Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 642-659)


29 JUNE 2006

  Q642 Chairman: Good morning, could I welcome you to this evidence session. Can I ask you if you would introduce yourselves and the organisation that you are from, for the record. Could I start with you, Professor Gray?

  Professor Gray: I am Selena Gray and I am the Registrar of the Faculty of Public Health, and I am also Professor of Public Health at the University of the West of England.

  Dr McKinlay: I am David McKinlay and I am the Director of Postgraduate General Practice Education in the North Western Deanery, a part-time GP in the Ribble Valley and I retire in eight days on the anniversary of 37 years' service in the NHS.

  Dr Archard: Good morning. I am Graham Archard and I am the Vice Chairman of the Royal College of General Practitioners and also Chairman of the Professional Executive Committee of the South and East Dorset PCT. I represent the RCGP today.

  Mr Holmes: Good morning. I am Paul Holmes; I am Chief Executive of Kingston Primary Care Trust and was formally Chief Executive of the South West London Workforce Development Confederation, which subsequently became part of the South West London Health Authority, where I was the Workforce Development Director.

  Q643  Chairman: Once again, thank you for coming along. Could I ask a question to all of you? The primary care workforce has expanded more slowly than the overall NHS workforce in the past five years. How much of a problem is this?

  Dr Archard: It has quite a radical effect. The complexities of secondary care are such that some of the work has had to be shifted towards primary care, and that is inevitable because of additional workloads in secondary care. To reflect the additional workload in secondary care there has been quite a dramatic increase in the number of consultant places to accommodate that increased workload. Add to that of course secondary care is also subject to the European Work Directive, such that particularly junior hospital staff are perfectly reasonably working far less hours than historically they would have done. The obvious knock-on effect of that has been that a significantly increased amount of work has been shifted towards the primary care sector. There has not been a comparable rate of increase in the workforce in the primary care sector and so inevitably there has been a problem in accommodating the additional workload, which is moving towards the primary care sector. This is not just in general practitioners but in all healthcare professions, such as nursing, physiotherapy, pharmacy and so on. So there is a very dramatic increase in workload in primary care, which is not being reflected in the increased workforce.

  Professor Gray: I think in terms of public health we are clearly very concerned that the public health workforce certainly has not grown at anything like the extent of the secondary care workforce, and yet we know the demands on public health are increasing, with chronic disease management, illness, the Wanless Report, there are increasing demands across health protection, health improvement and service quality improvement—the three domains of the public health practice—and yet we have a workforce that clearly is not growing and we are in danger of losing people through various reorganisations at the peak, sometimes, of their professional careers.

  Q644  Chairman: Your submission, Professor Gray, did point that out to us. Do you really think that this will be made worse by the reduction in the number of PCTs and SHAs?

  Professor Gray: I think we are very concerned that the current reorganisation does not lose yet more health professionals, and there clearly is the opportunity, with the merger of PCTs, in theory, to create larger, more robust public health teams. But we are anxious about the safeguards that are put in place to protect the public health workforce and to make sure that people are not lost along the wayside. I think we need proper guarantees that those posts are not going to be lost.

  Dr McKinlay: The difference in the ratio between GPs and specialists is quite dramatic. I used to give talks in the late 1980s and talk of an average health district and it was a quarter of a million people, 50 consultants, 100 GPs, 100 junior doctors and about a million consultations of which only 20,000 would have finished up in hospital. The ratio now is equal and so it was two GPs to one consultant, and it is now one-to-one. Then I think the other point that may be helpful to add is that the impact of the various reorganisations on young doctors on training is sometimes not appreciated. I set up the East Lancashire training scheme and in 1989 there were 130 applicants for four places on that scheme and in 1991 there were three applicants for four places on that scheme. As far as we were able to work out there was the 1990 contract which gave young doctors in training the idea that they were just going to push paper around for fund holding and not have time to see patients. At the same time there were the Calman reforms that gave young doctors the idea that they would all become consultants in six or seven years, and six or seven years later they found out that that was not the case. Then finally, in my own local area, there was a dramatic shift in the way that the University of Manchester trained its students and it kept them all close to the university, and to stereotype it we used to counteract two weeks in the concrete jungle with two weeks' hunting and fishing in the Ribble Valley, and the peripheral experience, the Ribble experience was taken away to keep the students close. Those three factors dramatically affected recruitment in East Lancs., and it took us most of the 1990s to turn that around.

  Mr Holmes: If I could give you a very local perspective from South West London? It is not a general pattern if we look at it by individual profession, so, for example, across five PCTs in South West London during the period from 2000 to 2005 we saw a 23% increase in the number of general practitioners. Conversely, the number of practice nurses remained very stable during that period; there was a very small reduction of just under 2% in the number of practice nurses. And there was 100% increase in the number of healthcare assistants to a total number of just under 100, and that was quite significant because we did not have healthcare assistants in place in 2000.

  Q645  Chairman: Dr McKinlay, you said that there was a severe crisis of GP numbers in the North West.

  Dr McKinlay: Yes.

  Q646  Chairman: First of all, how has this been addressed? Also, could you tell us has the recent growth in GP numbers been inconsistent across the UK?

  Dr McKinlay: I think there has always been a north-south divide and within our actual area there is a microcosm of the London versus the rest scenario because Greater Manchester medical school is the focus of training, and I am afraid still, although less, we are all trained in tertiary care and we all work in secondary and primary care, and I do see that modernising medical careers as an opportunity to actually change that to some degree. East Lancashire is very severely affected, but even we have difficulty in persuading a large PCT like Morecambe Bay. Lancaster is an extremely popular market town—very difficult to get doctors to go to Barrow-in-Furness in the same area, so you get a microcosm within a small area. The Ribble Valley, where I work, is a bit of an oasis in the desert; it is relatively easy to get doctors to come to a nice market town like Clitheroe—it is not so easy to get them to go to Burnley.

  Q647  Chairman: Effectively the increase in GP numbers is inconsistent but historically they always have been inconsistent in terms of GP ratios with patients.

  Dr McKinlay: I think that is right but the problem is that it is going to be compounded by the retirement time bomb. Again, it is a slight stereotype but the survey we did in 1999 of all the doctors of over 50 in the North West, the doctors who have gone to the under deprived area were very often doctors from overseas, they came and they tried to get on in the hospital service, realised that at that time there was a glass ceiling and moved into general practice, and when we surveyed them the older GPs told us that they were going to go on working because they did not have the pension rights because they had been junior doctors in the hospital for a long time. For the younger GPs, the worrying thing from our survey was that the 50 to 55 year olds said, "We have our ISAs, we have our pensions, we are going to go when we are 55 to 60." And the other issue with retirement is that the doctors working in the Health Service now tend to be full-time with long hours. The workforce that is coming through to replace them is a strongly female workforce, but it is not just the female doctors who want to practise part-time it is male doctors as well.

  Q648  Chairman: If you have a need of more doctors in a place like Clitheroe, has anything that has happened in recent years, particularly the new contract, been able to give the PCT powers to induce people to go and work there more than being able to in the past?

  Dr McKinlay: I realise that the new contract has had a lot of bad press in terms of finance but we have just undergone a recruitment round for general practice and I think it has had an extremely positive effect. The combination of the publicity, which in my own experience is wrong, of high salaries for GPs, but probably more the out of hours issue because the most important aspect with GPs really was to spend your lifetime providing a service 24 hours a day had become unsustainable because of the expectations of patients. Twenty years ago, when I was out of my bed at night, it was either to deliver a baby or to see a seriously ill patient. I stopped doing out of hours nine years ago when I became director because I could not be in the Valley all the time. But even nine years ago you get called out every night for relatively trivial problems, and I think that is about the expectations. The patients that need our support and have the serious problems are the very elderly and they have always had a low expectation of care because they remember before the Health Service. I had a patient who died aged 101 two or three years ago, and her notes were like this (indicating a small amount). I have patients who are 16 and their notes are like this (indicating a large amount) and by the time they have something really wrong with them the Health Service is going to be groaning.

  Q649  Charlotte Atkins: Mr Holmes, and in fact Dr Archard as well might like to comment on this. We have seen the Our Health, Our Care, Our Say called for a 10% shift of activity from secondary primary care. Clearly, that is the way we are going, but what kind of changes in the workforce do we need now to achieve that shift?

  Mr Holmes: If I can give you some very practical examples of the sorts of changes that we have implemented in Kingston recently to respond to the shift of care into primary care settings, and I will give you two specific examples? We have a small number of community matrons within the Primary Care Trust and the work which the community matrons are doing is to develop an approach to individual patient care, which is called case management model. We have an assessment tool, and the acronym for it is PARR, which stands for Patients at Risk of Readmission, and basically through the process of assessment one can identify a cohort of patients whose history indicates that if they have a range of long-terms conditions there is a higher risk if they hit a crisis point at some point that they will tip into A&E and possibly subsequently into secondary care admission. The work which the community matrons do is that they each carry a caseload and they work with the GP, they work with the secondary care clinicians, and they develop a very comprehensive care plan to support individual patients, very much with an emphasis on supporting and helping an individual patient to recognise the symptoms, the signs of when they are likely to hit a crisis point. They provide support and advice to individual patients, and to give an example of the impact on that—and it is early days yet—

  Q650  Charlotte Atkins: My own Primary Care Trust does a lot of work in this field and has been incredibly successful.

  Mr Holmes: It is very impressive and it is early days, but just to give an example one of our community matrons has 36 patients of the type I have described on her caseload, and over the previous year those 36 patients accounted for 85 admissions. The average length of stay for each of those patients is 10 days and that equates to 852 bed days. Over the period since they have been caring for that cohort of patients we have had no emergency admissions. So it is an indication of the impact of that sort of change.

  Q651  Charlotte Atkins: Dr Archard, would you like to comment?

  Dr Archard: The 10% saving is very readily achievable when we look at what might be achieved as far as the shift in the work, as far as things like outpatient procedures and so on into primary care. Everything comes down, of course, to resourcing or human resources in the end. There are a number of ways in which this can be achieved and the most important of course is skill mix. While in an ideal world you would be able to recruit other members to the primary healthcare team to extend that work the reality is that we still do have a great shortage of other healthcare professionals, such as nurses, pharmacists and so on. I am very fortunate in my patch in as much as I live in a fairly well heeled area so it is not difficult to get hold of nurses to join the team, and as a consequence of that we have a very large number of nurses and a very small number of doctors by choice. In our particular practice we have over double the usual amount of patients per practitioner in our area because we are able to recruit nurses. The sort of areas in which we are trying to make some sort of headway into this sort of area is slightly different. Although there are community matrons in our area we are also trying a rather different tack, which is a liaison sister, which is some work that we are doing with the National Health Service Institute, which looks at nurses who are specifically dipping in and out of vulnerable people, usually the elderly, to try to reduce admissions to hospital and once in hospital to go into hospital to facilitate discharge, but unlike community matrons, who have a caseload, these nurses actually dip in and out and have a changing caseload. That is not a substitute, that is an addition to the community matron role, but it is something that as yet has not been explored very widely, but it is something which needs to be explored. The other obvious way of addressing the issue, of course, is with general practitioners with special interest, but because of the shifting balance of work towards primary care practices commonly are not very keen on general practitioners moving general practice with a special interest role because that will obviously remove them from the coalface of work at the practice, which leaves the remaining partners to do a great deal more work. So consequently there is a bit of a hiatus here in as much as a number of people would like to be general practitioners with special interest but they cannot move on in that direction. A third way of moving this forward as far as GPs are concerned is a fairly embryonic model which I am trying to introduce at the moment called a practitioner with extended knowledge, which would be that this would be somebody who had probably historically had a lot of clinical experience in a particular area when they were in hospital practice and as a consequence of that has maintained that interest but is not of the sort of level that one might expect from being a general practitioner with special interest. But this knowledge could be used within the practice; in other words, it would not take referrals from other practitioners outside the practice but would certainly look at areas within their own practice. These sorts of skills can be relatively quickly brushed up so that work could be shifted away from hospitals to the practice without having very much of a detrimental effect on the workload within the practice.

  Dr McKinlay: If I could add that areas of deprivation are not just with GPs, they are with the whole primary healthcare team. I think the mean that is quoted for practice nurses is 2.3 per GP; but in Cumbria and Lancs it is one nurse to 2.3 GPs.[1] So we have difficulty in recruiting all the way around. The other thing is, in practices that have developed the skill mix it is already factored in. I think most of the first QOF round that took off have really been delivered by good practice organisation, including practice nurses through chronic disease management and things. So I am a little bit sceptical about skill mix being the panacea for everything; I think developing practices have already been working on skill mix for a very long time.

  Q652  Charlotte Atkins: We have had a lot of publicity about all the redundancies in the acute sector. Do you think that these redundancies are needed to achieve the changing structure of the NHS workforce overall, the balance between the acute sector and primary care?

  Dr McKinlay: I think it is vital that resource follows activity into the primary care sector and I think the nature of the Health Service of the future is that it should be well delivered at a primary or an intermediate care level. I do not think it is for me to decide how that resource shift comes about. It seems to be probably short-sighted to cut the coalface workers, but I am not qualified to answer that. I was very pleased to see in the new White Paper support for the community hospitals, but they need to be adequately resourced. We spent £100,000 of our fund holding savings on putting X-ray facilities into our community hospital and that enabled a large number of consultants to come and start delivering outpatients in the community hospital and saved a lot of patients a lot of journeys but also improved the service.

  Q653  Dr Stoate: I would like to pick up something that Dr Archard was talking about, GPs with extended knowledge. GPs have always done that. In my own practice, for example, I have a partner who is very good at dermatology, a partner who is very good at minor surgery and I do a lot of joint injections, and we have always referred people to each other. But does the Royal College see this a much more formal role with perhaps some way of actually providing resources to do it, or do you just see an extension of what is already going on?

  Dr Archard: I think it is a bit of both really. As you say, most practices do have these areas of extended knowledge within their practice team, and it is not just GPs of course, it is nursing colleagues as well. It is purely the fact that we all know, as practising doctors, the sort of skills that one has on leaving hospital practice are very soon lost, which is a disaster and a waste of enormous resource, and if we could look at the training structures, such that those people who have those interests are nurtured through their career in general practice to maintain that knowledge, that would be helpful. While there are those such as me who was a registrar in ophthalmology at one time—and I know very little ophthalmology now but perhaps more than the average GP—it would not take very much to bring me up to speed at a much higher level than I currently am at because these things come back very quickly, as you know. If we were able to put that resource into those people who do have this bit of knowledge it would take very little to really bring those people up to speed really quite quickly, and this might provide a facility to accept some of the work that is coming from the secondary care.

  Q654  Dr Stoate: Is that not something the College could be involved in? Could you envisage, for example, a diploma type of qualification for GPs with extended knowledge in particular areas, and the College might be overseeing that as the educational overseer, if you like, of general practice.

  Dr Archard: Certainly the College should look very carefully at this sort of thing and there is no doubt that the College, as you are probably aware, is run on a faculty basis and in some faculties it is already being undertaken in as much as there are local certificates in knowledge of a particular area, which may take between three and five days training to bring people up to speed again. This is not national but certainly it is something that the College is looking at and it is something which I think the College could be encouraged to undertake even further to undertake these sorts of diplomas.

  Q655  Dr Stoate: To me that would be an extremely worthwhile thing to do. I want to move on to Dr McKinlay and talk about whether you think there is too much emphasis in medical training on the specialist workforce at the expense of a primary care workforce?

  Dr McKinlay: I think there is some recent evidence—it is not published yet, I have been supporting a young doctor who started looking at these issues when he was a student and he is now doing it in the FI—that there is still what has become known as the "hidden curriculum". Young doctors, undergraduates are prejudiced against general practice and the danger is that if they get a bad experience on their general practice attachment then that reinforces that prejudice. So we have evidence from an evaluation we did of giving PRHOs GP experience. In that, 55% of them who had not made their mind up before did opt for general practice once they had experienced it, and this is one of the great opportunities of modernising medical careers to make sure that every doctor has some experience of general practice in their foundation programme so that they are making a more informed choice. A charismatic lecturer was often the reason we made our career choices to graduate level and that is not good practice. The study seems to suggest that about a quarter of undergraduates think of general practice as a career, but the country needs half of them to be GPs.

  Q656  Dr Stoate: Do you think the MMC might put some of that right?

  Dr McKinlay: I do, once it is bedded in; if it is allowed to. I do not have figures for elsewhere but it seems from the publicity I am seeing that certain deaneries are going to make the expected cuts in their allocations by hitting general practice. I have worked with a Dean who is general practice centred and we will have over 90% of the Foundation II doctors going through general practice in the North West, but the funded aim for the first year is only 55%, although it is expected that it will be for everybody in due course. We have a particular problem with timing.

  Q657  Dr Stoate: Mr Holmes, with the reduction of PCT numbers from 303 to 152, do you think that will have an effect on workforce planning in primary care?

  Mr Holmes: Prospectively, yes. In London I think it is unlikely because in London the number of PCTs has remained stable. Outside of London, the experience which we typically have is of PCTs serving relatively small populations and therefore in terms of the management resources to support the work of the PCT in some cases is struggling, and to develop specialist management skills in areas such as workforce planning. So I would hope that there is potentially a positive outcome from the amalgamation of PCTs into monitoring areas in terms of being able to share those scarce resources.

  Q658  Dr Stoate: I appreciate that there is a management sharing and obviously you get greater expertise, but do you think that there may be some loss of local focus with PCTs, for example, becoming much larger geographically. Do you think that that might make it more difficult or less difficult for them to plan workforce needs in their area?

  Mr Holmes: Workforce planning takes place at a number of different levels. The level of the individual practice, for example, very, very practical workforce planning takes place, as you will be well aware, on a day-to-day basis as staff working in practices deploy their resources. If we think about longer term workforce planning—and your example of GPs with specialist interests is a very good example—to date in my personal experience that has often depended on the individual interests of individual practitioners and where those services are then delivered will often be dependent on where those GPs are practising. If we think about a more coordinated approach to development of such practitioners—and a good example in my own PCT is diabetic care—through the process of practice based commission 27 of the 29 practices are signed up to a model of diabetic care which they would like to develop, which is their initiative, and they want to develop a hub and spoke approach to diabetic care with one practice in each of four localities, providing up to level 2 diabetic care. To enable them to do that, we need to develop GPs with specialist interests in each of those four central surgeries. So it is a good example of where there is a potential by planning over a wider area where there could be a more coordinated approach to workforce planning.

  Professor Gray: I think there are some concerns that some of the issues that you heard about in the last session with SHAs taking money from the levies that that will affect both public health training and GP registrar numbers. There is some evidence that some of those things are seen as easy targets for savings and the numbers have been cut, so we have got four regions that have not got any public health training. I know there are regions where GPR numbers have been cut and again, not related to demand but related to balancing the books.

  Q659  Mr Campbell: What changes to the education funding systems are required to ensure that a greater proportion of resources go to primary care?

  Dr McKinlay: I could start with what was the basis of my evidence, that there was an extremely effective initiative three or four years ago but it was not from the levies, it was from the workforce group where £30 million was invested through the deaneries in capital premises to develop training capacity and that produced about 650 new training slots across England. That was so successful that we tried to keep it going in the North West with the co-operation of two SHAs. We have spent about £2 million and we have created the numbers that were in my evidence: 29 new GPRs, 37 new foundation 2s but also 29 undergraduates and postgraduate nursing. In order to access this fund, our would-be training practices need to develop a multi-disciplinary approach and the SHA has supported this on the basis that it is for allied health professionals as well. If we are putting funding in to provide a seminar room for teaching, that room is not just to be occupied for the two hours a week that the GP registrar is getting his tutorial, it has to be in use all the time. Our strategy to deal with these problems has been three-fold. It has been to get out and talk to the PCTs, to produce the guide for the PCTs that I mentioned in the evidence, `The gardener's guide on how to grow and keep your own GPs', and to invest in the capital. I think it has been a really good bang your buck for the NHS and the other thing is that patients benefit because there is some evidence that training practices are quality assured to a high standard and so the patients probably get a better service as well.

1   Note by witness: This should read "I think the mean that is quoted for practice nurses is one per GP but in Cumbria and Lancs it is one nurse to 6.7 GPs". Back

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