Examination of Witnesses (Questions 642-659)
DR DAVID
MCKINLAY,
DR GRAHAM
ARCHARD, PROFESSOR
SELENA GRAY
AND MR
PAUL HOLMES
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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