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Mission impossible


28 July 2015

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A seven-day NHS, 5,000 more GPs and a requirement for £22 billion in efficiency savings – both the government and the service have their work cut out

A seven-day NHS, 5,000 more GPs and a requirement for £22 billion in efficiency savings – both the government and the service have their work cut out

The majority government has little room for excuses when it comes to delivering its election promises on the NHS. With no coalition partner to blame, promises of delivering £8 billion over the next five years, creating a seven-day service and recruiting 10,000 more nurses and GPs into general practice are no mean feat.
It’s the seven-day NHS that has been the headline grabber.
While in theory it is a good idea, many point out the challenges that lie ahead with the proposed plan.
Chaand Nagpaul chair of the General Practice Committee at the British Medical Association says: “It is clear that general practice is suffering burnout. It’s under resourced and overwhelmed. It’s not possible to identify that there is a real crisis of resource workforce and workload and then expect general practice to do more before you’ve corrected that.”
He branded the seven-day service a “surreal obsession” that would “damage quality care by spreading GPs so thinly”.
“Nowhere in the world does any nation provide a state-funded routine GP service seven days a week, and here our government is pretending we can do more than anyone else with fewer GPs per head than in Europe, while spending less on health compared to virtually all other comparable nations,” he said at the Local Medical Committee’s conference.
Joe McGilligan, former chair of NHS East Surrey Clinical Commissioning Group (CCG) and chair of The Commissioning Review editorial board, drew upon his own experiences of working with out of hours services.
“I worked in Australia with a 24/7 service and patients still complained that it was the wrong doctor at 4am in the morning. So no matter what service you put in someone will be unhappy about it,” he said.
McGilligan’s concern over patients’ requests to see a particular doctor is echoed elsewhere.
The Tories claimed in their manifesto: “We will restore your right to access a specific named GP… We will ensure your family doctor appointments.” But in reality will this work?
As Sarah Schofield, chair of West Hampshire CCG, explains: “Managing the public’s understanding of what is on offer is a major issue. It needs to be clear to the public that they will not be getting access to their ‘favourite’ family doctor every day of the week.”
The government has failed to address how seven-day access in primary care is going to be implemented. And this is a recurring concern for those working in clinical commissioning groups.
Nadim Fazlani, chair of Liverpool CCG, highlighted the limited resources that general practice is already operating with. “Whether it’s a small or large practice you are just stretching the same resource over a long period. You simply can’t make people work longer hours, you will have to go to a shift system.”
A shift system seems to be an option that has already been tried and tested and it showed some promising results.
Dr Jonathan Serjeant, GP lead of Brighton and Hove’s Prime Minster’s Challenge Fund, EPIC, has had out of hours and seven-day a week services running since September 2014. The pilot consisted of 16 practices that split into groups where the out of hours services would be at one practice for that particular group.
Patient records from the other practices could be accessed electronically. EPIC’s out of hours service appointments were used but it was tackling the staffing issue that was the problem. He says: “Monday to Friday was a problem in getting GPs to work the extra hour and a half. For them to come and do that and earn £150 is not worth their while. If you want to make it sustainable you get into a shift system within practices and this requires total change.”
Serjeant went on to say that staffing on Saturday was not a problem as staff could work a six hour shift. Appointments were also taken up by patients.
Sunday, however, saw a decline in patient numbers. The few that used the service needed support but different to the out of hours care.
“This particular group of patients are people who have many multi complex psychological needs that need someone who actually understands what’s going on when they get into a crisis.
“Really you need a different type of service for that and I think some of the more progressive proactive care models that have come out around the country will deliver that. I’m not sure just opening GP practices will make a difference,” he says.
GPs are saying they are already spread thinly as it is and seven-day working will just exacerbate this situation.
Mark Porter, BMA council chair, returned to the question of GPs taking on leadership roles in clinical commissioning groups (CCGs) – an idea implemented by previous coalition government’s Health and Social Care Act. He argued that the very system that is supposed to help primary care has in fact taken doctors out of surgery hours. He says: “All parties have acknowledged that we need more GPs but we’ve taken some hundrends of them out of general practice and set them to doing management tasks.”
CCGs and others fearful of another top down reorganisation welcomed the stasis implied by the new government. Julie Wood, director of NHS Clinical Commissioners, says: “The government is really committed to clinical commissioning groups (CCGs). The Prime Minister is really clear that the Conservatives see leadership groups and CCGs being critical and they’ve made that very clear, that’s absolutely welcomed.”
Another election promise is the extra 5,000 GPs by 2020 that has since been revised to a maximum of 5,000 by secretary of state for health Jeremy Hunt.
And given that it takes 10 years to train a GP many are questioning where these GPs are going to come from.
Fazlani sums up the problem: “There isn’t a factory that produces doctors overnight.”
The Tories as the majority government will be held to account over their election promises but as Porter says: “The problem is that political announcements don’t really have detail behind them.
“There is a failure to have a grown up conversation about this [promises the Tories made] in the public space and we are getting simplistic slogans, simplistic problems, and solutions and answers thrown around that actually get in the way of having a sensible discussion about a good way forwards.”
McGilligan’s thoughts aren’t far off from Porter’s. “Such promises should not be led by politics, especially when those that have to deliver are not those that make the promise. Promises should be led by evidence,” he says.
Wood is more positive on working with the new government. She says: “With the new government we have got stability in terms of policy.”
While the deliverability of political promises may be called into question, and as yet there is little detail, the NHS is working with some immovable facts – the aging populations, rising patient expectations, increasing costs and the grim task of saving £22 billion.
Wood did, however echo the sentiments that many in the NHS have stated. She said: “What we’ve now got to do is make sure we can rise to the challenges that we’ve got, irrespective of which government.”

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