Primary and Community Care: Improving Patient Outcomes
Lord Baker of Dorking Excerpts(2 years, 3 months ago)
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Baroness Finlay of Llandaff (CB)
My Lords, like others I congratulate the noble Lord, Lord Patel, on raising this crucial debate. I declare that I am a fellow of the Royal College of General Practitioners as a GP—indeed, a medically qualified Dr Finlay—and got my fellowship before moving to hospice work. I am also a patron of the Louise Tebboth Foundation to prevent GP suicides and am president of the Chartered Society of Physiotherapy. I will focus on family medicine specialists—GPs—but we must not forget the major impact that physios and others have on conditions through direct access.
I chaired the Independent Commission on Medical Generalism for the Royal College of General Practitioners and the Health Foundation. Our 2011 report concluded that the generalist approach is essential across healthcare and that if it did not already exist it would have to be invented, while work by Barbara Starfield showed that the health of a nation depended on the quality of its primary care services. I do not believe that that has been dented by Covid.
Patients are the raison d’être of healthcare delivery. People become ill at all times of the day and night, presenting with undifferentiated conditions. Some conditions progress rapidly, in others the course is fluctuating or resolves. In our communities, many people live, work and contribute to society with a broad range of chronic long-term multiple co-morbidities. Some have rare conditions. Differentiating abnormal from the normal requires diagnostic skills and risk-assessment experience. Good primary care training is essential, providing adequate experience in paediatrics, women’s health, acute and early presentations of serious illnesses and the complexities of medicine in the elderly—and now the workload of GPs has become increasingly linked to social problems in society and mental health.
However, the problem we have is that GPs are leaving practice faster than they can be recruited. The 27,500 whole-time equivalents GPs are made up of a workforce with a headcount of around 40,000. As the noble Lord, Lord Hunt of Kings Health, pointed out, there are now 2.5% fewer GPs than in 2019 and 5% fewer than in 2015, but the average GP is responsible for 16% more patients than 10 years ago. More patients need to be seen than there are 10-minute appointments in a day, let alone time for home visits.
Seeing 40 to 60 patients a day, many of whom have complex medical and social problems, for five days a week is unsustainable. GPs become burnt out and leave. They seek work in other areas in medicine, but often in much more administrative or peripheral roles. Many GPs develop an extended role, developing expertise in some branch of medicine, such as women’s health, diabetes or hospice work, or in emergency medicine departments as part of a portfolio of clinical work. They need to carry on working but feel burnt out with the workload of routine general practice.
The GP is the first point of contact for undifferentiated complex problems. They can provide a holistic and comprehensive service for the long-term and acute care of the population they serve in their communities. An integrated approach must address the whole person: the physical, psychological, spiritual and emotional aspects which have led to the condition that has presented. Importantly, there is good evidence that, where continuity of care is in place, there are better clinical outcomes at lower cost, with greater patient satisfaction. We desperately need more GPs—incoming newly qualified GPs—but also to find ways to retain our experienced, highly skilled doctors who are leaving the profession in large numbers.
These doctors are trained family medicine specialists, and they need parity of esteem with consultant specialists in secondary or tertiary care. From that position, some will need to be able to pursue particular special interests, which will support other services such as mental health—thereby combining the family medicine specialist’s interest with some days in community practice—where integration with social care provision is essential.
There have been efforts to increase the numbers of allied health professionals in primary care to help with the shortage of GPs. But there is increasing evidence that, unless these professionals are carefully integrated into the primary care team, they cannot replace the experience and value of a GP. They need support and nurturing. The incoming chair of the council of the Royal College of General Practitioners, Professor Kamila Hawthorne, wants to create associate membership of the college for those allied health professionals who contribute to the primary care team to ensure better integration and understanding between the different disciplines in proper team working. In GP clusters that work well, all disciplines coming together has been shown to improve clinical outcomes and decrease the burden on secondary care. Change will be embraced if those delivering care can lead it and funding issues cannot be ignored in terms of the way that people are paid and reimbursed for their services.
There are other disciplines and services in the community. Hospice home care teams and Marie Curie nurses can be an essential supplement to primary care provision, but they need to be involved early. As many GPs have an interest in palliative care, I hope that the specialty will reopen to those with MRCGP, rather than allowing entry to consultant level training only to those with RCP membership, because their mature clinical experience in the community is invaluable, especially for hospice at home.
We must recognise that the diagnostic, management and risk-assessment skills of the trained GP are essential for our communities and the NHS. Community work is not easy, but it can be very fulfilling if allowed to work properly. The employment of family medicine specialists, with parity of esteem with the hospital consultant body, would allow those who wish for a much more flexible career approach to develop their special interest roles while retaining a firm foothold in family medicine in the community, with all its complexities. Working with their communities, with their own patient population and with all aspects of social care, they can be community leaders.
In the pandemic, around 30,000 doctors were granted temporary emergency registration and over 9,500 have remained licensed to practice until now. At the end of the month, they must apply to restore their registration and for their licence to practise to remain. To date, around 8,000 have not acted despite a streamlined process being in place. Will the Government request NHS trust responsible officers to be available to doctors in their area who wish to relicense?
I have not focused on pensions, but it has aggravated the problem of the loss of GPs from practising. As judges have been given an exemption from the pension cap, will the Government review the pension cap for clinicians? It would be far more cost effective than gaps being filled by expensive locums or leaving services with gaps unfilled and a population without the healthcare it needs.
More medical school places, greater flexibility around revalidation and an ability to have flexible career paths could help supply and retention. However, the problems leading to attrition must be addressed, and the scenario from dentistry is the flashing warning light in front of our eyes.
Lord Baker of Dorking (Con)
Before the noble Baroness sits down, I thank her for a very interesting, well-informed speech. She identified the pressures placed upon GPs, which are not going to be relieved easily. Would she welcome what happens in a country such as France, where many—
Baroness Bloomfield of Hinton Waldrist (Con)
I am very sorry, but the noble Lord is not on the speakers’ list.
Baroness Bloomfield of Hinton Waldrist (Con)
No, not in a time-limited debate with a provided speaking time.