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We are all aware that general practice is in crisis across much of the UK.
Even NHS England has acknowledged the need for action in its GP Forward View, released in April 2016. Much of the GPFV concerns workforce development and some of this attempts to address the workload of both GPs and practices in general. It is my view, based on discussions with colleagues, that the single most important cause of the current crisis in general practice is our reluctance to control the workload within our block contract (GMS/PMS).
This week, the GPC (General Practitioners Committee) published its first ever attempt to quantify the workload required of GPs under their NHS contracts in a paper called Safe working in general practice.
This is in total contrast to the GP’s traditional ‘can-do’ attitude, which assumes anything is possible.
Managers understand that you get what you pay for, but many GPs resist the idea of anyone telling them that they shouldn't work beyond a safe level. A comparison might be made to US citizens who resist state health funding such as a national health service because they don't want big government deciding which doctor they can see.
Our paper sets out a logical case for a limit to GMS work, which will give patients a safer system and create attractive GP partner posts. At present the only way most GPs can control their workload is to become employees or locums.
Practices which are unable to control demand and workload are simply not recruiting or retaining GPs.
The paper concludes that 13 face-to-face appointments per session, within a nine-session WTE week, is safe and sustainable. This gives an average appointment number below 25 a day, seen increasingly as a sensible maximum.
The control of workload within a fixed clinical capacity with little prospect of immediate improvement leads to reduced access for patients or the need for a support system for practices. We are proposing the commissioning of locality ‘hubs’ whose primary purpose will be the integration of general practice across a district in order to support hard-pressed practices and allow the gradual expansion of the workforce. Hubs are often seen as imposed and contentious parallel systems - such as Danzi centres - but our view is that a hub which is controlled by practices and works for their patients could stop the current trend away from independent contractor practices and re-establish what is best in UK general practice.
This is not a road away from independent GPs within a national service, it is the modernisation of a great tradition into a format which fits with tomorrow's healthcare and the future workforce. Brian Balmer is a member of the GPC executive
25 patients a day ... luxary
Absolutely right ! We need more consultation time
Old people take 5 mins to come and sit on chair
Impossible to finish any consultation in 10 mins
We need more flexibility in consultation time and limiting the no of patients per day is s good idea
Finally- something to save us from the strangling hold of the 10mins consultation!!
If they halve the number of face to face daily contacts ( I agree - Luxury!) the money will diminish accordingly too- not sustainable -so we will end up doing the hub sessions as well -so workload not addressed. Where are the hub doctors coming from otherwise? I see no incentive to stay in practice in UK here.
15 minute consultations are the only real way forward. This allows sufficient time to access and actually READ patient records (eg hospital letters and discharge summaries), LISTEN to and if necessary (!) EXAMINE our patients and then DISCUSS options with them. 10 minute consultations force doctors and patients alike to cut corners. Many patients feel pressurised in 10 minutes and may not be able to explain one problem properly, let alone "self triage" what concerns are most urgent. 10 minutes is a false economy - things get missed, patients have to return for a further appointment to be examined etc. 15 minutes in many cases actually is quicker than having to use 2 x 10 minute appointments.
All initiatives such as a GP hub that seek to improve access will inevitably increase demand. Triage is wasteful of time and resources.It is admitted in the paper that there is no evidence of its effectiveness at practice level - why should it be any different in a hub model? Who will staff the hub? We are short of appointments because we are short of doctors. The only solution is expansion of the workforce. Nurses and others cannot do what GP's do in terms of first contact and risk management. Nurses are the people who are trained in, and effective at, complex case management.
High time consultation time was taken seriously!
Following the GPFV money being announced, I sent a proposal to our CCG to look at moving all "Urgent" appointment request to a central hub( we are due to have a brand new emergency centre expanded from the old A&E). This I said could be achieved via a universal telephone system for all practices, where at the press of a button the call for an urgent appointment / visit / advice, could could be passed to the Urgent care centre. This centre could mirror the Out of hours service during in hours.
Staffing the centre could be manned by all practices sharing the workload and this could be statutory and obligatory, weighed up to list sizes. Practices could use locum sources to cover their shifts if need be. The locum said we currently use in many of the practices are to cover this burden of "urgent appointments"
There is good evidence that nearly 27% of patients attending general practice can very easily be sorted by other resources if available.
We have excellent Out of hour services who look after our patients for more hours than we do, during our in hours for urgent problems. We could have a very similar service during in hours.
Our elderly population, complexity of cases we see, the trend of secondary care transfer etc need to be safe. We cannot guarantee that with 10 min appointments.
Not so long ago transfer of care to out of hours service was thought to be a pipe dream. It is a successful service today. It is time we stopped accommodating "urgent appointments" in surgeries. We need urgent appointment centres and GPs need protected appointments just like consultants and every other practitioner in secondary care. It's time for change and it has to be quick before the jewel in the crown of the NHS is completely crushed!
Dr Muthoo - "manned by all practices sharing the workload". Why should those practices who CAN manage give their time to others unless they are paid? Locum sources - who will pay? If you have the money, just employ more doctors in practices. You seem to be suggesting "my practice cannot ofer enough appointments, so one of my staff will work somewhere else for a session or two a week". It really does not make sense.
I agree - it's at least 27% don't need to see a doctor - probably more, but only doctors can decide which 27%. The jewel in the crown is now voting like turkeys for christmas.
Crazy Eddie solutions (for the full flavour of the meaning of this please read The Mote in God's Eye and The Moat around God's Eye). Many of the proposed solutions try to fix previous solutions, all of which have either a poor research Base, or have already been shown not to work. The state has to reduce expectations or improve resources to a point it can neither afford nor obtain. It would be nice to have time and resources and the power to use them effectively, but given the steady drift do you really think our culture is going to accept the risks yes
The sharing of workload is possible if all your urgent appointments for the day are not our responsibility any more. It does not mean that every practitioner is spending one day a week in an urgent centre. My suggestion was commitment to a share of the workload according to the list size of the practice. Your work load would diminish hopefully by 20-25% with no urgent appointments. Some of us will not need locums anymore and these locums do need work. Advanced nurse practitioners , physicians assistants , Pharmacists, physiotherapists Healthcare assistants etc could all be part of the urgent appointment centre teams. Of course this needs extra funding and not shifting of the global pot.
We can moan and groan about every eventuality but surely the system we currently practice with is impossible to sustain.
Dr Muthoo -if you remove your responsibility for urgent appointments, if you decrease your workload by 25% the contract holders will reduce your pay accordingly, as you are no longer providing the same service as the GMS contract stipulates. You could then earn it back by working at the hub, but then your workload hasn't really diminished. All those paramedical people you cite are not the appropriate workforce for first contact. A GP is. No one else can risk manage like we can. I reiterate - if someone injects more money into the system, and there really are more doctors around, give that money to the practices and let them get on with it. If practices can't cope, they have to get real and close their lists. Why should practices who can cope share their resources? Sharing workload in this way signals the end of the independent contractor status.
This is a crucial point. "Caveat Patiens" - patient be ware.
This is our contention (as in 10 good men and true) that as one professional body, we have agreed that we can no longer guarantee your safety.
By all reasonable doubt (trust overspend, commissioning group overspend, average consultation length in primary care) your expectation for safe health care is not resourced by your central government. Our best is no longer good enough to ensure this safety - this is a conclusion by ourselves as guardians of your welfare.
Therefore if you suffer or die, we can no longer be held responsible.
If you suffer or die, you must first prove that your expectation is properly and adequately resourced.
Please BMA, set up an online petition for practicing GPs only - to endorse this - " Caveat Patiens" - let us take the stance of "ten good men and true" - no one else will - it is up to us.
Above all - this is a statement - a mark in the sand - concerning rights and responsibilities. No patient has the right to claim safe, free at the point of use access to health care if the requisite resources are inadequate - the age old alignment - rights and responsibilities.
Patients no longer have the right to passively claim their rights if , as case proven , they have neglected their responsibilities the ensure that these rights and expectations are appropriately funded.
Point taken with regards to contractual obligations. Probably the responsibility should rest on the negotiators for our contract changes. We have taken more than our share of "core contract" changes and alongside all the transfer of care.
Many of us do not have the resilience to carry on with the current state we are in. We need these changes. In the last five years we have had 3 partners in our practice retiring in their mid fifties.
In my very first blog comment I did mention that out of hours services all over do a great job. They have very good clinicians and not all of them are GPs. We need to mirror this service during in hours. It may be oversimplifying the magnitude of change but then when Out hour services take over by Cooperatives /collaborations and private providers first came in to the fray it was frowned upon by many" traditionalist " GPs. We now have a minuscule number of Gps doing their own out of hours. That's the kind of change we need. I'm sure this won't be the end and in a few years time there will surely be more shortcomings and stressors. We have to metamorphise. My proposal is just one way and I'm sure there are many more.
Sorry - meant to sign the last blog - "Caveat Patiens"
As a fucking GP with nearly 25 years experience most of those a trainer to young GPs, it is demoralising to see ones efforts minimised to purile arguments on whether I have 10 or 15 minutes per consultation
What I see is a job becoming increasingly complex and undermined by a failing hospital and social care system
More and more people consult me to help them navigate on their tortuous, often impossible journeys
Whilst other consult me needlessly simply for letters and free medicines they could buy easily buy from pharmacies, if it was not for the fact they don't pay for prescriptions
Remove this nonsense from my waiting room and I could do what I am best at dealing with complex patients with multiple different conditions trying to juggle the physical and psychological impact of their ongoing conditions
What I need is time and effective services to work with
None of this is solved by 5 minutes more or less when the whole system is so broken
Please don't focus on my consulting time but the true issue , which is grey suited faceless managers at every level of the NHS trying to destroy the NHS at request of Jeremy Hunt and Simon Stevens in pursuit of a new health service the nature of which is unclear to the people of England
I do the best I can for my patients regardless of 10 or 15 minute slots. Whilst I count the days to a premature retirement from full time NHS Practice
I see nothing here new here to prevent the destruction of General Practice as we know it!