Visit to Kennet and Avon Medical Practice
I was grateful to be able to spend an hour with the team at the Kennet and Avon Medical Practice today. This was a chance to understand more about how the Practice is set up to deliver primary healthcare and the issues that they face.
First the numbers, the Practice serves a population of 17,200 people and employs 75 staff, of which just over half are clinicians. There are 11 full time GPs and one GP under training. 8 of the GPs are “Partners”. This means that they jointly own the entire practice and have full responsibility (and unlimited liability) for delivery of not just the primary healthcare, but for the staff, buildings, equipment, power, health and safety, budgeting – everything. This firmly binds the GP and an individual to his or her practice and the community it serves. General Practice has, since 1948 effectively been a “contracted out” function, with GPs being self-employed rather than salaried. It is also a dispensing practice – meaning it can dispense medication to any patient who lives more than 1 mile from a pharmacy.
KAMP’s contract is with Bath and North-East Somerset, Swindon and Wiltshire Integrated Care Board (BSW ICB). This body can be thought of as our Local Area Health Authority – effectively contracting for our healthcare. KAMP also sits within the East Kennet Primary Care Network (EKPCN) – which brings KAMP together with GP practices at Burbage, Ramsbury & Wanborough, Great Bedwyn. The intention being to share services for patients, but this is often impractical outside of urban areas given the distances involved in patients accessing EKPCN services.
GP Appointments and Access to a GP
The data shows that 25% of patients that call in to KAMP are seen on the same day, which is good, although this seem at odds with the lived experience of many patients often forcefully expressed on social media – the issue is that non-urgent face-to-face appointments with GPs can be 2 - 5 weeks away. It was clear from the visit that the success of the practice in delivering healthcare is about so much more than the GPs delivering face to face appointments – important though these are, this is not the only measure of success. The practice employs 9 nurses, 3 paramedics, 5 Health care assistants all familiar roles within a practice and becoming increasingly highly trained and specialised. As a large, modern practice, KAMP also offers a whole range of specialist roles such as a physiotherapist, clinical pharmacists, a health and wellbeing team, social prescribers, and care co-ordinators as well as a team specialising in caring for the over 75s. They can deal with a huge array of patient problems as well as routine bloods, health checks, vaccinations, and preventative screening. The practice is trying incredibly hard to break the “GP” issue – patients who demand to see a GP when they could be seen more quickly and just as successfully by one of the other clinicians on site. This effort is not helped by certain sections of the media that still position a face-to-face GP appointment as the “Gold Standard”. Even Lib Dem policy in this area seems a little flawed “Give everyone the right to see their GP within seven days, or within 24 hours if they urgently need to”, when we should probably be talking about access to the clinician we need.
Funding
As it is April, funding for the next financial year has been (just) announced with an increase of just 1.9%. Given the inflation of the past year, and the recent increase of 10% in minimum wage this meagre uplift has not gone down well. The fact that it has just been announced also means that planning for the next year can only begin now – once the year has already started. The lack of ability to create any long-term plans given the lack of visibility of future financing really does hamper the operation. You could not run a business like this, and yet the practice must do exactly that. The practice employs just 2 staff to manage their entire finance, building, staffing function – and the simply cannot overspend, or go bust – the GP partners would have personal liability. Consequently, of all parts of the NHS, GP partnerships are probably amongst the most efficient.
Training, Recruitment and Retention of GPs
The practice is 2 GPs short and has had open posts for over 12 months. There are simply not enough trained GPs to go around allied to the fact that many younger GPs do not want the commitment and obligations of a Partnership. Without enough UK candidates, NHS England runs a GP International Induction Programme which has trained huge numbers of overseas students as GPs, but this does not provide an automatic Work Visa. After completing their training, these GPs either need to return overseas, or find employment with a practice that holds a skilled worker visa – this is a further demand on already stretched GP resources. The number of GPs available across England is still declining.
The Future
The partners most fervent hope is for less change and reorganisation. Some history is probably important here - Integrated care boards (ICBs) replaced clinical commissioning groups (CCGs) in the NHS in England from 1 July 2022. Bear with me! Clinical commissioning groups (CCGs) were established as part of the Health and Social Care Act in 2012 and replaced Primary Care Trusts on 1 April 2013. In turn, PCTs were established in 2001 under the Blair’s Labour Government. There has been a lot of change, and GPs and their teams want to treat patients, not to attend hundreds of meetings about yet more expensive reorganisation.
7 day a week surgery was not popular. GP partners already put in extended hours and personal financial commitment to their 5 day a week surgery and do not have capacity or incentive to extend this. It’s odd too that Private practice is still significantly restricted under the GMS contract. Practices that opt out of the provision of additional, enhanced or out-of-hour services, cannot charge any of their registered patients for supplying a similar service privately. So even if a GP wanted to work on a Sunday – privately, they cannot unlike consultants who can (and do).
Making it Better
As ever, there are no simple solutions, but if we want shorter waiting times, we must fund primary care properly and enable Partnerships to plan with confidence. We also need to train enough GPs and related clinicians and break obvious logjams like the Visa issue. Fully staffed surgeries will in turn balance workloads and help with GP retention and we might see numbers start to rise and appointment waiting times fall. As a society we all need help ourselves with prevention and healthier lifestyles, be prepared to embrace telephone appointments and seeing other professionals other than the GP.
Finally, a huge thanks to Dr Richard Hook, Dr Laura Freeman, and the Practice Manager Amy Lacey for their input and to Suzy Deering the Patient Services and Communications Officer for setting it all up. I know the time is precious.