Jeremy Hunt’s Folly

Soon we will have GP surgeries open from 8 in the morning to 8 in the evening seven days a week. And we are all supposed to think that this is the solution to all the problems in the NHS. Am I the only one that thinks this is folly – election-mongering – playing to the audience?

GPs work very hard at the moment. The good old days of 5 surgeries a week, a day off and two rounds of golf are a distant memory, replaced by exhaustion and burn out. Already the requirement for GPs to be commissioners is taking its toll with more resignations from board positions. Our delivery of services for long term conditions need to be revamped as the outcomes could be better and it is difficult to get an urgent appointment during the day. And we are still failing to link health and social care properly and many GPs feel that they are becoming social workers!

We are also expected to believe that it is both necessary and desirable for the practice in the middle of a residential area to open 7 days a week with the traffic and commotion that will be caused. And what about current lease arrangements – will the landlord change the conditions of the lease – and will the council approve it. Has Jeremy been advised on the feasibility of achieving this?

Do we want to go to a GP surgery at 7.30 on a Sunday evening? Is this late and weekend opening what is necessary to care for the vulnerable and the elderly in our communities?

Strangely, however, some practices manage very well. I can get an appointment to see the doctor of my choice – as long as I can wait a few days. I can get a same day appointment – as long as I am happy to see any GP or the nurse practitioner. I can book on line, manage my prescriptions on line and speak to a GP/nurse at certain times of the day. There is a sharing of resources between practices so I can get to see someone who knows about my conditions.  If it is late or the weekend I can visit the community pharmacy which already opens from 8 to 10 and offers a ‘Pharmacy First scheme. If it is a problem with my eyes or my teeth then there are emergency services in place for these. Actually the local GPs, the community pharmacies, the optometrists and the dentists are OK. I can’t comment on the link between health and social care and I can’t understand what all localities don’t work like this.

What do we know?

  • We know that there are barely enough GPs to go around, their locum rates are drifting towards £100 an hour and there is at least a 6 year lead time to create more.
  • We know that there are 57,000,000 GP appointments for common conditions that could be managed within community pharmacy.
  • We know that if we create more GP appointments, they will be filled with a variety of people, some who could have gone during standard times and some with common conditions that could have been treated elsewhere.
  • So what other options have been considered? I don’t know. I haven’t seen a report into the problem and an option appraisal. It has been driven before the Royal Pharmaceutical Society Commission on models of care has been published. It is all a bit of a rush – don’t you think – but it does make good headlines before a Party Conference?

So what is the real problem?

  • A&E is full. Actually it is not through an increase in ‘blue-light’ cases – these have hardly changed. It is full of the walking wounded and a third of these have common conditions that could be managed within a community pharmacy.
  • GPs are overrun. They are trying to manage an aging population with more long term conditions and meet targets such as QoF within an out-dated capitation based contract.
  • Walk in centred haven’t worked – because they are a sticking plaster to create headroom in a system.
  • NHS Direct demonstrated the requirement for access and information. NHS 111 has not been integrated with other front-end providers of healthcare – community pharmacy is usually not included.
  • Community pharmacy has not been engaged. They too are working within an out-dated dispensing focussed contract. Only 12% of the eleven thousand plus community pharmacies in England provide a ‘pharmacy first’ or a minor ailment scheme and some of those have been restricted when they needed to be expanded.
  • We haven’t thought through the role of social care and communities in this at all. Perhaps the Health and Social Care Commission run by the Kings Fund will redraw the boundaries between health and social care in the field of acute conditions to engage healthcare through a different process compared to calling an ambulance.
  • The population has not been engaged and offered appropriate solutions to their needs. The only constant feature of the system is A&E so you can’t be surprised when people go there.

The long term solution

  • Support General Practice to develop, working together to raise the standards of care across federations or consortia.
  • Redesign ‘Pharmacy First’ schemes to provide a real alternative to General Practice and A&E for people with acute presentations of common conditions.
  • Integrate ‘Pharmacy First’ scheme providers with NHS 111 so people can talk to a pharmacist on the phone as a first port of call.
  • Integrate ‘Pharmacy First’ schemes with GP practices and current out of hours providers to triage all patients with common conditions and offer a community pharmacy based solution.
  • Fix the limited supply of medicines through community pharmacy. If it’s free on prescription, then it should be free at a pharmacy. Allow community pharmacists better access to PGDs or develop Independent Community Pharmacy Prescriber (limited formulary) status.
  • Build the links so a community pharmacist can book a patient in with a GP on the next available appointment time and support teleconsultation, particularly with out of hours providers.
  • Communicate this to the public, nationally and locally. Let the people know where to go and for what condition.

Will it work?

  • I have been very impressed talking to Caroline Kirby on how their federation of GP practices share skills and expertise and deliver great care to their population of approximately 80,000. The next opportunity will be to join up community pharmacy and other out of hours and social care providers with them. I am sure that there are other great examples of working together across primary care providers and plenty of potential.
  • We know that ‘Pharmacy First’ schemes such as in Croydon, Bury, Yorkshire, Birmingham and many others are working well providing alternative sources of healthcare, reducing demand in general practice and A&E.
  • Many pharmacies are open long hours – nearly a thousand are open for 100 hours every week and many more are open 80+ hours already.
  • The pharmacy profession wants to be included within ‘Pharmacy First’ schemes and there are plenty of well-qualified pharmacists around – no shortages here.

In my past I worked as a business manager dealing with waiting lists. We provided additional capacity and the lists fell beautifully from 30+ weeks to below 6 weeks wait only to find that demand rose and the lists grew again. Throwing money at capacity without dealing with demand just doesn’t work.

So we are now doing the same thing and expecting a different result. The government must be insane and I must be Einstein!


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