Oral evidence: Primary care, HC 408Tuesday 10 November 2015

Oral evidence, 10 November 2015.

Witnesses

Professor Chris Ham, Chief Executive, The King’s Fund, and Candace Imison, Director of Healthcare Systems, the Nuffield Trust, gave evidence.

Chair

Thank you very much for coming this morning and for your patience. I am sorry we overran slightly earlier on. Could I ask you to start by introducing yourselves?

Candace Imison

I am Candace Imison. I am director of policy at the Nuffield Trust.

Professor Ham

I am Chris Ham, chief executive of the King’s Fund.

Chair

Thank you very much.

Mr Bradshaw

Professor Ham, first thank you very much for your briefing—commendably clear and succinct. You sum up the challenges facing primary care as ones of investment and reform. It sounds familiar. What reform are you talking about?

Professor Ham

Reform is probably more important than investment because, given the big challenges in primary care, it cannot just be more of the same—more money, more doctors, more nurses—partly because there are not people out there to recruit into general practice. On reform particularly we would argue for more development of what we are already seeing around federations and networks of practices being established in different parts of England. Patients still look to their practice to receive their care, but practices are collaborating across bigger footprints, sharing more of the workload and the responsibility, providing access at more convenient times for patients—because they do not have to do it individually—and providing a platform on which you can then deliver a much wider range of out‑of‑hospital services. Our argument in a paper we published last year at the Fund was for what we called family care networks. It is another way of describing federations, not just of general practices, but general practices working hand in hand with community nurses, social care and out‑of‑hours services to provide a much wider range of care led by general practice.

Mr Bradshaw

What are the current obstacles to achieving that vision?

Professor Ham

The main one, we would say, is the way in which we commission, contract for and fund general practices. In our paper we argued that there should be an option for a voluntary contract. The recent dispute around junior doctors is a clear warning about forcing a new contract on any group of healthcare professionals. We think for federations, not just practices, that have an interest in delivering a wider range of services in that way there should be an option for them to be commissioned by NHS England and CCGs together to do precisely that, and to be funded in a different way, beyond the current GP contract, to provide the resources and the contracting mechanisms to build on what already exists. The exciting thing from our point of view is that GPs themselves are taking the initiative. About a third or 40% of the country is already covered by federations of GPs set up by GPs, not because they have been told to do it by NHS England or anybody else but because GPs see that as the future.

Mr Bradshaw

But if it is going to be voluntary—we are all aware of the challenges in renegotiating contracts with medical professionals—how is that going to work universally? How can you be sure that that is a system that can be implemented universally?

Professor Ham

By definition, it will not happen universally. If it is a voluntary option for GPs who have the interest and the capabilities, it will start in places where there is that interest. We believe that, once it gains some traction and other practices in different parts of the country see what can be achieved, they will want to become part of it too. It is nudging people in that direction rather than mandating them to do it.

Mr Bradshaw

What about the challenge in rural areas?

Professor Ham

The challenge is in rural areas, but if you look at the federations we already have they are not confined to the big conurbations.

Mr Bradshaw

Finally, do you think that the GP’s status as a private contractor is sustainable for the long term?

Professor Ham

Yes. I think we are seeing already, though, greater variety in the contracting arrangements and the employment status of GPs. Quite a high proportion of GPs now have chosen to become salaried GPs, or there has not been the option of them becoming partners and continuing with the model that we all know and understand. That variety will continue to be the case in future, but there is no reason, it seems to me, why the changes we would like to see around family care networks cannot be delivered through the independent contractor model.

Mr Bradshaw

Candace, do you want to add anything to any of that?

Candace Imison

I want to underline something that I do not feel has necessarily come through in the discussions you have had hitherto as a Committee: what Chris described sounds in a way quite easy—maybe it doesn’t to you—but actually the scale of change that is required within general practice in terms not only of how GPs work but, exactly as the conversation came out earlier, how they work with other professionals, is very significant. We want and need general practice to do things it has not historically done, so there is a need to think very strongly about population health management, proactively manage chronic disease, support people to do self‑care and relate very differently to patients and local communities. Those are all things that move general practice away from its traditional model, and that is going to require significant investment and change. As Chris said, the federated model is a really crucial step to facilitating that. But it is a facilitation to do something very different. It is not just scale for the sake of it.

Chair

Thank you. It is interesting, to return to your point, Chris, that it is not just about investment; the key is reform. You have often yourself spoken in the past about the need to front‑load some of the money from the £8 billion coming through for the NHS in order to create this transformation and to create the headspace for change. Given that the spending review is just around the corner, could you set out your thoughts about how much we need to see invested in the NHS and what the consequences are for these kinds of reforms if that is not available?

Professor Ham

I can best refer to what both Simon Stevens and Stephen Dorrell said yesterday about the importance of the spending review and the announcements on 25 November. It is a really welcome commitment the Government have made to further investment—£8 billion by the end of the Parliament. We do not yet know how quickly that will come in. I think Simon Stevens echoed what many of us have been arguing: it needs to come in soon, not later, because the current financial problems will get worse if that money does not arrive next year. If there is a delay in the injection of the funding, I think the Government have to be honest with the public about the consequences for patient care. There have been welcome commitments around seven‑day working and improved access, both in primary care and secondary care. We would all like to see that, but they come with a price tag attached and that £8 billion is needed to keep existing services running. It will not be sufficient to fund some of the new commitments that have been made. They are really important and welcome commitments—let me be clear about that—but if we want improved access in hospitals at weekends and if we want seven‑day access to GPs, we need to provide both the money and the staff to deliver that. Front‑loading is essential, and we would also say so is protection for social care, because of the close relationship between health and social care, which I think was Stephen Dorrell’s key point yesterday, and some pump‑priming. We have done some work with colleagues at the Health Foundation making the case for a transformation fund over and above the money we need to put into the NHS to keep existing services going. That would help to promote more of the vanguards and the innovations in care we are seeing in different parts of the country, including perhaps this idea of family care networks.

Chair

Over the years we have heard so much talk about the need to put more funding back into primary care, but, if anything, we are continuing to shift in the other direction. What proportion of that £8 billion do you think the Government absolutely have to insist comes into primary care in order to create some of this change?

Professor Ham

Can I answer it in a slightly different way, if I may, Chair? Rather than say what proportion of the £8 billion it is, we need to restore the share of the NHS budget going into primary care as it was four or five years ago, because there has been, as we know, a steady decline in the priority and the resources attached to primary care as more money has gone into hospital care, also for good reason. From memory—Candace may correct me on this—it was about 12% of the budget going into primary care, and it has come down to 9% or 10%. We need to go back to the figures as they were in about 2010.

Chair

Thank you. In terms of the capitated payment systems being successful, could you talk a little more about that, and how we can move more towards that system?

Professor Ham

In arguing for family care networks we said that they require a different contract, a different way of commissioning and paying for primary care leading extended out-of-hospital care. We suggested that is best done through a capitated budget, which would be negotiated between NHS England working with CCGs and federations and networks of practices, or in some cases the super‑partnerships we are seeing begin to emerge in cities like Birmingham, and there would be a negotiation about how big that budget should be, reflecting the range of services that would be taken on by those federations in collaboration with the other out‑of‑hospital services. There would not be a single national approach. We believe there needs to be some flexibility. A lot would depend on how capable the federations are, and, to echo what Candace said earlier, there are big challenges in making a reality of a very different way of working in primary care. Some of the federations are very new, embryonic organisations that are not yet in a position to lead in the development of this new model of care. Others are quite well established, and we would be confident they had the wherewithal to do it. It needs to be a bit horses for courses within a national framework.

Chair

In other words, just empower it where people are ready to move to that model.

Professor Ham

Yes.

Chair

Thank you. Candace, is there anything you want to add?

Candace Imison

I would certainly underline leadership capacity within primary care—I know you have picked up questions previously—and certainly the leadership capacity within the emerging federations requires support in order for them to have the potential that we want them to have. I would like to go back to the funding issue, because we must be under no illusion—that £8 billion is going to leave extraordinary challenges within the NHS. Previous people have talked about it as if it was an extra sum, and, as you will know better than most, it is actually £22 billion less than the NHS needs to meet future demand. I would absolutely echo the point that Chris made about rebalancing back to primary care. In the Nuffield Trust’s submission about financing for primary care in the future we cited a piece of work that had been done in NHS London, which said that, if you are going to get this new model of primary care, you need in the order of 2% to 5% of the NHS budget extra to go into primary care, which would exactly mirror what Chris has just been describing.

Chair

Thank you.

Andrea Jenkyns

I am trying to get an understanding of how long, realistically, it will take to develop the new team envisaged by the Primary Care Workforce Commission. What timeframe should we attach to the development of the new team?

Candace Imison

Goodness. The first point I would make, and I think it came out very clearly from the previous submissions, is that everyone is starting from a very different place. There are elements of good practice in all places. As you know, I sat on the Primary Care Workforce Commission, and when we looked at examples around the country there was no one place that had everything. Everyone had something. Chris famously cited others who have talked about the future; it is just unevenly distributed. That is exactly what we would observe. Depending on your starting point, your rate of progress to your end point is going to vary. The vanguards are going to be a helpful vehicle for, hopefully, accelerating some of that development. That will teach us something about the way in which people can develop. If you think about a place like Whitstable, which has been developing a broader range of primary care services now for, what, five to 10 years—

Professor Ham

Yes.

Candace Imison

They will really be able to give us a vision of what the future might look like relatively rapidly, I would say. They are using paramedics to assess patients in the community. They have extended roles for nurses. They have relationships with specialists coming into the practice. They have many of the things that we would want to see in the future of general practice. In other areas, particular professions have been brought in. One of the places we cited in the Primary Care Workforce Commission was the Old School in Bristol where they had made use of the pharmacist that you talked about earlier. That pharmacist was not only improving pharmacy practice and improving long‑term conditions management, but actually— something that has not come out of the discussion today—they were driving forward the improvement programme within the practice as a whole. The pharmacist was acting as the lead to help the practice think about itself and how it met the needs of its population, and driving an ongoing set of improvements. The practice was then starting to think about other roles that it would incorporate in its team. That, it seems to me, is a really critical element.

Andrea Jenkyns

I understand that we are coming from different starting places, depending on the GP practice, but you have to start with the end in mind really.

Candace Imison

Absolutely.

Andrea Jenkyns

How long is a piece of string? You must have an end goal in your mind. Realistically, is it going to take five years or 10 years to develop this new primary care team?

Professor Ham

Can I come at it in a slightly contrary way? I do not think we are moving from stable state A to stable state B. We are moving from unstable state A to unstable state B, and then to somewhere else in future. It is a very dynamic environment out there. Just to add one point, in the discussion earlier with the previous witnesses one bit that was really missing—Karen Middleton mentioned it once—was not just the role of the healthcare professionals in the team but the role of patients in the team. A wise man—it was a man—said to me about 10 years ago that the most important members of the primary care team are not doctors, nurses, pharmacists and therapists but the people receiving the care, particularly in an age when chronic medical conditions represent a huge proportion of the workload presenting in general practice. We all know from our own experience, and from friends and relatives, that there is so much we can do to remain in good health by taking our medications and adopting healthy lifestyles. Frankly, we have not given enough attention, in my view, to what we need to do to support people to be more confident in managing their own health and wellbeing.

Andrea Jenkyns

What policy measures are required in the short term, would you suggest, to alleviate the challenges facing primary care, particularly in the case of general practice?

Candace Imison

Goodness me. If you are thinking about underpinning GPs with that broader range of healthcare professionals, one thing that I have been really struck by is the fact that at the moment we do not have a consistent approach to defining those roles and explaining what competencies sit underneath them. I know it is something that HEE are thinking about, but it is absolutely critical, it seems to me, that we are clear about what these roles are and what competencies they equate to. Certainly, if you think about practices trying to develop these roles for themselves, having that clarity would be incredibly important.

Professor Ham

Can I add one thing? Going back to the idea of a new voluntary contract, the Prime Minister spoke about it—I think just before the Conservative party conference—and Alistair Burt, the care and support Minister, has reiterated that it is very much part of the Government’s thinking. To put it on the table and to be very concrete about what it might look like and how it might work with the emerging federations would be a very big and welcome step forward.

Andrea Jenkyns

Health Education England is confident that by 2020 there will be equal supply and demand of nurses in England. Do you share that confidence?

Candace Imison

There are significant threats to the supply of nursing and they come from a number of places. There are particular threats within primary and community care because of the age profile of that nursing workforce, and because it is not traditionally a preferred career pathway for nursing. The points that were made about increasing exposure to primary care for nurses in training are incredibly important. But there are significant threats from the international migration of healthcare workers, not only to nurses but to doctors too. We have underpinned our nursing workforce—traditionally—from international sources, and as things change internationally people who have come here may well go back again. That argues for an active policy to oversupply nurses, not to try to land the jumbo jet on a pin, which is traditionally what we have tried to do in workforce planning and inevitably come unstuck.

Professor Ham

If there is equilibrium in demand and supply, it will be the first time in the history of the NHS.

Andrea Jenkyns

Good answer. Moving on to pharmacists, should the surplus of trained pharmacists be harnessed by directing patients towards community pharmacy or attempting to create roles for pharmacists within the GP teams?

Candace Imison

I think it is a “both and”. There clearly are big opportunities within community pharmacy for pharmacists to undertake medication reviews and support people with long‑term conditions. What was very interesting in the Old School surgery that we visited as the Primary Care Workforce Commission was that they had “both and”. They had the pharmacist who was the partner in the practice but they also had a community pharmacy sitting within the practice itself. Interestingly, one of the real facilitators of the potency of that community pharmacy was them having access to the summary care record and therefore understanding the conditions that somebody was coming to them with. Again, it may not have featured as much as it might in your discussions, but the role that IT is going to play is really key, in terms of facilitating people both within the practice to work in a multidisciplinary way but, crucially, to get the links into secondary care, which is another important part of the piece for primary care going forward, and indeed into community pharmacy.

Professor Ham

I cannot improve on that answer.

Andrea Jenkyns

Do you think it is realistic to expect pharmacists to take on a greater share of the primary care workload and, in the short term, possibly to relieve the burden on general practice?

Candace Imison

I think it is highly realistic. What really struck me were the significant benefits this brings. It is not just about substituting for GPs. It is actually bringing a whole new skill set to play within primary care, which has huge benefits for patients as well as professionals. You got the same message, I think, from Karen when she was describing the opportunities around physiotherapy. There are some real win‑wins with these extended roles.

Professor Ham

Especially around the challenges of polypharmacy. That was referenced earlier too—the medication reviews that pharmacists are particularly well placed to undertake. I think somebody said that about an hour a day of a typical GP’s time is spent on those issues. That is a lot of time for patient consultations and using the skills of GPs to best advantage.

Helen Whately

You were talking about the cost side, the investment and the impact, and I want to pick up some questions on that. One of the things you mentioned, and it was mentioned last week as well, was the shift in spend from acute to primary and the need to go back to where it was, at the 12% kind of level, from where it is now. Clearly, that translates into quite large amounts of money, be it in the £2 billion, £4 billion to £6 billion range, when you are talking about something like a 2%, 3% or 4% shift, depending on where you see the starting point. I have seen different numbers, so I am not being specific, but given that they are quite large amounts of money, do you have a view on what aspects of primary care they should go into? What is a good model by which the money should be distributed—change of payment models? What impact on patients will that increase and shift in spending have, and will we be able to say what difference it has made compared with where we are now?

Professor Ham

Part of it for me here is something that we have not mentioned in this session, which is recognising the impact of the funding pressures in primary care on GPs and members of the primary care team. In the evidence that Martin Roland gave to you last week, I observed he said that, in the survey the University of Manchester does, the most recent results this summer show the highest level of reported workload stress among GPs in the many years this survey has been undertaken. I certainly recognise that from the discussions we have with GPs. It is the ageing population, the more complex presentations that GPs receive from that ageing population and the difficulty of providing the care that GPs, nurses and others want to provide in the treadmill of the 10‑minute consultation. The resource, I think, ought to help particularly in addressing that set of issues. The challenge is that we are not going to magic up 5,000 more GPs and 500 more physios every year, given the time it takes to train them. That is why I go back to this having to be about reform and doing things differently in the workforce—not just more. What does that mean? In discussions among GPs, should GPs become much more consultants in primary care—consultants to the nurses, the pharmacists and the other members of the team—because if they are increasingly a scarce resource perhaps we expect them to do too many things in that team, and we should focus on what their particular skills, training and expertise can offer? That is already happening in some parts of the country. Going back to a previous point, we ought to do much more to support patients and people, to take more responsibility and provide them with the skills and the training to do that for their own health and wellbeing. It is about the workforce, because primary care, above all, is workforce-intensive.

Helen Whately

The impact is particularly on the sustainability of the model.

Candace Imison

There is a very quick win, which I think Martin cited to you, which is that if you brought in medical assistants to primary care—his calculation, which is in the report, was that it is the equivalent of about 1,400 GPs—those would be people whom you could very easily recruit.

Helen Whately

In this approach we try to learn from many international examples. From your experience of looking at those, are there any mistakes that we need to make sure we avoid, things we have to make sure we do not do?

Professor Ham

Generally—I am glad you have asked the question—we are lucky to have the system of general practice primary care that we have. In my work and the work we do at the Fund we have the privilege of visiting many other healthcare systems, and I would say that, eight times out of ten, people in those systems would give their eye-teeth to have our general practice primary care arrangement, warts and all, compared with the one they have. One of the common mistakes is around the payment model for GPs, and particularly those systems that persist with a fee‑for‑service payments system, which incentivises activity and contacts rather than continuity of care. Very often, it gets in the way of GPs delegating to other members of the team because they will only get paid when they personally see the patients. What incentive is there in that arrangement to build the team that I know you are looking at as part of this inquiry? Getting the payment model right is really important.

Helen Whately

Is it your view that it should be a capitation model rather than a fee‑for‑service model?

Professor Ham

Every country generally has a mixed‑payment model rather than going for a purist fee for service, capitation, what have you, and we need to do the same. I would argue strongly for capitation as the foundation stone but also argue for linking payments to the quality of care that practices are able to deliver. Don’t get me wrong: I am not talking about QOF here. I think QOF in its current form is past its sell‑by date, so the model of family care networks operating within capitated budgets would have incentive payments linked to population health improvements because they would be covering much bigger footprints, rather than the narrower, clinically defined QOF incentive payments.

Candace Imison

I would totally underline that point but also add a note of caution. People can all too often see the payment mechanism being the solution, and the learning from ACOs and others in the US is that the outcomes are very variable and you need a whole load of things that sit behind the payment model to make it really have the impact that you want it to have. So be under no illusion: that is not a quick fix in terms of solving things.

Professor Ham

Occasionally there is a debate, is there not, about whether we need to migrate away from GPs as gatekeepers and have more open access to specialists? My view is that we should not. Whatever the disadvantages of our current primary care system, there are clear benefits in having that relationship between people and their families and their practice, seeing GPs and the teams as the first point of contact, and making sure there is much better communication between what happens in the primary care teams and what happens in the specialist teams in the hospital. I do not know if you want to go in this direction, but we would certainly argue for much greater collaboration between specialist teams and primary care teams of the kind that you see happening in some places.

Candace Imison

I would really underline that point. That is a huge opportunity and is important. While people absolutely celebrate the quality and the focus on a registered population of primary care in this country, they find the division that we have between primary care doctors and secondary care doctors very confusing, and patients suffer as a consequence of that division. We really have to bridge that gap. It is very welcome that the vanguards are experimenting with models that do that, but it is utterly critical, and both the Fund and the Nuffield Trust have really pushed that this is a divide we have to get across.

Emma Reynolds

What is the barrier to that working?

Candace Imison

There are many. Some of you practising GPs will probably be able to tell me more eloquently than I could tell you, but going back to some of the payment models for informal interactions between GPs and secondary care has not helped. Putting people in these very clearly distinct geographic areas has not helped either. But there are emerging models of really good collaboration between secondary and primary care, and, as I said, this is where new technology will come into its own. Email consultations and teleconsultations will all enable a much stronger working relationship.

Professor Ham

History is important, is it not? Roy Porter, the pre‑eminent medical historian, talked about the division in British medicine that happened 150‑odd years ago: specialists got the hospitals and GPs got the patients. That is a divide that you do not see in all other healthcare systems. In the best integrated systems that you see outside this country you have co‑location of some specialists with family doctors; you have much more of a multi‑specialty model of medical practice where you turn up and, down the corridor, if you have a problem, you can go and see the dermatologist or the orthopaedic surgeon, and there is that ease of communication and contact that we can only envy. We cannot do that everywhere in that sort of way. History is a big barrier, but people are overcoming this. Eileen Burns, a geriatrician in Leeds, is working across hospital and the community. There is a good paediatric service in west London that is doing something similar around children’s health. There are good examples in diabetes care. Partha Kar, who is a diebetologist down in Portsmouth, works across hospital and the community. This is not a kind of drag-and-drop model where you simply shift outpatient clinics from hospital into the community. It is a model where the specialist teams support the primary care teams to do much more of the routine work, and only the patients with more complex needs get referred into the hospital where there are those expert facilities in diagnosis and treatment that you need for that cohort of patients. But surely these are the models of the future of which we need to see much more.

Candace Imison

Yes, and the job plans of consultants in hospitals change so that they have dedicated sessions to supporting primary care. They genuinely become a consultant to primary care, as it were, rather than to patients.

Helen Whately

I would like to pick up on the “GP as gatekeeper” point that you made. I heard you emphasising that that should broadly stay, although there is an argument for a shift from having the individual GP as a gatekeeper to the future world where you have much more multidisciplinary working. Will it shift from being a GP to a more multidisciplinary team that somehow acts as a gatekeeper?

Professor Ham

Yes, which I think it often is these days in those practices that are working as they are in Whitstable or Bromley‑by‑Bow, which would be another favourite example I have, where you have a much more innovative holistic approach to primary care through Sam Everington. So yes is the answer.

Chair

We have heard some really clear examples of excellent practice, but listening to the State of Care report and Steve Field’s comments on it afterwards commenting that the “poor” is very, very poor in a general practice, how can all of these models do more to reach out to failing practices to bring them up? What are the key drivers that are going to make that happen?

Professor Ham

This is why we need federations and networks. In a different context, Mid Staffs, as Robert Francis said, was an isolated hospital where progress had passed it by; it was not benefiting from the opportunity to collaborate with other specialist services. Much the same applies in primary care where we have poor standards because we still have this outmoded corner‑shop, cottage-industry model of general practice, which has served us pretty well until recently but is not fit for purpose in future. If we can get practices to come together much more in federations and networks, we are breaking down that isolation.

Chair

One problem, though, with that—and I know this myself having been in practice—is that practices generally are not keen to take on a failing practice. It is much easier to federate with other practices that want to take on change and be progressive than it is to take on a practice where nobody wants change or where there may be other difficulties within relationships within a practice. What are the things that are going to encourage federations to scoop up failing practices?

Professor Ham

It is partly what you are saying about the reluctance, but also can I give a different example that might help on this? When Candace and I, and others, talk about challenging poor standards of primary care, we keep on going back to what happened in Tower Hamlets about 10 years ago. The PCT, if we can remember PCTs before we had whatever they are today, had a man called Doug Russell, a medical director, a GP by background, who originally worked in Wales and came to Tower Hamlets. He was shocked at the time—and he has spoken about this publicly—about the appalling standards of primary care and the variability: some of the very best, like Bromley‑by‑Bow, and some simply unacceptable. He found the levers and the courage to challenge those poor standards, with support from local GP leaders in Tower Hamlets, as the medical director, not himself a practising GP but responsible for quality and the planning of GP services. My belief is that, if we encourage federations and family care networks, they will see the benefit in recruiting people like Doug Russell and working with the practices to achieve those much more consistent standards of care that we all would like to see.

Chair

Currently, are the levers held by bodies like the CQC, who go in to a failing practice and say, “This is unacceptable. You must federate”? Who makes that happen? Is it that they close the practice down because it is unacceptable and somebody else takes over?

Professor Ham

NHS England has the formal responsibility, but, increasingly, as we know, it delegates responsibility to CCGs where there is an interest in co‑commissioning of primary care. The problem has been that NHS England itself, frankly, has not always had the capability or the understanding of quality in primary care.

Chair

Whereas local organisations do know who the failing practices are.

Professor Ham

Exactly.

Chair

What levers will they currently have? I am sorry to press you on this, but I want to know where are the levers now to force change on underperforming practices to make sure that they come in and come up to standard?

Professor Ham

The main levers are with the CQC on the individual practices and the quality of care they deliver through Steve Field and his teams, and greater transparency around outcomes of care and performance, but there ought also to be levers through CCGs as they take on more co‑commissioning responsibility; and the levers are the same as the levers that Doug Russell used 10 years ago. But you need people with the courage and the understanding of primary care to be able to go in and do it at a CCG level. This is probably a topic for another day, but our current distribution of scarce commissioning expertise around 200-plus CCGs does not seem like the right model for the future.

Candace Imison

When I have spoken to leaders of some of the more advanced federations, they are very motivated by the population health picture and it disturbs them greatly to see some of their colleagues not supporting that and some patients in their area not getting an equivalent quality of care. Principia went in and challenged individual practices to improve and meet the standards of others. I do see those GP leaders as prepared to take on that task, and I suppose it then underlines again the importance of developing and supporting those leaders in a federated model and, crucially, supporting succession planning for them too, which is something that we traditionally do not do nearly enough of in the NHS.

Chair

Thank you.

Julie Cooper

Carrying on with the theme of consistency across the country in good practice and trying to address that, recognising that GPs everywhere are under pressure, as to the teams that have been developed in primary care, Professor Roland said there are no tight boundaries. In your opinion, which specialist practitioner should be included in every primary care team?

Professor Ham

That is a good question.

Candace Imison

I would echo Martin’s point that you do not necessarily have to be a core part of the team. The key is to have the linkages across to others. It would seem to me that it is absolutely essential that you have the nursing roles in their various guises and you have the underpinning administrative support. Pharmacy is a critical component of it, and then the challenge is to have the appropriate linkages to the other specialties that need to support it. I would pick out geriatrics, child health and psychiatry as being the three core areas, and then, crucially, the specialists for the other specialist input. But, again, something that maybe has not come out of the discussions as much as it might and that has really struck me is that we do have a significant issue within general practice as a consequence of the way that GPs have historically been trained, which has not always equipped GPs with the skills that they need to manage the workload that they face. Hilary Cass will speak very potently about how many GPs got their paediatric training through working on a neonatal intensive care unit, but they face a huge body of children coming through their practice and need broader skills to manage those. We know that a huge proportion of our patients, and certainly the most needy patients, have psychiatric disorders and mental health problems, and those are all skills that general practice has not traditionally had as a core part of its training.

Julie Cooper

Would we agree then that some of the patients coming through the door have additional needs in terms of—I suppose what might be described as—social needs rather than medical needs, and therefore would you think it appropriate to have someone within the team that assists with social prescribing, or is that going beyond a boundary that GPs should not? Is that a separate service? Should it be separate or should it be an incorporated part of the team?

Professor Ham

It could be either, could it not? That is what Sam Everington and colleagues do in the Bromley‑by‑Bow Centre. They provide advice on claiming benefits, on housing, on a very wide range of issues that in their community are probably more important than the clinical advice they get within the centre itself. So it works there. I am just thinking about some of the smaller practices and some of the rural practices too that might find it more difficult to offer that wider range of expertise, but with the technology available today there must be creative ways of providing access, if not in person, remotely.

Julie Cooper

We have come across that a lot today, people citing—you and other witnesses—good practice in different areas, and you are mentioning now, geographically, this happens here and that happens there. How do we make sure there is a consistency across the country? How do we stop people falling through the gaps where, for different reasons, different good practice develops? How do we make sure that this is very best practice, and, therefore, that is why I come back to the core team that would be a requirement perhaps of every primary care team?

Professor Ham

I would not want to argue for uniformity.

Julie Cooper

You would not.

Professor Ham

No. In general practice, a degree of variety and innovation in different parts of the country is something we should welcome and encourage. The concern I would have is the one that Sarah raised earlier: the unacceptable and poor standards of primary care that still exist in a proportion of practices that Steve Field has spoken about. We need to tackle that and get everybody up to a basic minimum. Over and above that, for me, we will only see what works and where the future models are if practices have quite a lot of local flexibility to do what we see in Whitstable, Bromley‑by‑Bow and other places that we have been talking about.

Julie Cooper

Thank you. I have one final point. Do you see there being any role whatsoever for volunteers in terms of support with social issues? In some areas I think that has been piloted. Do you think that is a possible way forward?

Candace Imison

It is not an area I know a lot about. I have experience of it in a secondary care context where volunteers are an increasingly important part of how many trusts are operating. The huge advantage of volunteers is that they can facilitate the engagement of patients and act as an advocate for patients—that patient voice that Chris was underlining. It was striking to me when I was a non‑executive director in a trust that had volunteers that our dining companions in that trust were the people who ensured that the food was changed, because they saw it as totally unacceptable. They will argue for things in a way that patients will not. For me, that is one of the big pluses of volunteers, but there is a whole range of issues that runs alongside that. As Chris said, it is a whole subject in itself.

Julie Cooper

It is a can of worms, is it not?

Professor Ham

We are going to do some work asking what we know about the current use of volunteers in general practice next year, because, to my knowledge, there has not been any serious work on that topic, whereas there has when it comes to hospital care.

Julie Cooper

That is an area to be explored further. Thank you very much.

Chair

Does anyone have any further points that they would like to ask? Can I ask you both before you leave, and from the work of both the King’s Fund and the Nuffield Trust, are there areas we have not touched on so far during this inquiry and in our previous session that you feel we should be exploring in more detail or you would like to tell us about?

Candace Imison

One point—and it may seem like a very tiny one—which may have come up slightly in your first session, is the role of indemnity insurance. At the Nuffield Trust we run a learning network for some of these larger federated practices, and a number of them have fed back that it is a big obstacle to recruiting these extended roles. The MDU likewise has said it is a big challenge for them particularly, and it goes back to the point I was making earlier about needing clarity about what these roles are and the competencies that run alongside them. Because there is general confusion out there, there is not a clear framework for the MDU to link into around offering insurance, as I understand it, and it can be large sums of money that practices are facing as an obstacle. I would urge you to have a look at that.

Professor Ham

I have two quick points, if I may. One is that we have not talked in this session about the role of technology as a mechanism of reform and changing access, and the relationship between patients and primary care teams. We know there is some interesting work in some parts of the country. To use a different example, the Hurley Group in south London is an innovator in the use of technology to help patients access information and to facilitate email and other contact between patients and GPs. It is an issue that has been widely debated, but particularly in primary care there is huge potential there if we can get it right, and we are making some progress. There has always been the functionality within the main GP information systems for patients to email their doctors, but it is just that very often it has not been used, and I think there is more encouraging evidence that it is being used. That is one theme. The other thing—again, you may have touched on this in previous sessions—is the challenge of GPs coming towards the end of their careers and the worrying evidence about more of them retiring early and then not coming back. We know that they often have retired in their late 50s or early 60s, but, historically, they have chosen to come back having taken their pensions and work on a part‑time basis. Anecdotally, it seems that is happening much less frequently now. So we are losing a lot of really experienced doctors for a variety of reasons. I think it is partly, again, the workload pressures and the stress, and partly to do with wider changes in pension arrangements that are impacting on people across public and private sectors. But we need to find creative ways of stemming the outflow because the loss of all that experience of people who still have a lot to give is a real worry.

Chair

Again, I have been hearing some reports that it is professional indemnity insurance that is also a deterrent for people coming back part time towards the end of their career. Is that something that you have heard?

Professor Ham

I have not heard that specifically in relation to general practice. I know it is an issue for other professions, but if that is a concern then absolutely.

Chair

Thank you both for coming today. We appreciate your evidence. Oral evidence: Primary care, HC 408 21