Through the pandemic the news cameras and media focus has been largely on the hospital system, with distressing scenes from COVID wards and ICU. Perhaps now the focus should move onto primary care?
As it states on the NHS England website: if general practice fails the entire NHS fails. The current GP crisis long predates the pandemic, but is currently very much in the news. The RCGP's Fit for the Future blueprint for general practice set out its view of the GP crisis and potential solutions - with further detail emerging in its workforce roadmap.
Healthcare has changed beyond recognition since January 2020, when this author set out nine key changes that could revitalise general practice - but many of the core issues remain the same.
During the pandemic, the entire NHS was on a war footing, and over the past 15 months general practice has undergone a digital transformation with remote consultations as default. Addressing the RCGP virtual conference in October 2020 health and social care secretary Matt Hancock praised general practice for its rapid and 'seamless' adoption of technology and remote consultations during the pandemic, which he said had provided a ‘lifeline for the NHS’.
However, as we know the shift to remote consultation has exposed a digital divide in society and risks increasing health inequalities.
The enforced move to 'total triage' and the national advice to stop online booking and close the doors to walk-in patients seems to have fuelled a perception that GP practices have been closed. There are clearly problems with access for many patients, and mounting media pressure culminated in a recent letter advising GP practices to ‘open up’ again, causing further upset for the profession.
General practice is open
GP teams have remained open throughout the pandemic, transforming the way we work overnight: triaging COVID cases, working for the COVID Clinical Assessment Service and out-of-hours, managing many patients with long-term conditions awaiting delayed outpatient reviews and operations, dealing with the burden of long COVID, managing our day-to-day non-COVID workload - and more recently dealing with over 75% of the COVID-19 vaccine rollout thus far - plus all the associated queries.
While GPs appreciate the pressure in hospitals, and poor IT infrastructure, there is a growing sense in general practice of ‘secondary care shift’ with increasing requests in clinic letters for GPs to follow up patients, prescribe medication, arrange further investigation or make onward referrals that would ordinarily have been made in clinic.
The phenomenon has been labelled #CommunityHouseOfficer by many GPs. At the same time many emergency department teams are complaining of increasing numbers of patients attending claiming that they are unable to see their GP. Obviously both points of view have substance to them. The fact is that the entire NHS system is under great strain. We all want the best patient care - infighting helps no-one and causes upset between professionals and can erode public trust.
What are the potential solutions?
At our appraisals we look for SMART items on our personal development plans- specific, measurable, achievable, relevant, time-bound.
Small steps can make a huge difference. The 2019 changes to indemnity allowed many GPs to increase their sessions without worrying about the associated professional insurance costs, and has been a huge boost to the profession. Changes to the NHS pension might help keep some more senior GPs in work without facing punitive, discriminatory and unfair tax bills. This shows that with professional lobbying and political will things can quickly improve.
With that in mind, here is a list of 'suggestions from the coalface' to help general practice:
1. Continuity of care
Keep patients at the centre of everything. Always think ‘what is best for patient care’ and the patient's ‘journey’ through the NHS. This is particularly important at times of change, and I would argue that systems and policy should focus on continuity of care with all its recognised benefits for both patients and care providers.
2. Media campaign
A comprehensive and sustained media campaign on how best to make use of the limited NHS resources, and to dispel the false and damaging vitriol being heaped on the profession.
It is clear that many patients still do not understand new ways to access the NHS and GP care. For example the use of e-consultations for non-urgent enquiries, which allows GP teams to triage enquiries, direct problems to the correct member of the team - and save a long wait on the phone for the patient. We need a co-ordinated public information campaign, explaining the above and also showing that GPs are ‘open’ albeit in new ways.
3. Staff wellbeing
Think about practitioner wellbeing, safe working hours and workload. It is clear that we have an exhausted and demoralised workforce at risk of burnout.
Red tape and long hours are key causes of low morale and burnout. Much of the GP box-ticking is tiresome, not evidence based, adds little to patient care, and distracts us from our core work. Where GP teams are allowed freedom to deliver, they will deliver. Just look at the COVID-19 vaccination programme success.
Why not defer the QOF and Investment and Impact Fund this financial year and remove extra pressure from CQC inspections and appraisals. Any essential regulation must be light touch, supportive and respectful.
Ensure our trainees are well supported, and that their exit exams are fit for purpose and realistic - for example a virtual CSA (rather than the stressful RCA) which has been branded discriminatory).
4. Improve hospital IT to limit workload shift
Address the secondary care interface with improved IT, so that virtual hospital consultations are able to send electronic prescriptions, use interactive SMS, make their own onwards referrals and arrange their own follow-up care to prevent this being pushed into GPs. At the same time ensure that any patients attending emergency departments inappropriately are directed back to 111 or their GP, to support our hospital colleagues.
5. Ramp up and accelerate ARRS funding
With demand outstripping supply in general practice, and the chances of 6,000 new GPs being in post by 2024 looking like a pipedream, we need realistic workforce solutions. Extra staff via the PCN additional roles recruitment scheme (ARRS) are already making a significant impact, but the ARRS has been quite inflexible, with unused funds last year. We are due a massive boost in ARRS funding next financial year - which could be brought forward. The ARRS could be made fully flexible, and would immediately assist with workload pressures at the coalface.
6. Flexible working
Enable flexible working to become the norm. NHS policy suggests 'total triage' could remain a fixture in general practice post-pandemic. Remote working opens the NHS up to a whole new cohort of workers who can provide certain services such as e-consultations and telephone triage from home, simultaneously creating more consulting rooms for face-to-face appointments. We saw this workforce at scale in the COVID Clinical Assessment Service.
7. Retain experienced GPs
This must be a priority. We are hearing of many GPs reducing their sessions or leaving the profession altogether. A simple career structure might help address this in some way. Unlike our hospital colleagues, there is currently no salary progression in general practice. Seniority payments were phased out several years ago and removed as of 2020. This can be addressed easily by paying some form of seniority or time in service award to help retain senior GPs. Bring this in line with the secondary care system - just as has been achieved with indemnity.
8. Health inequalities
Schemes to address health inequalities and improve health promotion can take years to see benefits, but should be a key health policy. PCNs are ideally placed to assist education and support at a community level, to help address the lifestyle elements that contribute to many chronic diseases, and address health inequalities.
Put healthy lifestyle and the NHS as key learning on the school curriculum. Educate the public from childhood about the costs of care, the basics of NHS funding, and how to appropriately use the NHS. By educating children, they will by proxy educate their parents and households. With so many new ways to access the NHS, knowing ways to navigate the system and where, when and how to seek care for urgent and non urgent problems - could help everyone appreciate and make best use of the limited resources available.
9. GP consultants
Perhaps we could rename GPs ‘consultants in family medicine’ or ‘consultants in primary care' to recognise in both name and job description the highly specialised and the complex care that we are providing. GPs are increasingly responsible for clinical leadership within their PCNs, and supporting and mentoring a wide range of ARRS staff. Giving GPs consultant status and recognition would bring various benefits in both public opinion and professional regard.
10. Encourage GP partnerships
We are rapidly losing a partner-led GP workforce who would stay in post for a career and be the traditional ‘family doctor’ running their practices. We have a shift to salaried and locum GPs who work on sessional rates and do not have the commitment or responsibility required to run practices, which often erodes continuity of care.
Traditional general practice has always been maintained by the partnership model in running premises, recruiting staff and ensuring all the mandatory training and regulations are in place. If the partnership model goes, who will take all this on? The importance of the partnership model has been highlighted by a formal review. There is no good reason why the current general practice contract could not bring back a financial incentive per partner (pro rata) to incentivise and re-invigorate partnerships once again.
Bedrock of the NHS
Being an NHS GP has to be one of the most varied, rewarding, and interesting jobs available. However, it is becoming increasingly demanding, complex and challenging, leading to poor morale and burnout. The five-year GP contract framework published in 2019 stated that: 'General practice is the bedrock of the NHS, and the NHS relies on it to survive and thrive’.
If the pandemic has taught us anything it should be the need for strong, adequately resourced public health and primary care. Urgent action is clearly needed to reverse the crisis in general practice, and many issues have relatively simple solutions. Implementing these solutions should be a national priority, and requires political will and focus.
- Dr Simon Hodes (@DrSimonHodes) has worked as a GP partner in the same Watford practice since 2001, and is also a GP trainer, appraiser and LMC rep. The views expressed above are his own.