Scottish GPC leader Dr Andrew Buist says plans by commissioners in England for GPs to provide only complex care will be opposed north of the border
I don’t often disagree with editor Jaimie Kaffash, but I would be very much against removing the responsibility for on-the-day urgent care in Scotland. Wherever you work in the UK our biggest challenge in general practice is workload demands that outstrip the resources allocated by our respective governments. But removing urgent on-the day care is not the solution to our problems and in fact I believe would play into the hands of those that want to see the end of NHS general practice as we have known it.
General practice USPs are managing undifferentiated care, risk managing complex care including frailty and being the clinical leaders of our MDTs. The first two make us incredibly good value to the nation, filtering out the serious from the non-serious with an accuracy no other service can match and risk managing patients with multiple conditions where other healthcare workers would be passing the responsibility to secondary care. Both these issues are parts of general practice that make it an attractive professionally rewarding role, few of us just want to deal with long term condition management. So I believe we surrender any one of those USPs at our peril, but why would any Government seek such a change?
The solution we need of course is more funding into core general practice to fund more general practitioners, as stable incomes help retention and make for stable practices. That is the approach I have taken in Scotland with our somewhat more pro-NHS government who I do believe want to support the NHS. The trouble is though that in the last 15 years while policies have said ‘care in the community’, their actions and funding have driven investment into hospital care such that we have lost over 5% of GP WTE in the last 10 years while over the same period the consultant WTE has gone up 30%. Correspondingly our share of NHS spend has fallen from around 11% to around 7%. This is something that must be addressed and is a message I repeatedly deliver to a succession of Scottish Health ministers. In the meantime, our own GPC Scotland safe workload guidance is helping practices to push back, recognising that patient harm and clinician well-being can be damaged through demands that exceed capacity. In effect our government gets what they pay for, and the excess has to wait or go wherever they feel they need to.
So going back to the question, why would any government want general practice to give up unplanned care? There would be significant cost to do this as a parallel service and new workforce would need to be established. This is fragmentation of our health service; the beauty of general practice is we do both planned and unplanned care as it’s often difficult to say where one stops and the other starts. A change like this would not be to patient benefit as I’ve no doubt much of the care would be provided by MAPs and the inefficiency and inevitable communication problems of running parallel services would be wasteful. In my opinion such a change starts to breakdown the established system to the point where more affluent patients increasingly opt out of NHS general practice and 2-tier healthcare and inequalities would widen further and the whole NHS starts to unravel.
So, I say reject this idea, protect our USPs, demand that general practice gets the recognition it deserves as the foundation of the NHS, with a fairer share of the NHS spend (12%), enabling the expansion of the general practice workforce to bring down average list sizes and provide longer consultations with more face to face. And finally, our governments must engage with the public on the need to protect our NHS with a national conversation on realistic medicine, what are patients’ reasonable expectations within what we can afford, and what is and what is not an appropriate demand on the NHS.
Dr Andrew Buist is chair of the BMA’s Scottish GP Committee
READERS' COMMENTS [5]
Please note, only GPs are permitted to add comments to articles
All very sensible. Might I suggest being noisy about DHSC/NHSE’s refusals to fund GPs as ARRS roles. It shows that there is money available and there are GPs seeking roles.
Completely agree, it plays into the hands of managers and politicians who wish to fragment the NHS and hand over large parts of primary care to private providers which will only create a huge surge of work into secondary care at 10 times the cost.
Some of us remember the costs of same day walk-in centres, a payment every time someone walked through the door and over one third of whom were then passed on to GP’s or secondary care.
It is part of the planned fragmentation and breakup of Primary Care, and the wilful destruction of the medical grade previously known as the General Practitioner. Surely the evidence is now so blindlingly obvious as to be undeniable. They mean to destroy us. It will cost them dearly financially, and the health outcomes will be worse through atomisation of providers and loss of continuity. Well, let ‘em have it. So to speak…
Why are GP.s on NHSE and ICB so keen to go along with this suicidal move for English General Practice
ICB apologises after same-day GP access plans trigger ‘confusion and anger’
By Nick Bostock on the 20 February 2024
North West London ICB has apologised to GPs over plans for a separate same-day access model for general practice that triggered ‘confusion, anxiety, concern and anger’ – and confirmed there is ‘no expectation’ that service delivery will change fundamentally from the start of April.
(Photo: Mike Kemp/Getty Images)
Board papers published last year by North West London ICB suggest the model it plans to implement is based on the 2022 Fuller Stocktake, which ‘identified the need to streamline access to care and advice for non-complex episodic care’.
The board papers said: ‘Our vision is to stream access to same-day care and provide this at scale as part of the wider integrated urgent care system. This in turn releases capacity within practices for routine appointments and for the proactive management of frailty and people with complex needs and the redesign of elective pathways and outpatient transformation.’
The ICB has built its plans for same-day access into the ‘North West London single offer’ – a package of locally commissioned services offered to practices – for the coming financial year, meaning that practices will be expected to work on the scheme from April and that those unwilling to take part in the same-day access plans could lose out on other enhanced service income.
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GP access plans
A letter from the ICB responding to concerns raised by LMC leaders earlier this month, obtained by GPonline, rejects calls to separate commissioning of the same-day access model from a wider package of locally commissioned services and confirms the plans will go ahead.
However, it promises to work with LMC leaders to ‘articulate key deliverables’ PCNs will be expected to work towards in the coming financial year and claims the ICB has no plans for an ‘inflexible top-down delivery’ and is ‘not looking to impose a blueprint for how the same-day access model components should be implemented’.
LMC leaders from north-west London wrote to the ICB earlier this month to raise concerns over the same-day access plans. The LMC letter warned of unrealistic timescales for implementation of a new model of care that it said would have a ‘far-reaching impact on individual GP practices, their day-to-day running and their contractual delivery of care to their patients’.
LMC leaders called for the same-day access plans to ‘sit outside’ the single offer ‘and not to be conflated with other enhanced services relating to clinical care’.
Locally commissioned services
The LMC letter warned that London’s GP leaders have ‘ongoing reservations about the specific one-size-fits-all target operating model and the speed of the rollout. We also believe that it is vital that any rollout should be based on evaluation and experience of pilot sites.’
It added that while all GPs want to improve patient access to services, ‘it is also important to be clear that the ultimate limiting factor of timely patient access is a gross mismatch between demand and capacity’. The letter said: ‘We need to recognise that, as a system, we are offering more appointments than ever in the context of one of the lowest GP-to-patient ratios in the country.’
Warnings over the impact of the same-day access plans come after LMCs at last year’s England LMCs conference voted against any move to separate planned and unplanned care in general practice.
The ICB response makes clear that it believes the access plans cannot be unpicked from other locally commissioned services. It says: ‘We have been through a comprehensive sign-off process relating to all of the funding of the single offer in our internal ICB processes. As you can imagine, a funding package worth a total of £75.4m requires a lot of scrutiny and agreement. We cannot now unpick the access aspects from the rest of the programme without calling into question the whole piece of work.’
However, it says PCNs will have ‘flexibility to determine the way services function’ – including around the ‘quantum of same-day demand being triaged at scale whilst the PCNs are transitioning, which we envisage will take some time’.
Skill mix
It says PCNs will also have control over ‘the roles and skill mix used for each component’ of the same-day access plans and over ‘developent of pathways for how the model will work locally and agreeing which groups of patients need to be re-directed to the individual’s GP practice’.
The letter says: ‘The phasing that is appropriate to each area will vary and consider what is already in place and any constraining factors that each area has, such as estates. It may be that at scale provision for a PCN can only work at a virtual level.
‘To be clear, there is no expectation that there will be a fundamental change in the same day delivery on 1 April 2024 and that this will be a process of transformation going forward. The principle of establishing same-day access models is to support general practices to free up the time available each day, to focus on proactive continuity of care and wrap-around support for their vulnerable and complex patients, many of whom have multiple long-term conditions and complex social care needs.
‘The clinical responsibility for any service provision in general practice rests with the clinician reviewing the patient and the model of care provided at PCN level sits within the clinical governance structure for each PCN.
‘The intention over the next few months is to work alongside the PCNs to understand their same-day demand and then support them in considering ways of managing this demand in a model of care which works for their individual populations and circumstances. As described above, we understand that PCNs will probably want to implement the model in a phased approach.’