Despite the very widespread and continuing pushback by GPs and their associations, health campaigners, many local politicians, NW London health bosses have still not withdrawn their proposal that patients book appointments through a centralised ‘hub’ or call centre rather than through their practices.

Continuity of care, through building up a relationship of trust over time with one’s own GP practice, is a key factor, as so many academic studies have shown, in keeping a patient well. How continuity of care can be ensured through contacting a remote hub has never been explained by health bosses.

It is well worth reading the short article by respected GP and academic, Dr Helen Salisbury, about how continuity of care has benefits for health, longevity, cost efficiency and doctor satisfaction – published in the British Medical Journal, 15^th August, 2023.

Triage, signposting, and care navigation are buzz words that crop up frequently in discussions about the future of general practice. They form part of NHS England’s vision of a leaner, cheaper service, in which simple health problems are attended to by someone with just enough skills and training for that task, leaving doctors free to concentrate on complicated cases that definitely need all that expensive training and professional expertise.

The concept isn’t new. Years ago, as a GP registrar, for a few weeks I had to fill in a form after each consultation about whether the patient’s problem could have been managed by a nurse rather than a doctor. Even then I was aware that this wouldn’t produce useful answers. After all, judging in hindsight that the patient hadn’t really needed a doctor is very different from making that decision in advance on the basis of the presenting complaint. Before you’ve seen the breathless patient you can’t know whether their problem is anxiety, infection, or a pulmonary embolus.

Even if patients who are diverted from seeing a doctor receive safe and adequate responses to their main problem, they’ll miss out on all the other parts of care that characterise an ongoing patient-doctor relationship. (What did you decide about the statins? How’s your mum doing now? Did you get that reminder about your blood tests?)

Alongside the move to greater triage—sometimes with online forms to flesh out that presenting complaint—comes the concept that continuity of care is a luxury needed by only a subset of complex patients, while everyone else will be fine seeing any doctor, taxi rank style, in a centralised urgent care facility. This direction of travel was set out in the 2022 Fuller stocktake report,1 badged as a vision for integrated primary care.

However, we don’t always know at the outset who or what will be complex. We can guess that older patients or those with multiple diagnoses will be in this group, but I’m concerned that patients with mental health problems or families with safeguarding needs may slip through the net and receive only anonymous urgent care. Even with physical diagnoses, complexity isn’t always obvious at first glance: the vomiting teenager may have a self-limiting gastroenteritis, or it may be the first presentation of diabetes or an eating disorder. Night sweats and sleeplessness may be the menopause, but they could be symptoms of lymphoma. If I already know my patients I’m more likely to recognise when they’re ill, but in the brave new world of urgent care centres this opportunity will be missed.

Overwhelming evidence shows that continuity of care benefits health, longevity, cost efficiency, and both patient and doctor satisfaction.2 The House of Commons Health and Care Select Committee recognised this in its report on the future of general practice and recommended a series of measures to restore the patient-doctor relationship, including capping list sizes. These recommendations have been rejected by the government.345

I’m strongly persuaded that the right person to see the patient—for a whole range of minor, major, new, or long term conditions—is usually their own GP. We need to train more GPs, and retain the ones we have, to provide this gold standard for all patients. If we continue down the current route of breaking up, reorganising, and down-skilling general practice it will be an increasingly unattractive career option, and the quality of care we can offer patients will deteriorate further.

It is also worth reading the longer piece by Craig Nikolic, the Chief Operating Officer of Barking and Dagenham GP Federation who explains why this proposal on same day access fails to answer any of the key access questions and does not take into account how GPs and their practices are working harder than ever while meeting more patients.

Why “improving access” with core hours same day hubs misses the point

• 18 APRIL 2024

The consequences of waits

If you were to take the NHS of a quieter time, with low waits and no decade of year-on-year cuts to services downstream of general practice, it may be something to consider. We’re not there though, and austerity general practice patients need GPs, not quantity of appointments.

Let’s start with an example: a patient needs a hip replacement. In a non-austerity system, the only time they’ll see their GP is when the GP refers them as it’d be refer > outpatient appointment > surgery > home with follow-up care. The patient is then freed of pain and gets on with their life. In a system with huge waits, the patient deteriorates with time, with their  mobility going and bringing immobility frailties, obesity, increased social isolation, and mental health issues. This increasingly ill patient needs their GP for repeated interim care for far more than their hip pain.

A simple guide that we’ve seen with samples of data is that patients needing interim care need two to three times as many GP appointments than comparable age/weighted patients. They need *GP* appointments to manage their growing issues and increasing complexity of need as they get more ill. Then, when they eventually get their operation, they are a far more complex patient to treat in-hospital, often needing significant care plans post-discharge, and frailties that become lifelong with even more NHS care needed. This of course loads more on community & GP care.

That’s just one example, if you’re anywhere near patient care, you’ll be able to identify more. Any time a patient is deteriorating because of social care cuts, hospital services reduced/removed, or the many cuts to district nursing, and on, they need more GP care.

The services that just aren’t there

The next issue: Every referral rejected for something that used to exist, or has been cut, often results in GPs having to treat the patient themselves, working right to the edge of their license and beyond. You may struggle to find one GP who hasn’t worried on that line. This weekend, we’ve seen in The Sunday Times story that “NHS chiefs” have been told to “think the unthinkable” on cuts. Where do you think these patients will go in the cut services? They’re not going to miraculously get better, but they will remember being told “no”.

Each time these people struggle, they have two “outs”, their GP practice, or turning up at an A&E because they’ve nowhere else to go to get care. Often in a far worse state because of a want of simple care in a cut service. It’s also in these places that their frustrations come out, so the GP practice & A&E staff get the abuse. This is why general practice is providing way more appointments than before yet the public are still unhappy with access. QUANTITY is largely irrelevant to increasingly ill patients who just want to feel better in a system that they feel has left them behind and not told them why.

GP practice appointments are increasingly being filled by people who need care and help elsewhere, and that care has been cut or closed entirely. Throwing on an impersonal hub of lower skillset appointments is just not what patients want during core hours.

The need for continuity of care

Back in 2015, Jeremy Hunt could see this coming, and was explicit in the need for more GPs in the manifesto. He’s not a stupid person, he could see the NHS needed GPs, not just to get more appointments out of the existing ones. In 2019, the aim increased to 6,000 more GPs by 2025. Good luck to the NHS doing that by 2025.

At the same time, the Urgent and Emergency Care system (UEC) has been battered by many of the same issues as GP practices: patients with nowhere to go and downstream capacity butchered on the altar of austerity. That’s your headline news of huge ambulance queues and ED waits.

Now, you’re the Government, and you cannot fund general practice or UECs with more as it’s party politically toxic, and you can’t magic 6,000 GPs out of thin air. So, what do you do?

Solve both with one thing, churn out as many appointments as possible using existing GP funding. You tell patients you’re giving them somewhere to call to see someone the same day, yet it’s neither proper UEC nor real general practice, and at the same time you’re defunding long-term historical planned and same-day capacity in general practice. Starting to see the problem?

Funding in-hours same day urgent care using money and resources that should be used for traditional continuity of care for GP urgent and planned care is, at best, dangerous as it is dismantling yet more NHS capacity. I’m not even touching the medico-legal liabilities…

Short-termism prevails

The NHS increasingly looks at its own feet, this year, this quarter, that’s it. Beyond that is someone else’s problem and that has led to increasingly ethically fraught short-term firefighting decisions being made that no-one has the courage to tell the patients about.

Take these GPAD statistics from my borough of Barking & Dagenham:

• 81% more appointments in five years. That’s unsustainable and resulting in general practice breaking across England. Yet, ask the wider public if that’s fixed “GP access” for them. It hasn’t, because that’s not what the public want.
• February 2019, Barking & Dagenham GP practices saw 62,497 patients.
• February 2023: 91,303 patients.
• February 2024, 112,910 patients. An increase of over 50,000, 81%, since 2019.

We’re at the stage where we have increasing numbers of unemployed GPs, a standing Government manifesto commitment to hire more GPs, and GP practices who can’t afford to hire any more, or even keep employed those they do. But appointment numbers are up, so all is well?

General practice access is struggling because the high skill-set GPs are overwhelmed with top-of-license cases, from rejected referrals, to interim care for waits, and a huge funding focus on diagnostics but zero funded capacity to care for newly diagnosed patients. As much as I love the extra capacity in general practice in the last five years, and I can see the good it is doing for patients, it has not resulted in an extra penny of money to hire GPs to cover the complex work that has been pushed into general practice from elsewhere.

The public attitude in the recent surveyis not something to be ignored or explained away as inconvenient, the public really do want more GPs, they really do want more doctor care, they really do want to get and stay healthy in a system that cares for them.

Back to the main point, there is a huge unmitigated risk that diverting funding into “same day hubs” in core hours will irretrievably break general practice and the personal bond the people of our country have with it. It will fix neither general practice nor UEC access.

Have a read of the Hampshire & IoW ICB considered plan, doesn’t mention GP practices at all, and has non-clinical triaging of care. Good luck explaining the first death to the coroner or CQC there then, whoever is medically responsible.

When someone up the food chain says “think the unthinkable”. Make them put their name on it. “(forename surname) says think the unthinkable”. Either that, or ask them to have the courage to go tell the public why they’re breaking yet another bit of the NHS.

Summary

This has been an explainer of why I think the same day access plans are dangerous, but it can be used for so many more points on why rearranging deck chairs will do nothing but make things worse. I sincerely hope that this gives more context to those reading this, and a different viewpoint to the “we’re doing this whatever you think” attitude I’ve seen in different parts of England.

A little after I first wrote the Twitter/X thread I was sent another ICB’s commissioned report from a big consultancy on this. It was mainly Google-searched similar schemes from around the world and why they would work there. If you’re tempted to do similar, start at the top of this page, and it explains why this is wrong.