patients’ needs and patient safety.

The GP as an advocate in the community for patients with complex needs such as disability, dementia or addiction, working alongside other professionals and practitioners, is a philosophy I can get behind enthusiastically.

I think, also, that the notion of pooling resources is also entirely consistent with how all organisations can be managed given their resources. I felt the argument presented here is entirely in keeping with the construct of the “dynamic capability” of an organisation as “the [organisation]’s ability to integrate, build, and reconfigure internal and external competences to address rapidly changing environments” (from David J. Teece, Gary Pisano, and Amy Shuen). With a backlog of needs and an over-pressurised relatively under-numbered workforce, as we hopefully exit most of the pandemic, this discussion point needs to be courageously aired.

We are stronger together than the sum of our individual parts. That applies to networks too surely? I wish everyone well.

nasir hannan 3 June, 2021 7:13 pm

Really well put shibley and this should not be dropped to individual attacks. I just feel that we can think wider and still retain partnership individuality.
We are doing this proudly in Chiltern Vale PCN and we have some really powerful relationships in Bedfordshire.
Destroying partnerships will send us back.

Pezhman Fard 4 June, 2021 5:50 am

Professor Gerada is without question of the most committed and accomplished members of our community. It is never acceptable for a colleague to abuse a member of the public with rude language, specially another colleague. Please take stock of your words and be reminded of your professional integrity. Although I disagree with the point about abolishing partnerships or merging lists, I recognise and agree with Prof Gerada about working together. PCNs will work if there is no threat to the practice lists.
Please remember that without colleagues like Prof Gerada we would all be worse off. She is an incredibly kind and generous doctor and an huge asset to our community.

Carlos Knorr 4 June, 2021 3:06 pm

Dear Clare
I’ll be 60 next year ( no plans to retire ) and 2 of my colleagues into their 70 and 80’s were working 2 weeks before they both died of covid ; they were well known GP’s in NEE . I assure you they did not catch covid on a TC but seeing F2F patients when clinically indicated and why the NHE letter to GP asking them to resume F2F consultation was so unsettling . So working pass 60 (as you do ) is not as rare as you think , thank god for that , the NHS will need all the help it can get .

Concerned GP 6 June, 2021 7:02 pm

Some of the points CG makes are valid especially re workload being unsustainable but I don’t agree that changing the model and getting rid of partnerships is the answer. Why is there such a push for this? Please ask us what we want and don’t assume that we are all ok with an alternative model eg salaried model – because that is far, far from true.

Mrutyunjaya Kuruvatti 8 June, 2021 10:56 am

I am a partner and I have also worked as a salaried in the Hurley Group. I have not always agreed with Clare, but my own opinion is that the model needs to change (along with lots and lots of other things and it needs funding). Just look at the workforce data on GP partners! We are a dwindling body and the curve continues to go downwards. The current partnership model is just not viable long term, if only because it is no longer attracting GPs into it in the way that it once did. The suggestion Clare makes about a mixed working week, taking in different elements of clinical care along with a strong role in leadership, could be attractive for future generations of GPs.

Toni Hazell 8 June, 2021 11:29 am

There are some sensible suggestions and points made in this article, but the one about GPs merging into PCN groups does of course make primary care more attractive to big private healthcare companies. It sits a little uneasily to see this suggestion made by someone who is a paid advisor to a big private healthcare company.