General practice is having difficulty recruiting and retaining a sustainable workforce.  The recent Westminster Health Forum keynote seminar, The future of general practice in England: workforce, partnerships and reforming the QOF, Thursday 20th September 2018, facilitated some interesting debate on the challenges facing health and care professionals in general practice, along with insights into the emerging primary care model of the future.

Dr Edward Scully, Deputy Director of Primary Care, Department of Health and Social Care, delivered findings from the recent GP Partnership Review.  The review sought to engage with general practice on the ground, through visits, events, discussions and key lines of enquiry.  The review identifies that the demand for GPs is not matched by current capacity, with the profession struggling to both recruit and retain staff. 

Young GPs are frustrated with a lack of career structure and progression, whereas older GPs are opting to take early retirement to escape the bureaucracy.  Long and inflexible working hours are also an issue, with stress negatively impacting on an increasing proportion of the workforce.  For many, the risk is now seen as greater than the reward. 

Dr Christine Tomkins, Chief Executive of the Medical Defence Union, warned that a significant increase in GP clinical negligence damages is making professional indemnity insurance unaffordable for GPs.  The frequency of claims has doubled over the last seven years.  GPs can now expect four clinical negligence claims over a forty-year career. 

Dr Tomkins highlighted a report by the National Audit Office in 2017, Managing the costs of clinical negligence in trusts, which attributes an underlying cause of the rise in costs to, "Developments in the legal market and the increasing level of damages awarded for high-value claims." Being subject to a clinical negligence claim can be an extremely stressful ordeal for health and care professionals, affecting confidence, resilience, colleagues, and quality of life. Read the full report here: https://bit.ly/2xfyLdd

Dr Clare Gerada, Medical Director of the NHS Practitioner Health Programme, reported that, "Doctors in general practice are leaving because they can’t cope with the pressure.” The Practitioner Health Programme http://php.nhs.uk/ provide a confidential mental health and addiction service to practitioner patients from across the UK.  Dr Gerada noted that, of the 1500 GPs accessing the service, two-thirds are being treated for mental health issues, including depression, anxiety and PTSD.  The rise in, and handling of, complaints, the burden of mandatory and statutory training, and not having the space to discuss or reflect on the emotional impact of their work, were highlighted as contributing factors.

Lara Carmona, Associate Director of Policy and Public Affairs at the Royal College of Nursing, highlighted the pressure of nursing shortages leading to nurses leaving the profession.  Practice nurses and nurse specialists have been particularly badly hit in the decline in the last year.

"Across the sector, we can see high numbers of vacancies which cannot be filled.”

Dr Clare Gerada, Medical Director, NHS Practitioner Health Programme and Council Member, BMA

The Royal College of Nursing are pursuing securing legislation, which details responsibility and accountability for ensuring that an adequate supply of registered nurses and nursing support staff is available throughout the health and social care system to meet the needs of the population.

Collaborating and Integrating Services

The reliance on agency workers and locum GPs to plug the gaps in the workforce is not sustainable and reduces continuity of care for patients.  The current primary care reforms seek to develop a wider workforce to support patients, expanding teams to include services such as mental health therapists, and adopting digital innovations to improve access to services. 

One example of digital innovation is the e-consult platform for online consulting.  Professor Martin Marshall, Vice Chair of External Affairs at RCGP, described some of the benefits:

• Convenience for patients
• Better access for some groups of people, such as adolescents and people with mobility problems
• Helping doctors to develop a portfolio
• Patient access to online consultation recordings — generally people don’t remember all of the advice given during a consultation

However, Professor Marshall highlighted the importance of online consulting mechanisms being subject to rigorous evaluation, so that policy decisions are made out of learning.  Online consulting introduces a different set of risks, such as online consultants not having access to a patient's record during a consultation, and the clinical risk of the consultant making an assessment without being able to examine the patient. 

James Roach, Programme Director of Integrated Care at West Essex Clinical Commissioning Group, cited the potential to deliver a high quality, seamless integrated care service for patients through the integration of community pharmacy and general practice teams.  The collaboration could bring the additional benefits of utilising existing patient and professional relationships and help to break down the silos approach that exists within the health system. 

Mr Roach highlighted that pharmacists are clinical professionals that are being underused because of lack of trust.  The introduction of enabled laptops within Community Pharmacies could avoid the need for unnecessary structural integration, allowing pharmacists to review repeat medications, change medication plans, and eliminate errors at source.  Mr Roach emphasised that pharmacists can offer, "Pro-active advice and support that makes a difference to patients.”

Dr Rebecca Rosen, Senior Fellow at the Nuffield Trust, noted that rising patient demand, administrative demand and the policy on seven-day working are placing funding pressures on small practices.  The GP Access Fund improved services by encouraging some practices to work together, with 51% of collaborations using formal arrangements and 30% informal. 

Dr Rosen highlighted some of the benefits of working at scale, such as efficiency and income, investment in tech and new ways of working, workforce initiatives, centralised support for new services, and resources and leadership for driving change.  There is the potential to centralise the back office (i.e. running a dashboard to identify areas that are underperforming and allocating support to help address the issues).  Peer support has also been identified as a perceived benefit – where previously people worked in isolated pockets, it is now possible to access support such as lending staff to cover illness. 

Dr Rosen described the benefit of integrated services to populations (individuals, families, and communities), as they have the potential to deliver an integrated, holistic kind of care.

Post Contributor:

Caitriona Fitzsimons Digital Reporter