The Kings Fund: Understanding Pressures in Primary Care
This is a typically well-written and closely argued King’s Fund report which elegantly sets out the problems that have increasingly beset general practice over recent years. It actually draws on evidence from practitioners and staff working in four case study sites in Plymouth, Shrewsbury, Sheffield and London, and, as such, has quotations that are redolent with authenticity. Readers are encouraged look at these, especially in chapters four and five. These make a refreshing change from the usual cant phrases about “working closely with stakeholders, pushing the envelope” and so on which more often than not mean little to real people struggling to do the work. We read about patients rarely presenting with one or two problems these days, of the fragmentation of society leading to less confidence dealing with self-limiting illness, the 24/7 culture meaning that people are less willing to wait for anything, the added uncertainty and time required for consultations carried on via an interpreter and the work added by QOF requirements (in a Bristol University study 43% of consultations included an extra question raised by the GP concerning this) and the fact that pre-bookable routine appointments are scarce leads patients “upping the ante” to get seen. Other services, especially in mental health and community nursing, can “close their doors” and GPs cannot.
It is necessary that a document as good as this will once again have to state facts all too well known although this time there is some proper evidence from 177 practices as well as the vignettes from the case study sites. One of the key points made is that better data about primary care activity, more like that now routinely collected about, for example, hospital waiting times or A&E ambulance handover times, would have provided advanced warning of the crisis and the DH and NHSE is criticised for not collecting it.
We read that face-to-face consultations increased by 15% from 2010/11 to 2014/15 and telephone consultations by a massive 63%. Unfortunately this has tended to be work “bolted on” to the normal working day. Over the same period the GP workforce grew by 4.75% but funding for primary care fell from 8.3% to 7.9% as a proportion of the overall NHS budget. Work is more complex as people live longer, survive with more long term conditions, more work has shifted out of hospital without commensurate funding and rising public expectations. Patient satisfaction with general practice remains high but is falling. Surveys show that NHS GPs are more stressed than their counterparts abroad. As well as recruitment, retention is proving difficult with older GPs choosing to retire early and the reduction in the lifetime pensions allowance and seniority payments have proved added disincentives to continue to work. More GPs are opting to work part-time, as salaried doctors or in portfolio careers and, whereas in the past, this was something which female and older male doctors chose to do, nowadays training GPs of both sexes are tending to prefer these options. A letter in the Daily Telegraph on 7th May from a presumably retired doctor characterised this as “doctors can afford not to work full-time” which is, we suppose, another point of view. However that does not address the shortage of practice nurses and practice managers. The trend to part-time working is also at odds with the drive for continuity of care emphasised by successive governments.
The King’s Fund is blunt as says that to “avoid the service falling apart” there must be practical support to apply established quality and service improvement techniques, accelerate the uptake of ways of working that can help deal with rising pressures (such as telephone triage and email consultations), further development of the role of nurses, pharmacists, physician associates, health coaches and volunteers. It also points out that supporting existing staff is as important as recruiting new ones. The bureaucratic burden must be reduced and dealings with secondary care and the CQC are specifically named. One of the best sections says,
“The complex and piecemeal nature of funding for general practice places a significant burden on practice managers and …partners. An adversarial approach to commissioning and contracting (my italics) has resulted in a ‘shopping list’ of tasks required of GPs from commissioners and politicians, and a protectionist responsive from general practice, with a lack of trust on both sides and a sense that each…is being taken for granted. Any commissioning of new models of care will need to carefully consider how these models will be transacted and how money and risk will flow, as perverse consequences are likely to undermine effort.”
CCGs are therefore encouraged to place general practice at the heart of sustainability and transformation funds. Patients should be “support[ed]” to use services more appropriately with signposting to other providers as well as to the wider primary care team. This requires initial triage at the highest level to prevent the GP remaining “the fount of all knowledge” for their staff as well as for the patients. Ipsos Mori found in 2016 that 75% of callers wanted to see a GP and only 6.7% wanted a telephone conversation.
The holy grail of working at scale through multi-speciality community providers and accountable joint ventures whilst making sure that the innovative new services are responsive to local people is seen as a longer term aim. Health Education England should also recognise the new career preferences of young doctors when designing training.
The report concludes that the huge range of clinical leadership already required from GPs already detracts from patient care The development of new models of care will require even more experienced GPs to focus further on managerial roles at a time of ever rising demand and this will have to be factored in to plans. Given that the extra funding for primary care set out until 2020/21 in the GPFV is supposed to extend opening hours and access further. This is clearly impossible and extra workforce will be required keep things as they are let alone to try to match supply with (supply-induced?) demand. General practice needs adequate and stable funding for core services. “NHS England should commit to reporting on progress towards matching capacity and funding to demand based on new monitoring systems that can provide real-time analysis of activity and demand.”
It seems to this reviewer that NHSE, already expecting “fewer delivery points” for primary care in future will also try to achieve matching demand with more staff who are less likely to be full-time GP partners. Perhaps the time is approaching for honesty about what this will mean for traditional general practice, that clichéd “jewel in the crown”, and continuity of care and how it is defined: in the words of one GP in the report,
“patients want immediacy, but immediacy with the doctor of their choice at the time of their choice. And that’s the gold standard…We’d all like that, but there seems little understanding among patients that that isn’t actually possible.”
But then again, as Shakespeare’s Portia so very nearly said, “all that glisters is not gold [standard].”
Margaret Thatcher was criticised for using private medicine so that she could see a doctor of her own choice when it suited her. Tony Blair, with this in mind, said that patients should be able to see who they like, where they like, when they like on the NHS and pledged to increase NHS funding to the EU average to achieve this. But the concept of one seer in PCT times that access would be transformed so that we would hear “the patient will see you now doctor” seems even more ridiculous now than it did then. In 1997 Blair said, “The White Paper we are publishing today marks a turning point for the NHS. It replaces the internal market with "integrated care". We will put doctors and nurses in the driving seat. The result will be that £1 billion of unnecessary red tape will be saved and the money put into frontline patient care. For the first time the need to ensure that high quality care is spread throughout the service will be taken seriously. National standards of care will be guaranteed. There will be easier and swifter access to the NHS when you need it. Our approach combines efficiency and quality with a belief in fairness and partnership. Comparing not competing will drive efficiency.”
This time we can only hope that it will be different.
Dr Barry Moyse
Deputy Medical Director