General Practice - Appointments, Capacity and Choice

Talk to anyone about the thing that irritates them about General Practice and the first thing they mention is appointments. It’s not just the patients! The staff also feel the pressure on appointments.

How can we increase capacity in General Practice so that there are enough appointments when there are a falling number of GPs?  What is ‘enough’ appointments anyway?

There are those who say we should also increase choice for patients in where they go for primary care – “more surgeries” is the cry.

The digital solution

There are several websites or Apps, such as http://askmygp.uk/ that allow people to enter their symptoms and answering some questions allows the GP to work out the best way to help.  These may advise the patient as to who is best p[laced to help them. This may create some spare capacity so that those who need to see a GP, such as people with complex needs, can do so.

The ‘do it on the phone’ solution

Instead of seeing a GP or other healthcare professional the patients the consultation will take place on the telephone or via Skype or some form of webcam interaction or by email. There are a number of solutions available to manage phone calls such as http://gpaccess.uk/ & http://www.digitallifesciences.co.uk/

Both of the above solutions could also be considered the ‘managing the demand side’ solutions.

The Changing traditional General Practice or more GP surgeries solution

(‘more of the same’)

This solution is about increasing the number of GP surgeries so increasing the number of appointments and increasing choice for patients.

So how do you go about developing a new surgery? You need to raise the cash to buy or rent a suitable building. You need to recruit the relevant staff. That means a full multi-disciplinary team to provide a 21^st century service. The cost of a building for 6000 patients could be around £1.5 million but could be more if an extended team is required.

 This investment has to come from somewhere.  There is the Prime Minister Innovation Fund (now with a smart new name) that was for existing practices if they developed 7 day working. There has not been any funding for new builds from central government for the last 25 years or so. If there is a new housing development and if the local planning authority is up to the mark such a new building could come from ‘planning gain’ and built into the cost of the development. However the developers would only build the bare minimum – based on 1990’s requirements.

However there is still the problem of revenue costs which has to currently come from the NHS. Unless, of course, there is a change in the views of the public on private healthcare or health insurance.

Finally there is the problem of recruiting the staff. GPs and nurses are hard to recruit or retain at the moment.

The nuclear solution

One way of increasing appointments with a GP is to do the reverse.  Patients will only see a GP after they have been seen by another health care professional, (a nurse, a pharmacist or an emergency care professional).  They would refer patients onto a GP as appropriate in the same way as a GP refers to a consultant.  Thus the GPs would see fewer patients.

Other solutions

• Reduce unmanageable & unsafe workload
• Improve perception of General Practice as a career option for junior doctors & nurses.
• Reduce administrative & regulatory burden.
• Return to self-management of minor illness.

There is a final solution 

There could be real and meaningful investment to restore the percentage of the NHS budget spent on General Practice back to the 10% it used to be.

So how will these solutions increase choice and capacity?

Really the only solutions to do that are ‘the more of the same’ solution of increasing traditional general practice by increasing the number of practices.

This is highly unlikely given that there is no investment in new building and real problems in recruiting new GPs.  If the government does not invest will private investors take that role?  Again, in my opinion, I think that is unlikely as there is no profit to be made from general practice at present.

Would a community enterprise or other not for profit organisations invest in general practice?  That is an interesting question.

So sadly I can see no way to increase choice for patients.

Similarly the only way for general practice to survive is to manage demand rather than increase supply.

#GPincrisis

Urgent prescription for general practice

Impact of a shortage of GPs

In many parts of the country GP surgeries are having trouble recruiting Doctors and Practice Nurses. 

What impact is this having on patients and the care they receive?

My guess:

·        There will be a shortage of appointments, so patients will have to wait longer to see a GP.

·        Telephone lines will be even busier so it will be harder to contact the surgery.

·        Patients will be asked (forced) to see someone other than a GP.  This may be a Practice Nurse or a pharmacist.

·        More locum staff may be employed.

·        Practices may close completely.

·        Surgeries will close their lists to new patients.

·        Branch surgeries will be closed.

New patients will have to join another practice which may be some distance away from their home.

This will put pressure on these other practices as they get more patients joining the practice and the cycle continues.

Don't just talk - do something.

Have you ever talked about your GP surgery over dinner, sitting in a café, standing in the checkout at the supermarket….?

Well you are not alone!

A Million people a day use their GP surgery and most of those will have something to say about the experience.

Most of those experiences are good.

However sometimes us patients have ideas about how to make the experience of talking with a GP or practice nurse better.

There can be problems with the phone service, making appointments isn’t always easy, seeing your own GP can mean waiting weeks, no privacy at the reception desk, access can be difficult for those with disabilities and as for car parking…!

So instead of talking about things on your own – join your Practice Patient Participation Group (PPG) and do something about them.

A patient participation group is a bunch of volunteers who want to make a difference.  They work with the practice to gather information from patients and to make suggestions about improvements.

They look at the surgery and ask:

What works well?

What works less well?

Are there services that are not provided but would benefit patients?

They also run an annual patient survey, hopefully the questions are set by the patients not the surgery.

Sadly General Practice is going to have to change. Being part of your PPG is one way you can help to make sure we keep the best bits of General Practice

Your voice on its own is very quiet.

But the voice of the many people in the PPG is much louder and will be listened to.

Please join your Practice Patient Participation Group.

Ask at reception or look on the practice website.  Maybe there is a social media page?

Has General Practice passed the tipping point?

Is this the future?

Unless something dramatic or revolutionary happens at the Department of Health after the election have we seen the end of General Practice as we know it?

Here are three possible scenarios.

Scenario 1.

GPs become consultants in the management of patients with complex and unsorted symptoms. Everything else i.e. minor illnesses, uncomplicated long term conditions, social issues, work related problems, etc. will be managed by other members of the Primary Care Team: Pharmacists, advanced nurse practitioners and physician assistants.

The GP will assess, investigate and sort out patients presenting with undifferentiated symptoms and look after patients with multiple co-morbidities and complex needs.

Patients will no longer have direct access to a GP.

Scenario 2

GPs will become disease specific consultants working in the community.  All acute patients will be managed by pharmacists, NHS 11, nurse clinics & physician assistants.

 Patients will no longer have direct access to a GP.

Scenario 3

Co-payments. Patients will pay for their primary care, perhaps with government paying for a set number of  consultations per year.

Personally I do not think that civil servants and politicians do ‘revolutionary’!

I am sure there are others scenarios.  Please suggest some.

Possible models of General Practice

Any number of organisations have looked at the possible models of General Practice in England (see below for some recent examples).  They have produced lots of glossy pages describing the issues and possible models.

So we thought we would produce a short list of the possible ways that a local community could get its GP service provided. In no particular order.

“The Status Quo”.  The partnership option.

Under the current circumstances, unless the government changes its attitude this is not a realistic option.

A Salaried service with GPs.

a)    Through Foundation Trust Hospital – Vertical integration.

b)    Through private companies i) groups of GPs, ii) multi-national companies iii) venture Funds etc.

A nurse led service

This would probably be with GPs as community specialists/consultants at a distance. (There would be no doctor as first point of contact, no legal right to a GP).

Walk In centres.

Patients would be triaged and referred onto the ‘appropriate’ Healthcare provider.

NHS111

All access to healthcare would be through NHS111 call centres

Federation

GP practices merge or federate to form a large organisation (Management & Admin merged to save money & probably staff used across all sites rather than based on a specific site).

Investment by Government

You never know it might happen. The government realises that the current system is the envy of the world and invests to support the development and innovation that has taken place over the last 30 years

I may look at the advantages and disadvantages of these options at a future date.

 Further reading

Nuffield Trust

http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/130718_securing_the_future_revised.pdf

RCGP

http://www.rcgp.org.uk/campaign-home/~/media/Files/Policy/A-Z-policy/The-2022-GP-A-Vision-for-General-Practice-in-the-Future-NHS.ashx

Kings Fund

http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/commissioning-and-funding-general-practice-kingsfund-feb14.pdf

NHS England A call to action

http://www.england.nhs.uk/wp-content/uploads/2014/03/emerging-findings-rep.pdf

How can the public hold Clinical Commissioning Groups to account

I think that 'holding to account' means that the public must be confident that the Clinical Commissioning Groups (CCGs) are answerable to the public and patients for the decisions they make on our behalf.

The sorts of decisions they will be making (maybe they have already made them) are:

• What healthcare do we need.
• How much.
• The quality of the care
• Where the care will be delivered and by whom.
• How long will it take to get treated.

There will be over 200 CCGs.  Our is a small one with only 190,00 people and a budget of about £200M.  Others will be much bigger and responsible for very large sums of public money. So it is crucial that they use this money for the benefit of their local population and get value for money.

So how can we hold these organisations to account.  It will not be easy as individuals to do so.  Organisations of this sort can hide behind a number of barriers. They use the Freedom of Information Act to delay answering questions.  They can also use the idea of 'Commercial Confidentiality' to avoid giving answers about the value of contracts, especially with private healthcare providers.  They also use jargon to confuse us.  Lastly one of the ways to ask them questions is at board meetings held in public and that isn't easy for many people. It isn't much fun standing up in from the board and holding them to account.

However there are a number of ways that the public can make sure they spend our money wisely and on healthcare that will benefit us.

Ask questions at meetings

CCG boards will have to hold their meetings in public and publish the board papers online.  Go to meetings and ask questions. CCGs will also hold other so called 'engagement' meetings so please go along and ask awkward question. 

Join your Practice Participation Group (Patient Reference Group)

Each GP surgery should have a group of patients, perhaps as an virtual group, who support the practice in many ways. They can ask questions of the GPs who in turn can ask questions of the CCG.  Our CCG intends to have a Patients Forum with one person from each practice participation group on it. Exact details are current unknown. The patients will need to set the agenda not the CCG.

Service User Groups

If you have a long term condition join the service user group/support group or set one up.  They may be able to ask questions about specific services as they are often considered as 'experts'.  These groups are often used when services are being redesigned or changed. 

Local Healthwatch

These groups will be taking over the role of the Local Involvement Networks on April 1st. They will act as the patients champion  and should be seeking the views of patients and the public about the health and social care services. They will be monitoring the quality of services and holding the CCGs to account if the services are not benefiting patients. These groups will be as new as the CCGs and will take time to become effective. Anyone can join a Local Healthwatch and support their activities.

GPs

Our CCG intends to have an 'accountability forum'.  Each practice will have a GP on the forum and their role is to hold the CCG to account on behalf of the GPs and the practices. Even more reason to get involved in your practice participation group so you can influence the GPs.

Local Health and Wellbeing Boards

This is a joint Council & CCG body that is responsible for strategic thinking and priority setting for health and social care. A lay person from the Local Healthwatch will be a member. CCGs should be answerable to the board to show it is matching commissioning to the health needs of the population. How it will hold the CCGs to account remains to be seen but it could be quite powerful.  

Health Overview and Scrutiny Committees

This is a Council committee that monitors the commissioning and delivery of services and can hold the CCG to account.  The meetings are in public and you can go along and ask questions.

CCG Governance procedures

CCG are required to hold meetings in public, publish their papers online and to publish the methods they use to make decisions.  We should make sure that they actually do use those methods when making decisions about our healthcare. There will be much talk of the use of 'evidence' and we need to make sure they use all the evidence and analyse it in a consistent manner. 

Lay people on the CCG board

Each CCG is required to have two lay people on the board and one of those must act as 'the patient and public involvement' champion.  Find out who it is and make sure they act on our behalf.

NHS Commissioning Board

The new NHS reform act makes sure that the CCGs will be accountable for their performance to this national organisation.  But there is nothing in the act to make the CCGs accountable to us.

Monitor

The CCGs will be accountable to this national organisation for their financial performance.

Conclusion

Those of you who have read my previous blogs about patient involvement might notice some similarity to this one. I feel this is inevitable since the two processes of involvement and accountability are two sides of the same coin.  Both rely on good communication and trust. The same limited number of organisations are going to be active in the involvement process as well as the accountability process. 

Meaningful and effective involvement of patients, at an early stage of decision making, and in a sustained manner throughout the process will enhance the trust that the public have in the CCGs.  The accountability process will follow naturally from the involvement of patients and the public in decision making. 

There seem to be very few ways in which individuals can hold their local CCG to account. So it looks like you will need to join one or more of the organisations mentioned above if you want to make sure the CCG does what it is meant to do and 'make no decision about me, without me'.

The trouble with joining an organisation is that you hope that the person representing you is able to stand up to the CCG board.  Will the CCG take more notice of that person than the opinion of an individual?

Lets hope that the evolving CCGs will be different from the old PCTs. and that they will act in an honest and transparent manner so we can be assured that they are working on our behalf. 

  

The Tipping Point?

Has General Practice in England reached a tipping point?

During the last eight years, since the negotiations that led to the new GP Contract of 2004, there has been an increase in the workload and an increase in the complexity of the work of GPs and their staff. Work as moved out of hospitals and is now done in the community and in the surgery.  Most doctors work long hours into the evening after seeing patients doing their paperwork. They are checking repeat prescriptions, writing referral letters, checking the results of investigations and consultant letters.  The quality of their lives and that of their families is suffering.  Many doctors already work only 4 days a week and other for less.  This is the only way they can survive.

More recently the NHS reforms and the Health and Social Care Act has further increased the workload by making them take on the task of commissioning healthcare as part of the Clinical Commissioning Groups.

The Government has changed the pension arrangements for many public sector workers including doctors and nurses.  This has meant increased contributions and reduced pensions.

Within the last few weeks the Government has proposed to change up to 30% of the GP contract by next April. If this proposal is not accepted they will impose it. They are offering1.5% extra to practice resources knowing that 61% of all gross income is currently used to pay expenses such as staff costs. They acknowledge that GPs are looking after an extra 3.7 million people for no extra funding. In addition they are asking for an extra 4% work for no extra funding. The GPs are not impressed!

A considerable number of current GPs are in their 50's and 60's and so near retirement age. It is possible that many of them will jump ship early due to the changes mentioned above.  Certainly their families hope they will.

This could mean that surgeries, already stretched to the limit by increasing demand, will not be able to continue to work safely.

Is this the tipping point?

Is General Practice sustainable in its current form?

Will anyone want to become  GP?