NHS reform part 2: connecting the parts together

In Part 1, Peter Livesey wrote about too many new dawns and too many inefficiencies in the NHS. Here he considers the future of GPs…and it does not look too good.

We all hope to have a GP who is clinically competent, empathetic and accessible. Don’t we? In rural Kent, where there is currently a shortage of GPs, perhaps it is unrealistic to expect all doctors to be selflessly dedicated.

But it should not be unrealistic to hope for a system of primary care that aims to uphold these ideals. Whether the way forward is with a polyclinic providing a variety of services, a small rural practice or a larger group cooperative, we all wish to be treated by a clinician who is friendly, skilled, competent, caring and accessible. Any structure adopted by the NHS should aim toward achieving this.

The reforms introduced by government to redress the blunder in 2005 of withdrawing 24/7 access has paradoxically made general practice less attractive as a career for young doctors. Those who do enter the profession no longer wish to become partners with overall responsibility for all the services provided by the practice. Instead, they prefer the freedom of sessional clinical work.

The subsequent shortage of GPs has led to a reduction in accessibility, the introduction of telephone consultations, the delegation of responsibility to other health care workers, the introduction of eCommunication and the diversion of experienced senior doctors to non-clinical executive roles. This depersonalises the system and does nothing to improve accessibility and all-round care.

One retired GP from Nottingham told me with a degree of cynicism that he wondered if general practice was on the verge of putting itself out of a job. Much of what it used to do is now being done by A&E departments, urgent care centres, on-line pharmacist for repeat prescriptions, and the call centre 111 for triage. Home visits are a thing of the past and the recent reform within the NHS is adding to this estrangement. Many patients don’t know who their GP is or if they even have one.

Until 2019 the decisions about which health services were needed by a locality were made by Clinical Commissioning Groups or CCGs. There were 135 CCGs in England. In Kent and Medway there were eight and each CCG was comprised of eight GPs, five lay members and three executive directors. All had voting rights. From time to time other non-voting members were invited to attend to discuss specific issues. In 2020, many of these CCGs were merged. In Kent they became one.

Solely because of changes since 2005, general practices were criticised for failing to provide surgery hours that were convenient for working people. Evening and weekend appointments, which had disappeared, were requested to be reinstated. Doctors, their receptionists and secretarial staff were less than enthusiastic. They had got used to hours of work more conducive to private life and didn’t want to relinquish their free time.

Practices were put under pressure to find a solution, which came in the form of merging practices so that the workload could be shared amongst a larger work force. Some practices accepted this and regrouped; others did not, preferring to remain as they were. Both the newly amalgamated practices and those preferring to remain as they were, then found themselves nominally grouped into Primary Care Networks or PCNS serving between 30 and 50 thousand patients.

A PCN is, therefore, not necessarily a merger of several practices; but what they actually are, is not at all clear. A PCN could be one very large single practice with many partners or it could be a number of unrelated smaller practices in the same locality, some of which might have merged and others not. The idea is that these PCNs should work cooperatively with community health, mental health, social care, pharmacies, hospitals and voluntary services. Primary care had already been doing this since 1948 so what is being introduced seems vacuous. It might be nothing more than a paper exercise. But I rather suspect something more cryptic is planned.

As an example, Canterbury has now two PCNs: Canterbury North and Canterbury South. The north has four practices, the Health Centre, Northgate, the Old School and Sturry Surgery and the south has three – the Canterbury Medical Practice, the New Dover Road and the University Medical Practice.

The only significant change to the previous structure, however, is the creation of the Canterbury Medical Practice which last year formed itself from four smaller surgeries and will work from three separate premises about three miles apart. The seven practices in the two PCNs will still retain their autonomy and be financially separate from each other. I would imagine this hotchpotch is replicated throughout the whole of England. Whether in time this new structure will have any function different from that which currently exists, remains to be seen.

I doubt that patients seeking care from their own practice will be aware of any improvement in accessibility or clinical care as a result. Let us hope I am wrong.

The only autonomous PCN in the area of East Kent has been in existence as a single practice for over thirty of years and is in Whitstable. It is based at three sites: the old Whitstable Health Centre, Chestfield Medical Centre and the newly built Estuary View Polyclinic organised by Dr John Ribchester. The latter works as a minor accident, minor surgical, specialist referral and urgent care centre as well as offering normal general practice. It is well-organised and much appreciated by the patients who attend. 

As with many such government initiatives, the white paper is full of aspiration but thin on detail. For example, it states “every part of the NHS, public health and social care systems should continue to seek ways to connect, communicate and collaborate”. To achieve this, the 135 CCGs will be replaced by 42 Integrated Care Systems, each established as collaborations between NHS providers, commissioners and local authorities. An ICS will be ”comprised of an ICS Health and Care Partnership, bringing together the NHS, local government and partners, and an ICS NHS Body. The ICS NHS will be responsible for the day to day running of the ICS”.

You could be forgiven for feeling unclear at this point about what exactly is being introduced, but further reading of the paper would leave you no more enlightened as it goes on to say:

“Measures will include reforms to the mandate to NHS England to allow for more flexibility of timing; the power to transfer functions between Arm’s Length Bodies and the removal of time limits on Special Health Authorities.” 

Arm’s Length Bodies include Public Health England, National Institute for Clinical Excellence (NICE), NHS Digital, NHS Improvement and others.

Aneurin Bevan said in 1946:

“No one recognises more than does the Government … that no legislation… can ever give the public a greater health service unless the people who administer it, want to do it and are enthusiastic in doing it.” 

 Is the NHS staff now ready and willing to accept such reform after such a terrible year dealing with Covid?  I doubt it.