Tackling the crisis in general practice
BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i942 (Published 17 February 2016) Cite this as: BMJ 2016;352:i942
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Martin Roland and Sam Everington rightly highlight the crisis in general practice and the need for greater investment in community and social services. However, there is a third “elephant in the room” they do not mention and that is the continued support for the current small business ‘independent’ contractor status in general practice that no longer gives GPs, as already de facto ‘employees’ of the NHS, much of the autonomy that GPs once had. The crisis has highlighted the complexity and inequity of current funding models with 3 different contracts that deliver variable and inequitable reimbursement based neither on measured workload nor population need. The average £136 per patient masks the significant variation where APMS practices received £192.85 per patient, compared with £140.52 for PMS practices and £131.45 for GMS practices in the last financial year (1), and further variation between GMS practices based on historic calculations. Furthermore, mixing money intended for patient services with money intended for GP remuneration can lead to government reluctance to invest more in General Practice for fear that money intended for service improvement will end up boosting GP income.
At a time when an increasing number of general practices are closing down, it is becoming increasingly clear that this is too small a unit to carry the risk of unpredictable financial burdens such as maternity leave or sick leave let alone long-term high cost locums. Ultimately it is patients who suffer, particularly those in inner city or rural practices that receive little financial allowance for deprivation within current funding arrangements, and it is unlikely that a new ‘fair funding formula’ will address this. The knock-on effects of the funding shortfall in these struggling practices are seen in the difficulties they have in recruiting GPs who turn away from the burdens of running a practice with the low reimbursement on offer. Young doctors want clear job plans, career progression, time for management and clinical leadership plus guaranteed employment rights such as maternity, paternity and sick pay. We need to build on federations developing NHS primary care provider organisations that are not-for-profit, and employ GPs and practice staff with mandatory standard NHS contracts. Our representative bodies need to lead this change or ultimately NHS general practice may become unviable.
1. http://www.pulsetoday.co.uk/your-practice/practice-topics/pay/average-gp...
Competing interests: No competing interests
Blaming 'the public' won't help if people in general and in local communities are uninformed about what is concerning healthworkers. Not everyone follows the ins and outs of what is happening in the NHS. And if there is not an open debate as Emma Rowley-Conwy suggests it won't change anything to simply blame the government, scapegoating 'the public' will simply antagonise.
Very little information about the detailed cost of running the NHS is in fact made public. But there are opportunities for debate within local areas, although it rarely happens. There could be a useful educational open debate to discuss reasons people are returning more often than considered necessary to E. Rowley-Conwy's surgery ... the 10% may not have been reassured or satisfied with the consultation; they may not have the confidence to say so; if they have caught the news about 'tired doctors making mistakes' they may be worried; if they have had a relationship with the NHS since the early days of its inception they may have a different understanding to younger health workers; if the initial contact via receptionists is rude or unhelpful it reflects on a practice. Making standard responses to complaints on feedback sites doesn't change much in reality. Some practices have successfully managed to solve problems. There could be a hub where suggestions of better arranging working time could be shared. There are people in communities who would be willing to assist in preparing information sheets to raise awareness of costs of services and medications and other issues relevant to the area.
But information also needs to show how much the practice or clinic is earning - paid per consultation; how much income is generated per individual registered; how much additional income is earned for different procedures or targets reached. Some of those who do become interested and properly informed will probably begin to more closely evaluate the services received and wish to have involvement in what is provided. A different and more mature relationship than that which has historically been possible could evolve in (oft mis-used word) 'partnership' with all sections of communities out of this critical period in the NHS.
Competing interests: No competing interests
We agree with many of the points made by Roland and Everington in their editorial on the crisis in general practice, but do think they have missed one of the elephants in the room: public health.(1) Urgent action is needed in key areas including smoking, obesity, and mental health. In addition, and related to all of these, is the ubiquitous problem of inequalities.(2,3) We believe that there is a growing consensus that public health action is needed to improve health and wellbeing, tackle inequalities, and relieve some of the burden on our overloaded NHS.(4,5,6)
Potentially, general practice has key roles to play in promoting health both at an individual and community level.(7) However, a recent scoping study found evidence that GPs often feel ill equipped to give prevention and health promotion advice to patients.(8) Furthermore, in relation to effectiveness, for many topics it is important that there is action in other settings as well, including workplaces; schools; and local communities. Public health departments should be coordinating and facilitating such activities and providing training for a wide range of professionals including doctors and nurses.
Although in the past there has been a dearth of information about the effectiveness of health promotion in the primary care setting, health promotion theory provides a number of frameworks that should be used to guide action.(7,9) Also, there are a growing number of reviews that highlight opportunities, especially in public health priority areas.(e.g. 10-13)
It is clear to us that funding in general practice is lower than current needs: a shortfall of over 3000 GPs has been estimated.(14-18) In addition, and critical for population health, is the geographical inequity in the provision of GPs. The workforce is unevenly spread across the country, with the fewest doctors in the areas of greatest need.(19) This has the potential to exacerbate health inequalities.
We are in no doubt that general practice has the potential to play crucial roles in maintaining and improving the health of local populations. However, doctors and nurses must be given the tools to undertake the tasks. Fundamental to this is having adequate capacity and sufficient resources; these are essential in relation to developing high quality health outcomes. The Government must re-order its priorities towards prevention and health promotion: funds must be found to tackle this crisis in general practice.
References
1) Roland M and Everington S. Tackling the crisis in general practice. BMJ 2016;352:i942.
2) Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012;380:37–43
3) Charlton J, Rudisill C, Bhattarai N, et al. Impact of deprivation on occurrence, outcomes and health care costs of people with multiple morbidity. J Health Serv Res Policy 2013;18:215–23
4) Wanless D. Securing our future health: taking a long-term view. Final report. 2002. http: //si.easp.es/derechosciudadania/wp-content/uploads/2009/10/4.Informe-Wanless.pdf.
5) Marmot M. Fair society, healthy lives: strategic review of health inequalities in England post-2010. 2010. www.instituteofhealthequity.org/projects/fair-society-healthy-lives-them....
6) NHS England, Public Health England, Monitor, Care Quality Commission, Health Education England. Five year forward view. 2014. www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf.
7) Watson, M., Going for gold: the health promoting general practice. Quality in Primary Care. 2008; 16:177-185.
8) Peckham S, Falconer J, Gillam S, Hann A, Kendall S, Nanchahal K, et al. The organisation and delivery of health improvement in general practice and primary care: a scoping study. Health Serv Deliv Res 2015;3(29).
9) Tones K and Tilford S. Health Promotion: effectiveness, efficiency and equity. Cheltenham: Nelson Thornes, 2001
10) BMA. Alcohol misuse: tackling the UK epidemic. London: BMA, 2008.
11) Academy of Medical Royal Colleges. Measuring Up: The Medical Profession’s Prescription for the Nations Obesity Crisis. London: Academy of Medical Royal Colleges 2013.
12) BMA. Promoting a tobacco-free society. London: BMA, 2015.
13) Watson M C and Errington G. Preventing unintentional injuries in children: successful approaches. Paediatrics and Child Health. 2016. http://dx.doi.org/10.1016/j.paed.2015.12.006
14) Goddard M, Gravelle H, Hole A, Marini G. Where did all the GPs go? Increasing supply and geographical equity in England and Scotland. Journal of Health Services Research & Policy. 2010. 15(1): 28–35.
15) Centre for Workforce Intelligence. In-depth review of the general practitioner workforce. 2014. www.cfwi.org.uk/publications/in-depth-review-of-the-gp-workforce.
16) NHS GP Taskforce. Securing the future GP workforce—delivering the mandate on GP expansion. 2014. http://hee.nhs.uk/wp-content/uploads/sites/321/2014/07/GP-Taskforce-repo....
17) Limb M. Increase GP trainees by 450 a year to avoid crisis, says taskforce. BMJ2014;349:g4799.
18) Royal College of General Practitioners. Seven day access to routine general practice – position paper. London: RCGP, 2015
19) Baker M, Ware J, Morgan K. Time to put patients first by investing in general practice. Br J Gen Pract 2014;64:268–9.
Competing interests: No competing interests
Your editorial hits the nail on the head. However as others have said, I suspect there is not going to BE any more money; it is clear the plan is to continue to privatise the NHS.
I have been a GP long enough to remember when a ten minute consultation was a luxury, most of my patients did not live so long and have complex multiple morbidity, and my young patients even in the deprived area I worked in, had an idea about how to look after themselves. Our hospital colleagues were generalists with a special interest, to whom we could speak if we had a concern. Now I work in another deprived area, patients have more info at their fingertips (literally) than ever before, yet seem to be unable to manage the simplest illness. Hospital colleagues are inaccessible, and so specialised they generally seem only to treat organs.
Elderly people require increasingly complex input, so I take issue with a colleague's RR 'In my youth, consultations took 8 minutes, now they take 12 to 15 minutes. If we are taking twice as long per consultation, then we are seeing only half the number of patients.' I can spend up to 40 mins with a patient, but with ten minute bookings I still see as many. I am past caring about keeping folk waiting. If they complain (which they generally don't; either they have waited at least two weeks to see me, or I have telephone triaged them that day) I tell them they will wait a lot longer in the ED. Most of them are very appreciative. I don't want to end my career with a complaint, and spend time at night worrying about patients I maybe should have admitted but in my efforts to be a good GP have kept them out of the ED and managed them myself. The single organ doctor scenario at the hospital doesn't help - care is increasingly fragmented for people who need joined up thinking in secondary care too. Whoever invented PBR should be sacked!
Patient education and management of expectations is a priority. This government loves to encourage people to 'want' not 'need'. Whether it is an ambulance, a same day appointment, a drug or a hospital referral. Yet there is no desire seriously to tackle the causes of health inequalities and disease, or encourage self care.
I spend endless time picking up the pieces from the savage cuts in social care. And sorting out elderly who have been discharged too soon. And filling out ridiculous forms. Competing my appraisal. Ensuring safeguarding stuff is sorted.
My practice manager is wearing himself out preparing for a CQC inspection when I would rather he helped us sort out a better appointment system to try to manage the demand.
I am 55 and though I love my work and genuinely relish almost every consultation on a human and holistic level, I am seriously considering my future. I don't want more money, I want less work, so I can worry less about missing things / making a mistake, so I can keep up with my education, so I don't have to log on to the practice at night and weekends to mop up, not be the 'ask your GP' dumping ground for everyone else's stuff. I want to do the job I trained to do.
Competing interests: No competing interests
Increased funding would be very welcome, but I agree it is unlikely to happen in this current parliament, So we need to look for solutions which will reduce demand, because If we increase capacity without addressing demand, the capacity will soon be swamped. We need to start a real and open debate with the public about what primary care should provide, and what it won't do, and how this precious resource should be used responsibly.
This week in my practice about 10% of patients I saw had already been seen in the previous week - and yet we only have 3.5 appointments per patient per year. Our recent demand survey showed that in order to meet the demand that we know about, I.e. Those patients who managed to get through on the phone, we would have to increase capacity by 50%, but I have yet to see a patient who has suffered harm because they could not get an appointment. In my view there is a widening gap between what patients want from primary care and what they actually need.
I am not in favour of charging for consultations, as I think this will lead to a huge administrative burden for general practice, but I do think the public need to understand the value of what they are getting in monetary terms. Why don't we have the cost of drugs on FP10's and on dispensing labels? And the cost of care on appointment cards and in appointment letters? And the cost of admission on the discharge summary? This may go some way to helping the majority of patients to appreciate what they are getting, free at the point of care, and maybe then they will use it more responsibly,.
But most importantly, we need to define more clearly to the public what we will not do, so don't waste our time asking us. For example, in most areas cosmetic treatments are not funded by the NHS, but this information is not in the public domain. We need to work with the public to agree what is the purpose and function of primary care, and have a clear and open list of what is excluded and cannot be provided, and make this consistent across the whole of primary care.
Competing interests: No competing interests
I agree in general terms with the recommendations made by Roland and Everington in their editorial on the crisis in general practice, but do take issue with the suggestion that new funding should be ploughed into employing more staff to deal with increasing bureaucracy. Surely the better policy is simply to abolish unnecessary bureaucracy. The danger otherwise is that Parkinson's Law comes into effect. What is the evidence that Appraisal and Revalidation are of meaningful value? Why the profusion of care plans? Why the pressure to attend evening meetings on service re-design? Why, as the authors do point out, the profligate and unselective application of CQC inspections? Let's tackle the causes of increased workload, not look at ways of accommodating it.
Competing interests: No competing interests
At last a welcome and constructive contribution to the debate. In order to achieve the ambition of a fully functioning and modern NHS, accessible to all at the point of need, there must be adequate investment in workforce, infrastructure and morale. Here are some sensible quick wins, and would help to regain the confidence of the profession. The tax-payer will have to dig deeper into their pockets, and the NHS must reorder its priorities toward prevention and proactive intervention. The prize will be a healthier Health Service.
Competing interests: Greater Manchester Primary Care champion for seven day access
For many reasons patients have lost confidence in managing their own health and that of their children/ families. Without increased funding and support for educational campaigns on eg management of minor illnesses we will continue to see general practice clogged with presentations earlier and earlier in the course of self -limiting illnesses and increasing access will only continue to squeeze out those patients with real health needs. How can GPs tackle this in a short appointment? Patients want access to their GP quickly but is it really in their best interests?
Competing interests: No competing interests
General Practice in developing countries: A SWOC analysis.
General practice is the backbone of the health care delivery system in almost all developing countries. Martin Roland and Sam Everington describe the crises in general practice and the NHS. The scenario in developed countries may be different, but in developing countries GPs have their own strength and weakness .
Strength of General practice:
In developing countries like India and countries of the Afro–Asian continent, the health care delivery system is mainly based on general practice for primary health care delivery. We must use the checklist manifesto like the Dutch College of General Practitioners (1).
Weakness:
1. The laws of the land
2. Consumerism .
3. Lack of standards from accreditation agencies.
4. Insurance coverage.
5. Improper maintenance of a registry of GPs.
Opportunities:
1. Opportunities are plenty.
2. They can reduce the burden on secondary, tertiary and super specialty centers for the most commonly occurring diseases like fever, colds, routine check ups, etc.
3. Improper implementation of recommendations made by various NGOs, Committees and experts.
Challenges:
1. Lack of advanced skill.
2. Lack of funding.
3. Lack of advanced technology as well as instruments for better health care delivery.
In conclusion
Governing agencies must look into these matters seriously and pass guidelines (2). Encouraging and funding accreditation as well as regulatory bodies to conduct CMEs regularly on both communicable and non-communicable disorders. Improving curriculum. Extending insurance coverage to GPs also. Financial support to the GPs to acquire new skills, new instruments, etc. Conducting workshops to reduce stress level as well developing soft skills. These all may help GPs overcome the crises mentioned by Martin Roland and Sam Everington.
References:
1. Thomas S. Standard setting in the Netherlands: impact of the human factor on guideline development. Br J Gen Pract1994;44:242–24
2. Grol R. Beliefs and evidence in changing clinical practice. BMJ 1997;315:418–421.
Competing interests: No competing interests
Crisis, what crisis?
Dear Editor,
I agree with Rowley-Conwy (1) and Hopkins (2) that we should turn the attention to the taps and not the mops.
I disagree however that we should attempt to discourage patients by putting up barriers, 'educate', or charge a flat fee.
I want to provide a good service, I do not think it is right that 'we' tell the patients which problems are 'inappropriate' for our service, I see berating or restricting patients as paternalistic, which is disrespectful to our patients.
A flat fee is inequitable, the fee should represent the income of the patient and the useage (per minute relating to staff grade) and effectiveness of the intervention. Fees need not cause an additional administrative burden as it could be collected by government through an NHS Credit card with biometrics, which would immediately also determine eligibility for NHS care. Fee levels could be determined by Inland Revenue and the DHSS that have the necessary information. Discounts could be offered if for instance the HbA1c is in range etc. rewarding patients for positive contributions to the NHS.
Capitation fees could be continued for practices to prevent provider induced demand and align the provider's incentives with those of the patients: To maximise efficiency.
This would leave our patients free to choose to book with the GP instead of the nurse for a blood pressure check, or to have their repeat medication issued by the GP, if they want to pay the additional cost, or book with the nurse or order medication at the reception if they do not want to pay the extra. They could choose to see the GP for their toothache instead of the dentist, discuss their benefits instead of attending social services or the citizen's advise bureau. Make an appointment to drop in an insurance report request instead of leaving it at reception and relate their experience in the hospital to the GP instead of contacting the hospital complaints department. Come in to get the sick note or prescription the hospital failed to issue them, have a home visit even though it may be more costly than ordering a cab to the surgery. Have an MRI scan instead of waiting a few weeks to see if things settle, attend A&E for the additional fee, forfeit the attendance fee and not turn up for appointments.
We need to trust our patients to make the right choices, but we need to accept that in healthcare as everywhere in life actions have consequences.
There is a crisis of inefficiency in the NHS, which could be soved politically when the will is there or when reality can no longer be glossed over by our representatives.
(1) http://www.bmj.com/content/352/bmj.i942/rr-3
(2) http://www.bmj.com/content/352/bmj.i942/rr
Competing interests: No competing interests