The IGPM was pleased to engage with government officials and NHS England over this plan by disseminating a survey to the practice management community and by attending and contributing to focus groups with Downing Street officials.
There is much in this plan that we are pleased to see, and there are also some serious concerns that we do not feel have been addressed.
Hundreds of our members have long been proponents of care navigation via reception staff, digital solutions to enable better access and signposting of patients to the right service, improved telephony to help manage patient expectations and reduce time spent on hold or receiving an engaged tone. We understand the value of this work and the need for it to be rolled out on a wider scale.
Communication with the public is vital for this to work. The days of the GP surgery being staffed by just doctors, nurses and receptionists are long gone. Lots of practices now operate with a multidisciplinary team of clinicians and administrative staff who can support patients with their needs in a variety of ways. We understand this can be difficult for patients to navigate themselves, not always knowing who the right person is to see for their problem and therefore defaulting to the GP due to their constant presence. Patients need to understand that more help is available, and that Reception staff are vital in helping them get
the right care, first time.
Patients also need to be empowered and directed to help themselves where appropriate. Or to use a service outside of the surgery that can help them, such as community pharmacy, walk-in or urgent care centres, minor injury units or social care services. There needs to be less reliance on the GP surgery for every problem.
We hope that this plan shows a commitment from NHS England and the government to help reinforce these messages, using a positive approach to ensuring that NHS resources are used appropriately. As a result, there needs to be a change in how general practice service are portrayed in the media and the government needs to support this. Only recently practices were criticised for not offering enough face-to-face appointments, and yet this plan places an emphasis on dealing with patient requests online or via the telephone. We would ask the government and NHS England to support practices to make the best decision
about the type of consultation based upon their expert knowledge of the people, place, and available local services. Of course, patient choice is important, but the expertise across primary care should be utilised.
We also appreciate the need to reduce unnecessary bureaucracy. Too often we see inappropriate workload pushed back onto primary care from secondary care – but as the
report itself notes, these issues were first highlighted back in 2017. ICBs will need to commit to helping us push back on this mission creep if it continues. Similarly local authorities and other bodies need to take more responsibility for making decisions without GP input – the days of “ask your GP for a letter” need to be numbered to allow our teams to focus on the clinical demand that we face every day.
The expansion of the Pharmacy First scheme is a great idea and the use of prescribing for certain conditions is already well established in many areas. However, pharmacies are struggling with demand as much as we are. Branches are closing across the country, and practices are often notified of pharmacies not taking referrals due to workload pressures. We are also concerned to see this expansion included in the plan but without formal sign-off from the relevant bodies. The media coverage over the last few days has implied that this is
a done deal. Patients are often reluctant to go to a community pharmacy, there will need to be support from the centre to establish the trust that patients have with GPs across the primary care team. The cost impact on individuals will also need to be considered.
Our GPs Prescribers are also concerned that a lot of their hard work on anti-microbial stewardship over the last 8 years will be at risk from increased prescribing of antibiotics at pharmacy level. Overworked pharmacists may not have the resilience or confidence to push back on patient demand for antibiotics.
Access is a huge component of this plan, and we understand that patients are finding it harder than ever to obtain appointments. As the report itself recognises, we are seeing more demand than ever, with fewer GPs than ever. Whilst there has been recruitment to the ARRS scheme roles, this is not consistent across the board. Many practices have not been able to recruit for a variety of reasons – lack of applicants, the roles available not matching the needs of the patient population, lack of ability to supervise new staff, lack of space to house them, sometimes simply the inability to see the wood for the trees and be
able to plan for new staff. One of the biggest areas of concern is also the difference of terms and conditions between primary and secondary care. This has always made it harder to recruit and people to make the move across the NHS. There has been a significant underspend in the national ARRS budget which bears this out. Whilst the plan aims to look at supervision responsibilities going forward and recognises the impact this has on the workload of clinical supervisors; physical space is one of the biggest factors for practices looking to recruit new staff. With a focus on face-to-face appointments being available for
patients who request them, this isn’t possible without consulting rooms.
Technology will certainly assist with practices’ ability to provide an assessment of need on the day. However, capacity is still a major issue here. If that assessment confirms an appointment is needed, but one isn’t available, what are practices to do? We are not a limitless service, and our staff need to work within safe staffing levels. Burnt-out clinicians make mistakes, don’t provide their best service and, in worst cases, leave. The plan states we are to divert patients to NHS 111 only in exceptional circumstances but leaves no definition of what “exceptional” means. There was previously a campaign to encourage patients to “111 First” for advice – has this been stood down?
Reception staff will also play a key role in navigating patients to the right care for their needs. However, this is a role that is becoming increasingly difficult to recruit to and to retain staff. The IGPM’s campaign video “If I Die” was released two years ago highlighting the level of abuse faced by reception staff daily. This has not changed. On top of this, they are also frequently the lowest paid members of the practice team. Whilst the National Living Wage this year represents a 9% increase, and many reception staff are on this wage, the general practice contract only allowed for a 2.1% funded increase to staff pay. These staff can earn more money, for less responsibility and abuse, stacking shelves in a supermarket, and we are losing many of them to this type of work. Practices who are struggling financially
are having to make the choice between reception staff pay and clinician pay. When our counterparts on Agenda for Change are seeing 5% funded increases, general practice is often unable to keep up.
The issue of funding has not been addressed by this plan. The capacity and access money is simply rebadged IIF funding and will need to be spent supplementing the costs of new telephone systems (for those on cloud-based already but without the functionalities that NHS England want us to have) and new online consultation systems (some of which may be funded by ICBs but not necessarily all). We also must keep on top of rising costs for everything else – consumables, utilities, increased pension contributions now that overtime is fully pensionable, maintenance contracts, equipment etc. It is a shame to see the ARRS underspend from 2022/23 not reinvested into primary care in other ways. Our
understanding is that this money has gone back to the Treasury. £240m of funding for new technologies is mentioned but with no detail on how we access this unless your practice is still on analogue phone lines. Our members tell us most of them are already digital – so how many practices is this going to help?
As mentioned above, the lack of funding for pay rises is a major issue. Staff are leaving to be paid better elsewhere. Retention is a huge problem across all roles in general practice at the moment and without staff, our access cannot improve. Pension reforms for GPs may be welcome, but GPs quite often don’t make up the majority of practice staff, and nothing is being done to financially reward them for staying.
Whilst there are some positives in this plan, there is still some way to go. The IGPM encourages an open dialogue with ICBs, NHS England and the government over the next year to feedback on these changes and what else may be needed to help really improve access to general practice.
