If you ask the government what is important about primary care, it is clear there will only be one response: access. Access is determined to be important to voters, and so it is access politicians care about. Whatever the cost to general practice itself.
Looking back to 2016, the GP Forward View feels very much like a solution to the strong governmental desire to introduce extended access, despite the crises befalling general practice. Here is a headline £2.4bn…with the condition you deliver extended access.
Indeed, recent reports suggest a huge investment in recent years into general practice. This is not what it feels like to practices. Much of the investment never reached practices, but instead went to extended access providers. As these providers deliver general practice, it all “counts” as investment in general practice.
The reality is, of course, that the introduction of extended access has made things worse for practices. The root cause of the workload and financial problems, alongside the inexorable rise in demand from a growing, ageing population, is the lack of GPs. Fewer GPs means more work for those who remain, plus an increased expenditure on locums which in turn creates a huge financial pressure on practices. The introduction of extended access simply creates an additional demand for GPs, stripping down further the numbers who can work in core, in-hours general practice.
The pledge to increase the number of GPs by 5,000 was a central part of the GP Forward View. But despite an increase in the numbers entering training, the numbers leaving has exceeded those arriving. GP numbers (FTE excluding locums and registrars) fell 3.4% between September 2016 and September 2018. The pledge to increase access to 8am to 8pm seven days a week, on the other hand, has been delivered.
What, then, do we get in the Long Term Plan? Yet another access pledge. “Digital first primary care will become a new option for every patient improving fast access to convenient primary care. Some GPs are now offering their patients the choice of a quick telephone or online consultation…. Over the next five years every patient in England will have a new right to choose this option – usually from their own practice or, if they prefer, from one of the new digital GP providers” (Long Term Plan 1.44, p26).
So now, in addition to GPs who choose to work extended access hub shifts (convenient, without the pressure and hassle of core general practice), we are going to have GPs who choose to work for “one of the new digital GP providers” (potentially ‘working from home’ for GPs). Further dilution of a precious and diminishing workforce, all in the name of access. All piling yet more pressure on a general practice that is creaking at the seams.
Amidst the plethora of documents that have come out already in 2019 (with potentially the most important, the new GP contract, due this week), there is one ray of hope. Dr Nigel Watson’s Partnership Review did explicitly recognise the pressure access is causing core general practice. His recommendation 5a states, “Primary Care Networks should be enabled to determine how best to address the balance between urgent and routine appointments during extended opening hours and weekends” (p32). He explains, “Extended access services in many areas are attracting GPs away from practices. NHS England should therefore consider how existing funding for extended access and opening could be allocated through PCNs as they mature, to enable local decision making on managing demand appropriately. This should also support partnerships to feel a greater sense of control and influence over managing the safety of their working day. It could also reduce fragmentation of services and increase opportunities to improve continuity of care.”
It is not a recommendation, however, that has been picked up in the Planning Guidance or the Long Term Plan. Whether it will turn into anything remains to be seen, but the priority this government has placed on access to primary care, regardless of the consequences for core general practice, makes me, for one, sceptical as to its chances. However, it is certainly a recommendation fledgling primary care networks would do well to remember as they move forward, as its chances of implementation probably relies on pressure from them.
BMA Council Chair Chaand Nagpaul summed it up well when he said, “There is no use opening the digital front door to the health service if we don’t have the healthcare staff behind it”. The current obsession with access is dangerous, because it is making a bad situation worse. A resource can only be stretched so thinly, and it is only a matter of time before more holes begin to show.
1 Comment
The core problem with “access” is that the government have a different definition of than patients. Patients want fast access to care when they need it: the government thing this means extended hours.
Extend hours doesn’t seem to be what patients want if the take-up of the extra slots is a good guide. What they want is better availability of quick appointments whatever time they are and extended hours has diverted resource from that goal to a service that patients don’t want.
But the drive for digital access is also misunderstood. it does not have to mean new providers taking yet more resource fro the core GP service (like GP-at-hand). Such providers point to what patients want (fast same day responses from their GP) but are far from the only way to achieve this. Many online tools can be used by existing GPs and, if implemented properly, can radically improve the sort of access that patients actually care about without draining resource from existing GPs (I have plenty of evidence about how transformative askmyGP is for existing practices and I’m sure that e-consult or engage-consult would also argue they too can transform exist services).
Improving existing GP practices is possible with the right digital tools and the right redesign of how GPs work. we don’t need new services from new providers that patients don’t want and that drain resource from the current system.