GPs and Primary Care (North East Bedfordshire)

Tuesday 7th June 2022 Westminster Hall

11:00

[Richard Fuller (North East Bedfordshire) (Con)]

I beg to move,

That this House has considered access to GPs and primary care in North East Bedfordshire.

It is a pleasure to serve under your chairmanship, Mr Betts, and to welcome the Minister to her place. The reasons for this debate are, in essence, two of the main commitments that I made when standing for election in 2019: to promote access to local services; and to maintain the rural character of North East Bedfordshire, in the light of high levels of persistent housing development stretching back over a number of years. Those issues are related, but each of them also has certain distinct resolutions.

What has informed me, in calling for the debate, is that over the past six months I have spent a considerable amount of time speaking to GPs and primary care staff across my constituency. I have listened to their points of view and analysed information from their practices. I commend the work of our GPs and their staff, most particularly in the period through covid. I will touch on some of my concerns about how GPs were feeling and about morale over that period when I talk a bit about the responses I have had from constituents in my email inbox.

The debate is also informed by previous debates about the impact of development and of population on access to health services, such as GPs and dentists, although the latter are not my primary focus today—I have participated in debates led by my hon. Friends the Members for Waveney (Peter Aldous) and for South West Bedfordshire (Andrew Selous). My inbox, however, has been full of emails from constituents on the issue of access to GPs.

This will be known to the Minister, but I always think it is useful for Ministers to hear directly from constituents, so I will briefly quote three of mine. One wrote:

“My wife is 75 and in acute pain. She can barely walk. Several days last week and yesterday she has been attempting to see a GP…she phones at 8 am and eventually gets through some 2 hours later. She is then told there are no appointments remaining that day!, and that she should phone the next day at 8 am to try again. This same pattern is repeated day after day. Hours and hours spent listening to a recorded message with zero result.”

Another constituent wrote:

“I am writing to you about the absolute terrible Healthcare Centre… I’ve phoned the surgery 3 times last week to be told they have no appointments…this is disgraceful. I rang again today to be told no appointments available again today and to phone 111. Apparently they have to hold appointments for 111 to allocate. The lady from 111…told me to go to A&E to sit there for hours on end to see a doctor”.

The third constituent wrote:

“I have tried phoning the practice at 8 am as told to in order to arrange a telephone conversation. For about 50 minutes the dialling tone cut off with a message saying the line was overloaded. Thus, redialling over and over again was necessary (not something it is pleasant to do when feeling unwell). Eventually you may get through to be told you are in a queue. When you finally get through to a receptionist you are told that GPs are only taking emergency calls. When querying what I should do now, I was told to try again tomorrow at 8 am.”

Such issues are, to a certain extent, part of the recovery from covid and of the post-covid period, but they also highlight issues of concern more generally. The Minister must recognise the irritation of my constituents at the requirement to repeat and repeat a process in order to do something as simple as seeing someone in primary care for their health needs. Further irritation comes from the pressure on the ability to find an appointment within a reasonable amount of time.

That also has a significant impact on the morale of staff in GP practices. Given people’s problems getting through, they are naturally at a rather heightened level of irritation, and that has often spilled over into abuse of staff. The Minister will agree that there is never a rationale or reason for any of us to be abusive towards staff who are trying to do their best.

I will share with the Minister some data on my area. As of April 2021, the patient-to-GP ratio of my clinical commissioning group area, which covers Bedfordshire, Luton and Milton Keynes, was ranked eighth highest of 106 clinical commissioning groups, with 2,169 patients per GP, against last year’s average of 1,772 patients per GP. I have looked at the data running back to 2014—I am grateful to the local medical council for helping me with it. From 2014 to 2022, the list size for GPs in my constituency—a subset of the clinical commissioning group area—grew by 13%, compared with national growth of 8%, so it is growing considerably faster than in other areas of the country.

Let us look now at personnel. For the same period of 2014 to 2022, the total headcount of qualified GPs grew by 2.1% nationally but fell by 2.2% in North East Bedfordshire. Over that eight-year period, the number of GP partners fell by more than a quarter. Those staffing numbers are troubling. The CCG area has 2,169 patients per GP, but for practices that serve my constituents the number is 2,482 patients per GP— up 28% in eight years. I point out to the Minister that housing growth in my constituency is already three times the national average. That problem will not go away, and nor will it stay the same; it is going to get worse.

I will go through some specific findings from my discussions with GPs. The first is fairly obvious: GPs—and I and my constituents—think that primary care in North East Bedfordshire is under severe strain. One GP told me:

“The vulnerability of the service provided by GPs in my area was off the scale large”.

I believe that my constituency is actually a test case for our Conservative manifesto commitment to infrastructure first. I will raise some points about that in a minute.

In my view, and in the view of the GPs with whom I have spoken, remuneration systems provide insufficient incentives for GP partners to take on additional responsibilities. If we wish to stem the decline in GP partners, the Government have to show by words, actions and remuneration that they value the additional work that partners take on to enable broader provision of primary care in their local practices. More generally, pay systems provide more reward, rather than less, for GPs who pick and choose their hours rather than work full time. On the issue of locums versus salaried GPs versus partners, what is the Government’s strategy and what is their preference? My view is that the partner model has worked well historically and is the best model for the future, and even if the Minister agrees, there should be some substantial changes to how the remuneration systems work.

The NHS provides practices with payments based on hitting specific targets set at a national level, or sometimes a local level, such as the qualities and outcomes framework and the investment and impact fund. I hear that some of those targets can be onerous and the benefit is outweighed by the bureaucratic cost of achieving them. I worry that there is a tendency to prioritise bureaucratic target setting and undermine the professionalism, integrity and insight of GPs. We have to recognise that GP partners are some of the best qualified people in the country. To drive them to little target boxes that they have to check is in some ways a little bit demeaning to what a GP thinks is best for their patient. I can see that there is a need, but I think that perhaps the Government are overdoing the balance, towards bureaucracy.

This is perhaps a very minor point, but to me it sounds quite significant if it is true. I was intrigued when I learnt that GPs cannot create a corporate shield against personal liability when they wish to become a leaseholder of property. Normally, if someone is in business, for example, and they are a director or chief executive, their personal liability is not put on the line for a lease that they sign. I was given this impression, and perhaps the Minister can write to me with an answer to this question: is it right that there is no personal liability shield on this issue? That seems to me an unnecessary disincentive to becoming a GP partner.

Increasing the pathways to contact GPs is significantly under way. These range from face-to-face consultations, to e-consultations, to phone consultations. This is currently adding to the frustrations both of my constituents and of some of my local GPs, but there are signs and reasons for hope that the change can be for the better. Some constituents greatly prefer the opportunity to have a phone consultation. Although 50% of phone consultations require a face-to-face follow-up, 50% do not. That creates opportunities for scale economies in telemedicine. One practice that tracks those changes very carefully has been positively encouraged by the reduction in missed appointments for face-to-face consultation, which is a real saving of GP time. I would encourage the Minister to pursue further those efforts for new pathways but to recognise that there will be teething problems as we broaden things out.

Similarly, the broadening out of clinical roles—particularly those of paramedics, nursing roles and other direct patient care positions—in primary care is generally welcomed by GPs, but they would make the point, and I make it to the Minister, that there remains patient resistance to seeing someone other than “my GP”, even if seeing them is not required, and that it can remain a bottleneck. Also, that will not be a full answer to the issue of GP access, even in the long term.

I also heard that the relationship between primary care and secondary care has become a little fraught post covid. I am not sure that it has always been the most harmonious, if I am being honest. But will the Minister look or has she looked at the additional roles that GPs took on during covid to relieve pressure on hospitals, to see whether the balance is right and whether the remuneration is still right or whether there needs to be some clarification on those roles?

Similarly, there is the issue of the relationship between GPs and pharmacies, specifically as regards regulatory intrusion on efficient communication and simple processes such as the issuing of prescriptions. I know that the Minister and Government are looking at that, but it seems to me, from what I have heard, that more progress can be made. That could have significant benefit in broadening the ways in which people can access primary care.

Customer service attitudes and procedures, particularly post covid, created widely different outcomes between practices. This was one of my two most significant findings. It really matters how the practice manager and the receptionist interact with the patients when they arrive or when they get through on the phone. It is interesting how some practices have done a fantastic job and some have fallen short—there is such a wide variety. I wondered whether there was training and protocols about that human interaction, to ensure that standards were kept up. A similar thing—this is the other thing that is most important—is phone systems. Who would have thought that a GP’s choice of phone system would be a critical factor in patient satisfaction with the service that they get? In my own constituency, there is one particular practice whose choice of system A rather than system B has created for it an enormously larger problem with its patients than other practices have.

The rate of population growth in North East Bedfordshire has been so high for so long, and I am afraid to report that I believe that the NHS has failed to keep pace with regard to the modernisation of premises, particularly ones that bring individual practices together. This will be my final and key point as part of my asks of the Minister. The slow pace of NHS performance has been further frustrated by inefficiencies of section 106 and community infrastructure levy payments. That is most vividly highlighted in my constituency by the plans for a new surgery to serve the villages of Biddenham and Bromham. The land was promised years ago, all the houses have been built and yet the building of the new practice has not begun. That is a crucial “infrastructure first” test case for the future.

North East Bedfordshire is already near to the top of ratios, and population growth at three times the national average means that, without action, the situation will get worse. I ask the Department to look at North East Bedfordshire as a test case for our manifesto commitment on “infrastructure first”; to go back over the past eight years, to identify lessons learned from the inability to keep pace in personnel, processes and facilities; and to map out what could have been done and what could now be done to improve the situation. I am asking for a specific test for my constituency for that historical analysis, and I hope the Minister will agree to that today.

Practically speaking, I also ask the Minister to get her Department to look at unblocking the jam on the hospital site in Biggleswade. It appears that Treasury restrictions, which are legitimate but causing a problem here, are blocking the transfer of facilities so that it can provide GP services in one of the fastest growing towns in my constituency. I have spoken with Central Bedfordshire Council, which is willing to fund the rebuild, but it needs more reassurance and flexibility on long-term use. Will the Minister please talk with her Treasury colleagues to enable progress, as that would be a vital element in relieving the strain?

There are similar issues at Great Barford surgery, which is still located in cramped facilities. Right across the road there is an available facility, which everyone knows is the right one and has been talked about for years. I ask the Minister to look at that issue and see whether it has to be resolved locally, between the council and the local clinical commissioning group, or whether the Department can assist. In closing, I am grateful to our GPs, who have worked, sometimes with hostility from their patients, exceptionally hard in my constituency in difficult circumstances. I am very grateful to them and their staff.

11:17

[The Parliamentary Under-Secretary of State for Health and Social Care (Maria Caulfield)]

It is a pleasure to serve under your chairmanship, Mr Betts. I thank my hon. Friend the Member for North East Bedfordshire (Richard Fuller) for securing the debate and raising important points about the good work that is happening, as well as the substantial issues facing his GPs and constituents. I will not stand here and pretend everything is rosy: I want to work with him to address a number of the issues that he raised.

I start by thanking GPs, general practices and primary care for all their work during the pandemic, and for the work they are doing now, increasing their workload, such as dealing with people on elective waiting lists who need care because they are not able to get procedures done as quickly as normal, or helping with the covid vaccination booster. They are dealing with almost a tsunami of patients who are now coming forward to seek help, after we advised them to stay away and protect the NHS during the covid pandemic. We are seeing almost 11,000 cancer referrals a day, for example, and each one comes through a GP. On average, there are 1.6 million appointments nationally per working day, which is an increase of 5.3% on April last year, and 62.5 million covid vaccinations have been delivered by general practices.

That gives the scale of the work that has gone on, but I do recognise some of the issues raised. To reassure my hon. Friend, GPs—whether they are salaried or partners—are generally not directly employed by the NHS. They are independent practitioners who have a business of their own and have a contract to deliver NHS care. Some of those historical arrangements limit the interventions we can make, and some GPs want more integration than others—we have to be flexible in the support that we give.

My hon. Friend the Member for North East Bedfordshire is quite right to identify the issue of telephone access. I know from my own constituents that getting through to the GP is half the battle; once they have got through they usually have a positive experience seeing the GP, or other healthcare professional in primary care. We tried to help with this in autumn last year with the winter access fund. Part of that help meant that practices could bid for funding to introduce cloud-based telephony systems, which can transform the way that appointments can be made. My hon. Friend highlighted systems where GPs can see how many people are waiting on the line and how long they have been waiting for, and can divert resources to get calls answered quicker, even doing so remotely, with receptionists not having to work directly in the surgery to answer the phone, book appointments or organise prescriptions.

Cloud-based telephony is really transforming access to GPs. Unfortunately, some GPs are already signed up to contracts with other telephone providers that they cannot get out of, and some have signed up with other cloud-based telephony systems that are not as good as others, as my hon. Friend pointed out. NHS Improvement is working with GPs to drive full adoption of cloud-based telephony across the system. We are working with surgeries and sharing best practice of what really works. He is quite right that when patients are frustrated about not being able to get through they take it out on staff and GPs. To deal with the telephone access issue and make it easier to get through will transform the lives of both patients and staff.

We must also bust the myth around the 48-hour appointment model, which was in place under previous Governments, where patients had to be given an appointment within 48 hours. Patients had to phone up every morning and could only get an appointment within that 48-hour window. There is no need for that, and we are trying to say to GP practices that that is a historical model—they do not need to stick to it. Very often, a patient will be happy with an appointment next week, rather than having to phone up on the Tuesday, the Wednesday and the Thursday but still not get an appointment. There is a lot of work around practice management, and the systems in individual practices, that we are happy to help GPs with.

We are also working on the pharmacy consultation service, which has been used very successfully during the pandemic. If a patient phones 111, or the GP practice, there is a range of minor ailments that a pharmacy can deal with face-to-face, quickly and expertly. Those ailments, which range from sprains to colds and flu—even those patients with long-term conditions and on long-term medications, such as some diabetics or those with high blood pressure—can be well managed by a pharmacist. We want to go further with that and introduce more services provided by community pharmacists. We are in negotiations with pharmacy teams to see if we can do that. Scotland and Wales have a pharmacy-first system that works extraordinarily well; we are keen that patients in England have access to similar support.

We are introducing changes to the GP contract this year—some of those are more popular than others. For patients, one of the key elements is about extending opening times to evenings and Saturday mornings, to make it easier for patients to be able to see their GP if they need to. That comes on top of the point that my hon. Friend made about other healthcare professionals working in primary care. Primary care is changing dramatically. We have already recruited over 18,000 additional primary care professionals, such as nurses, physios, pharmacists and paramedics, who are often better placed than the GP to provide the care and support a patient needs. My hon. Friend is quite right that there is sometimes a reluctance from patients—a feeling that they are being palmed off on someone else rather than seeing the GP. However, we are finding that once they have seen the paramedic or the physio, they are very pleased to see that professional the next time an appointment is offered. We are hoping that the take up of that will improve.

We have a commitment to recruit 26,000 more healthcare professionals by 2023-24 in addition to the GPs. We are on track to meet that, so that primary care becomes a multidisciplinary experience for patients, and it is not always the GP who they need to see first. However, as my hon. Friend says, we do need more GPs, and a record number of 4,000 doctors have taken up GP training posts this year, which is a real boost to the numbers, but I recognise that they will take several years to be trained and to come through.

Although my hon. Friend speaks well about the pressure on whole-time equivalents, his local clinical commissioning group allows GP registrars to see patients, which boosts patient appointments and capacity in the local area. He will be pleased to note on housing—again, my constituency in the south-east has similar problems, where housing developments are in their thousands rather than their hundreds and spring up overnight with no consultation with the local GP, who then has to take those patients on—that I am meeting the Housing Minister, my right hon. Friend the Member for Pudsey (Stuart Andrew), this month to discuss the very issues my hon. Friend raises about primary care being a key feature during planning and when things such as section 106 and community infrastructure levy money is being allocated. As he rightly says, the health centres need to be built first before the housing.

[Richard Fuller]

I am delighted that the Minister is taking such an active interest in the impact of development on access to services. In my speech, I requested that, ahead of my meeting with the Secretary of State, the Department look back at that history in my constituency as a test case to see what could have been done differently and what might be done now. Will she commit to that being done ahead of my meeting with the Secretary of State?

[Maria Caulfield]

I am not sure when my hon. Friend’s meeting is—I think it is fairly soon.

[Richard Fuller]

July.

[Maria Caulfield]

It is in July. We can certainly look at that, because we need to look at the lessons learned if we are to make progress going forward. The Housing Minister is keen to address this problem, so it is good to look at what has not happened in the past that should have, so we can take that forward. I cannot commit 100% to that being ready for my hon. Friend’s meeting, but we can certainly look at it.

The final point was on the GP partner model and support for GPs in their role and in some of the challenges they face, whether that is taking on premises or taking on liability. There is definitely a trend where partnership numbers are going down, but salaried GP numbers are going up. That is because younger GPs coming forward often do not want to take on the responsibility of being a partner and everything that entails, but partners feel that being bought into the practice gives them a huge amount of additional investment in terms of time and finance, as well as guidance, development and support for patients.

The Secretary of State has instigated the Fuller review—that is not my hon. Friend, obviously, but a GP—around the future models of GP practice, and whether that is partnership or salaried or whether there are different models available. We will take a good look at those recommendations because there may not be a one-size-fits-all solution. Some partners have a definite view of where they want to go; others are struggling and need support and help. I do not think it will be that one size fits all, but the Fuller review will certainly make some strong recommendations.

I hope in the short time we have had that I have been able to acknowledge the main challenges my hon. Friend’s constituents and GPs are facing and have outlined some of the measures we are taking to support primary care and enable patients to see their GPs more quickly and easily, whether that is virtually or face to face.

Question put and agreed to.

11:30

Sitting suspended.