Brenda Allan & Alan Morton, North Central London NHS Watch & Haringey Keep Our NHS Public

1 Introduction

Since our deputation in June, the crisis facing primary care has grown and received greater adverse publicity.  Year-round winter pressures, exacerbated by the pandemic, have left anxious patients facing another winter of reduced services, and uncertainty about accessing timely care.  Additionally, trends accelerated by the NHS’s responses to Covid 19, with increasing weight placed on e.g. e- consult and Total triage, are adversely impacting many patients, causing further frustration and risk, with postponed access to appropriate, sometimes lifesaving care.  

Demographic factors in North Central London – deprivation, age and diversity, all highlight the need for very robust, well supported primary care services – handling as they do 90% of patient contacts, and winter only intensifies this need. If general practice fails, so will the NHS, with patients diverting to emergency departments (ED/A&E) and other unscheduled care provision. Some Local Medical Committees reported that GP practices could close on a temporary or permanent basis this winter. (1)

We urge the JHOSC to press the CCG/ICS as to what additional, effective support it can give primary care, to ensure patients can access timely, safe care, during the winter, by addressing the workforce, workload and stability of provision issues.

Our view is that some pressures and risks to local patients are the result of longer-term priorities of NHSE, particularly the move to supersize practices, relying heavily on e-consult and other remote services. Recently a practice with an Inadequate CQC rating in Haringey  was taken over by the Hurley group, a large south London practice, and an  early and heavy user of e- consult. Local Healthwatch findings indicate an association between e- consult and increased A&E attendance, an alert that patient views need to be more seriously considered.  While e-consult and other remote contact is convenient for some patients and some routine  appointments, it is not easy or appropriate for others. In addition, providers relying heavily on e -consult and digital provision, tend to attract fitter, infrequent users,  leaving  sicker patients to over-burdened, traditional GPs with attendant financial disadvantages. 

Mega practices pose risks to provision if they sell to a large profit-making health care organisation. as with AT Medics, and  one of the Centene practices has already been judged unsafe by the CQC. Legal opinion  obtained for the Judicial Review was that  commissioners were wrong to assume that they had limited grounds to refuse the Operose acquisition, failed to consider the financial risk to GP services, or the financial suitability of Centene, given controversies over access to healthcare and fraud in the US, and failed to consult patients and stakeholders. (2)

Research suggests that patient satisfaction levels are lower for very large and private company practices, as compared with smaller ‘NHS’ practices, so the type of primary care contract matters to patients. (3)

2. Recommendations -we urge JHOSC to press NCL on the following, and monitor progress:

• What constraints, budgetary and/or other,  are limiting the effective support that the CCG/ICS offers; it appears that the assistance outlined in the Primary Care Commissioning Committee papers and the Elective Recovery programme may be insufficient. How are they tackling the constraints?
• What further support can be given primary care to cope with their growing workload, waiting times for appointments, and waits for secondary and emergency care?  See 3. below
• What more can the CCG/ ICS can do to improve recruitment and retention rates over and beyond its current proposals, and how effective is the current approach in improving the staffing problem?  See 3. below
• Ensure primary care has a greater say in NCL services, with increased  GP representation on the ICB – the GP Provider Alliance seems too weak to do this. 
• A number of openly procured primary care contracts in NCL are due for renewal between 2022 and 2025.  Othe practices may also be in danger of closing or failing for retirement, or other reasons.  What plans does the CCG/ICS have to ensure primary care contracts remain with NHS providers  e.g.  GP Federations, PCNs, larger practices or local NHS and Foundation Trusts, (perhaps with salaried general practice options), rather than private APMS ones?
• If larger GMS/PMS practices are considering selling to private companies, as with AT Medics, what can the CCG/ICS do differently, with regard to greater scrutiny of financial, ethical and clinical issues.

3. Pressures 

GPs and other members of primary healthcare teams have faced a massively increased workload over many years, with a growing and aging population, the pandemic,  secondary care moving more tasks and patients into the community, and more patients with long term conditions managed at home, but without adequate resources flowing into primary care or social care. 

Discharge to Assess, enshrined in the Health and Care Bill, will only add to these pressures.  Demoralised GPs are leaving, retiring early, or working part time etc,  piling on further pressure, with the danger that practices may close/fail. Eight practices in NCL received a Requiring Improvement rating by the CQC, and three were rated Inadequate, the latter all in Haringey.(4) 

• To increase support and tackle workload, consider a greater emphasis on promoting collaboration and  supporting joint projects between practices, and between primary and secondary care, fast tracking new initiatives proposed by Federations or practices, facilitating mergers and partnering, enabling PCNs, Federations or larger practices to provide ‘back office’ services to others, delivering economies of scale but preserving clinician/patient relationships, expanding  the extended hours hubs scheme to ease waits for GP appointments. 

There was a 10% vacancy rate in the NHS pre-Covid, now higher, a major shortage of GPs, nurses and other primary care staff, and major difficulties with recruitment and retention.  In NCL, nearly a third of GPs are over 55 years and about a half of nurses, except in Camden, highlighting  the need for a massive succession planning effort, in addition to addressing the current shortages. 

• To improve GP recruitment, consider improved returnee schemes, better terms for part timers,  salary supplements for GPs in less popular areas, increases in  practice  GP training places, expanded Additional Roles Reimbursement Scheme, creation of promotional grades for non-medical professions,  fast tracking refugee and asylum seekers with medical or other health qualifications, and  assisting practices to deliver attractive staff remuneration  and support packages.

Funding for primary care has shrunk as a percentage of healthcare spend to under 10%, well below the OECD average of 14%. NCL CCG/s Annual Report 2021, noted a cumulative deficit of £112,000,000, which given that ICS budgets will be capped, raises the prospect of massive cuts to services, including primary care, unless transitional funding is available.

(1 ) N. Merrifield, Pulse, 3 August 2021

(2) Phantom of the Operose,  Private Eye, no.1560, 12-15 Nov 2021

(3) Cowling TE et al. Contract and ownership type of general practices and patient experience in England: multilevel analysis of a national cross-sectional survey. JR Soc Med 2017;110:440-51.                                                                                                                                                                                                                                                                                                                                                                                                                                                                 

(4) NCL Primary Care Commissioning Committee 21 Oct 2021.