Like much of the rest of the country, general practice in London is at breaking point. In 2016 Londonwide LMCs declared a 'state of emergency' and launched a campaign to highlight the problems practices face and a toolkit to help them push back against inappropriate work.
For many practices in the capital, life remains tough. At this month’s Londonwide LMCs’ conference chief executive Dr Michelle Drage described the situation as ‘dire’. Speaking to GPonline she says that last year around one practice a week contacted the LMC's support service because they were ‘under deep threat of closure’.
‘Of those I think we managed to save - in one way or another including mergers - about half of them,’ Dr Drage says. ‘For us that’s 50% not saved. But it’s also 50% saved.’
She believes that there are steps NHS England and policymakers could take to help alleviate the pressure on GPs. In the short term they could reduce the admin burden on practices, by 'switching off' everything not related to frontline care and streamlining regulation, including revalidation, appraisal and CQC inspections.
System is 'broken'
In the longer term Dr Drage says the system needs transforming ‘because it’s broken’. ‘It’s broken when you’ve got colleagues facing 70 consults a day. That’s just unsustainable. So we’ve got a demand problem, and we’ve got a supply problem.’
She says the key to reducing workload and making general practice more sustainable is better integration between primary care, community services and social care. Policymakers are too focused on trying to integrate hospitals with primary care, which is ‘the wrong way round’.
She says NHS England is starting to embrace the Primary Care Home model and the idea of primary care networks, but 'they've done it in a way that still doesn't get what it's about. They've seen that as a journey to something that they can contract with on an at-scale basis - they have to contractualise everything.'
By focusing on integration of community services ‘in its broadest sense’, managers and politicians ‘would get what they wanted,’ says Dr Drage. ‘Which is better services, faster flow through hospitals, fewer of the wrong patients in acute care.’
Social prescribing could help support this integration, although she does not believe that in itself it is a solution to spiralling GP workloads. ‘It’s one of the things that aligns with the community focus and the integration of community services. But it only works where you’ve got good existing community services,' Dr Drage says.
‘I take issue with the prescribing word because it perpetuates the medical model. It’s just an illustration to me of integrated community and social and mental health services with the patient at the centre. So if you’re using [social prescribing] as a proxy to drive all of those things then it’s a good thing. If it’s just seen to be the next messiah it’s going to have a very variable impact unless people look at what you need to make it work.’
Dr Drage says in boroughs that have been ‘bled dry’ it is much harder to get initiatives like social prescribing off the ground, which can make people feel cynical. More funding would help, but better management is the key to delivering improvements and integration, she argues.
‘Everything needs more funding and resources and should have it. But it needs better management and support and a focus. If the effort that was put into micro-managing GP contracts and trying to get hospitals integrated into the rest of the system was spent on building community services and social prescribing I think you’d get much more traction and much more delivery.’
Giving the mayor’s office more control over health policy in the capital could also help deliver this change and improve the situation for London's GPs, Dr Drage believes.
Some things are better done regionally, she says, ‘particularly in London, where our needs and services are completely different to most of the rest of the country’. However she warns that a replication of Manchester's devolution deal may not be the best solution for the capital.
'Manchester is a single thing for 2m people. Here we’ve got 9m people, 33 boroughs, umpteen hospitals in the wrong place. It’s really complex,' Dr Drage explains.
‘I want an arrangement for London that works for London’s people - where the mayor’s office has much more than a token acknowledgement of health issues. And I’d like to see the NHS in London not having to kowtow to national performance management priorities for populations that are vastly different to the national average.
‘This is a massive political challenge and it is really difficult. In the absence of that I think we should work as if we could do this - things could be possible. We could change the focus in London to focus on communities rather than acutes. That doesn’t mean we starve acutes of resources, it means we help them to do the job that they do best.’
She would also like to see a London approach to GP recruitment and retention. She says London has ‘more trainees than we’ve got training places for and yet we’re hungry for GPs’.
‘We’re training for the rest of the country, or for Australia. Surely it’s not beyond anyone’s wit to say we’ve got this number of places, we’ve got this amount of need - let’s try and match the training with the need.’
With significant changes to the system likely to be some time off, day-to-day the LMC remains focused on supporting GPs and their teams. The next step in the its state of emergency campaign is a new app, Beam to LMC, which allows GPs to report any cases of inappropriate or unnecessary work they are asked to do, or ‘other frustrating stuff’, quickly and easily to the LMC.
The LMC has a dedicated practice support service for issues that need urgent attention, but Dr Drage hopes that the app will help it identify trends or issues it should look into – as well as providing a place for GPs to ‘off-load’ about some of the non-urgent issues that are ‘driving them mad’ in their day-to-day roles.
Getting this right, she says, will help the LMC not only meet the needs of the 1,271 practices it represents across 27 local LMC areas, but also help ensure 'the continuation of safe, quality care for our registered patients'.