Primary Care: Plymouth

Plymouth’s primary care is in a state of crisis. Our GPs are working to the point of exhaustion because of the lack of funding and resources not just in primary care, but throughout the system. I think that it would be helpful to hear the voices of those on the frontline. An inner-city Plymouth GP, Dr Williams, told me:

“I don’t know of a GP at the moment who isn’t working at full capacity. We are all working way beyond our contracted hours, late into the evenings, on our ‘days off’ and at weekends. Not for money, not for glory, but to give our patients the best possible care.

I have colleagues who have burnt out, friends who are burning out, friends who are back at work too soon after serious illness because we are…putting our lives on hold to prop up the job we love and the patients we are passionate about. But the system is failing, and it’s feeling like that may be intentional. We believe we are set up to give the most cost effective and best patient care—but maybe that’s wrong. Can you give an honest answer about where NHS England see primary care going? Is there an agenda or even a plan in place for change?

It has been said that Plymouth is being watched to see what happens when Primary Care fails. If there is any truth in this please tell us now—don’t watch it fail”,

but act to stop that happening. That is a common view among most of the GPs I spoke to. They have a real sense that primary care in Plymouth is being watched by NHS England and other NHS bodies to see what happens when a system falls over. Whether or not that is true, that is the sense they have.

As a result of underfunding, nurse and GP vacancies in Plymouth’s primary care sector are hard to fill. If GP practices cannot fill vacancies, the quality of care they can offer suffers as more and more patients chase fewer and fewer available GP appointments. NHS England estimates that one in seven GP posts in Plymouth have not been filled, which is alarming. A GP in Plymouth who recently advertised for a vacancy at their surgery told me that they did not receive a single application. We know that the far south-west has trouble recruiting healthcare professionals at primary, secondary and acute levels. Our peripherality as a region compounds an already extremely difficult recruitment environment for health professionals. I know that the Government have considered support for GP recruitment in Plymouth in recent months, but it has not produced the additional GPs we are looking for. Will the Minister update us on GP recruitment and on what will happen next?

A common theme in feedback from GPs is that funding and pay have decreased while job pressures have increased. If there is not enough funding GP practices cannot recruit enough doctors, nurses, healthcare assistants and other health professionals, receptionists or managers. Everyone therefore works harder, yet many GP surgeries feel they cannot meet patient demands or expectations. An inner-city Plymouth GP, Dr James Boorer, told me yesterday:

“Working in Plymouth is hard. But we are not alone—there are many other practices in similar deprived cities around the country where it is equally difficult. The problem probably stems from systematic under-resourcing of primary care over the last 10 years where demand has increasingly outstripped resource and funding.

This has led to a failure to recruit new GPs and retain others who have left the profession early because it has been so difficult. The challenge is so great that we feel abused by the government who know we are dedicated and will stay until the job is done no matter how hard it gets. But there is a limit—we do break.”

That sense of getting to the point where they cannot go much further came across from a lot of GPs, and we have witnessed that in the number of practice handbacks across Plymouth. About 15% of Plymouth’s population is now covered by non-general medical services primary care, where a contract has been handed back and an emergency provider has stepped in. That should worry the taxpayer as well, because those organisations consume two to three times as much resource as normal primary care. Last year, instead of about £79 per patient, the step-in provider got about £191 per patient. If that is acceptable as a step-in provision, I would like the Minister to look at whether increasing the per patient funding would avoid the need for practices to hand back their contracts. Levelling funding across a city in this respect, rather than adding extra resources to those practices that have handed back their contract, might be a more efficient tool to address the funding crisis and to deal with the emergency situation.

Deprived practices in Plymouth are not the only ones that are underfunded and under-resourced; the crisis is a national one affecting the whole of primary care, but the crisis is crystallising in hotspots, where the funding and resources are more markedly different from elsewhere in the country. It gets tough in those hotspots first, so GPs leave to work in better resourced areas, and it is harder to recruit in those practices when partners retire. This inequality in funding is driving the crisis. Will the Minister reconsider whether levels of deprivation and health need can be taken into account in the funding formula to ensure that inner-city practices are well resourced?

On average, GPs in more deprived areas have a higher workload, with 20% more consultations with patients, who are more likely to have multiple morbidities, with both physical and mental conditions, but they do not necessarily receive the additional funding to address those complex needs. The Care Quality Commission has described primary care in Plymouth as at a “tipping point”. It found 15% GP vacancy rates, with several practices having handed back their contracts or at risk of doing so, in some cases owing to recruitment difficulties. It also found that between 25% and 35% of GPs and practice nurses would be retiring in the next five years. I realise that issue is not specific to Plymouth, but it is a trend across primary care that we need to address if we are to continue providing patients with the care they deserve. I should be grateful if the Minister responded to the concerns that those GPs have raised and set out what steps her Department is taking to address GP recruitment and retention, in particular. I think that a lot of GPs will be watching the debate and looking for reassurance that there is light at the end of the tunnel, albeit the route to it may not be an easy one. They are looking for confidence that there is a plan.

In a similar debate in March 2018, I spoke about primary care in Plymouth and the Minister’s predecessor, the hon. Member for Winchester (Steve Brine), agreed to meet to discuss the issue with Plymouth GPs. I spoke to him about it in the Tea Room the other day and, while I realise that the Minister will not be controlling her diary in the same way as she did before being elevated to ministerial office, I should be grateful if she confirmed that she too would be happy to meet Plymouth GPs, so that they can raise their concerns directly with her about the direction in which primary care in Plymouth is going. I should welcome it if the meeting were with a cross-party delegation, to make sure that the concerns were not party political.

A crisis in primary care means longer waiting times. It means patients will experience longer waits for routine appointments, have trouble getting through on the phone, and face reduced availability of urgent appointments. Healthwatch Plymouth published a report in November about primary care in our city. One patient had this to say about their experience:

“I had a brilliant surgery. But since merging with another I have had problems. I had the flu bug over Christmas, I received a diagnosis of a throat virus over the phone. I waited 7 weeks to see my doctor. Then when the results of my ultrasound came in, I found out from the receptionist that my doctor had retired. I have just tried to make an appointment and have been told I can’t make an appointment”—

for many months—

“as they are changing their systems.”

I think that is an isolated example, but it is part of a trend of concerns that patients express not only to the patient participation groups in practices—groups of patients who deserve special thanks and who are often overlooked in our debates—but by way of representations in the postbags of councillors and MPs.

The Care Quality Commission found that people could not always access a GP when they needed one and GPs told the CQC that it is not uncommon for the waiting time for a routine appointment to be four weeks. There are even some areas of the city where people are having difficulty registering or cannot register with a GP, because GP surgeries have closed and there is not sufficient bandwidth in the system to accept additional patients. I know that because my GP surgery in Plymouth closed and it was a struggle for the patients to find another with places available.

People in Plymouth have reached out to me on social media, and I have been inviting comments on my Facebook page. It was nice to get comments that were not about the B-word. I will recount a few of those experiences, but should the Minister or officials want to look at them again there are plenty more on my Facebook page. I heard from a pregnant woman who told me she had to wait three weeks for an appointment. Someone else said:

“For months now, it’s been impossible to book appointments online at my doctor’s. It takes three weeks to see a GP, and two just to see the practice nurse. After becoming part of a merged practice, the surgery has declined drastically.”

Another told me:

“Telephone consultations now seem to be the norm. Better than nothing, but a poor substitute for thorough examination.”

There is, of course, a growing role for community pharmacy in Plymouth, as there is across the country, and our pharmacists do a superb job. More people need to access services provided by community pharmacists, and I encourage the Minister to continue to promote the services that pharmacies offer as part of the broader array of services to address the primary care crisis.

GPs are on the frontline of healthcare and many people in Plymouth have told me that pressure has increased as community services have been cut back in other areas. A large proportion of the patients that GPs see consists of patients with severe, complex and enduring mental health difficulties who need regular GP support, and for some their GP is their only point of contact. While GPs continue to go above and beyond for their patients, they are not being given enough help to ease the pressure, particularly with patients with complex needs. Mental health services in Plymouth have significantly longer waiting times than other areas in Devon. Patients struggling with their mental health consult their GPs more frequently, until they are accepted into a specialist service that can support them in appropriate settings. That means that GPs in Plymouth have far more appointment demands to support patients with mental health needs than GPs elsewhere in Devon. At a meeting I held with GPs last year there was general agreement that integration of general practice, mental health and community services would be beneficial and would lead to patient care being not only better but more efficient.

This is a good moment to talk about something that Plymouth is really good at, as well as having challenges: the introduction and roll-out of health and wellbeing hubs. Plymouth City Council, our local clinical commissioning group, and Livewell Southwest—our social enterprise that provides NHS services in Plymouth—have come together to roll out health and wellbeing hubs across our city. Many of them are in the north of Plymouth, which is represented by the hon. Member for Plymouth, Moor View (Johnny Mercer), but three weeks ago I attended the opening of an all new wellbeing hub at the Cumberland centre in Devonport in my constituency. Those are genuine attempts to provide wraparound care, in addition to primary care, and to provide more thorough and effective services. I believe that Ministers should roll that model out across the country as it has real benefits. We should listen to our doctors, not just when it comes to our health but about what is best for our health services. They claim that the health and wellbeing hub model is an important addition to GP services, although not a substitute for them.

Plymouth City Council has submitted a bid to Ministers for £13 million funding to create more hubs across the city, including a superhub in our city centre. I have spoken to the Minister of State for Health about that a number of times, and I will be grateful if the Minister looks favourably on that funding application if it crosses her desk, as it is a genuinely pioneering project. The superhub would bring together in one location NHS dentistry and Plymouth’s award-winning dental school, sexual health testing, mental health support, social care, and new forms of directly employed general practice doctors, as well as wellbeing services. A site has been identified for those services in the Colin Campbell Court development, and my Labour colleague on the city council, Councillor Mark Lowry, and our health lead, Councillor Ian Tuffin, would jump at the chance to brief the Minister and her officials about that project.

As GP services in the localities continue to close in Plymouth, that project would create a new south pole in Plymouth for health services, as well as the north pole at Derriford Hospital in the northern tip of our city. We all want to discourage people from attending hospital if they can access their care in local communities, and health and wellbeing hubs, as well as the new superhub, could make a transformative difference in Plymouth.

The doctors and patients I have spoken to in Plymouth all agree that our primary care is in crisis, but recognising that there is a crisis is the first step to solving it. The crisis is not because our doctors, nurses and health professionals are not working hard enough; it is because they need more support and a better system to support them in their work. Dr Boorer said:

“We regularly continue working late into the night, often still doing administrative tasks and checking bloods at 10 to 11 pm, or catching up at weekends so we can meet the needs of our patients. But this level of work is unsustainable as evidenced by practice closures. With the current crisis, related as a result of sustained under resourcing, we see sub-optimal care for patients, burnt out GPs handing back contracts and leaving the profession”.

I praise those GPs who have chosen to work in inner-city practices such as those in my constituency, because they genuinely care about their patients and the quality of care they receive. I am concerned, however, that the current GP partnership model, and the high costs of buying into it, is not sufficient or appropriate for 21st century Britain, especially when we are suffering from a recruitment and retention crisis. We need to attract more younger talent as we seek to replace those GPs who are nearing retirement, and I believe there are ways to flex the model of providing primary care.

Research shows that cities such as Plymouth have been hit hardest by some of the cuts to public services. Levels of deprivation are high, and the wraparound care provided by other providers—in particular council services—is not as present as it used to be. We know that when the primary care system breaks, costs for the taxpayer rise and people suffer. The scale of the challenge we face is great. I genuinely welcome the Minister to her new role. I hope we will be able to work together to address the specific challenges faced by Plymouth, and come up with some solutions.

Another huge cause of concern for GPs has been professional indemnity. In recent years, the spiralling cost of purchasing professional indemnity cover has been a major source of stress and financial burden for GPs. That is why we addressed it in the GP contract and why just last week, on 1 April, we launched the new state-backed clinical negligence scheme for general practice. That brings a permanent solution for indemnity costs and coverage and includes all staff delivering primary medical services, including out of hours. It will remove a huge cause of worry for GPs, which will help with the recruitment and retention of GPs.

As the hon. Gentleman mentioned, we are looking at how to make the general practice partnership model fit for GPs working in the NHS in the 21st century. We recognise the huge contribution that the partnership model has made over the last 70 years of the NHS, but we know that it faces huge challenges, because many GPs, like other NHS doctors, want more flexible and varied portfolio careers; perhaps they do not want the long-term financial and geographical commitments of joining a GP partnership. That is why we commissioned Dr Nigel Watson to lead an independent review of the partnership model to understand those challenges.

As part of that review, Dr Watson visited more than 25 practices around the country, some of them small and some super-partnerships. As the hon. Gentleman alluded to, Dr Watson visited areas that are experiencing the greatest difficulty in recruiting GPs, including meeting some in Plymouth. Those visits played a key role in informing the work of the review, which reported in January and made seven key recommendations about workforce, business models and risk. We are grateful to Dr Watson for his important work, and we will respond to his recommendations in due course, with a view to reinvigorating the partnership model and making it fit for the 21st century.

I have set out that general practice is a priority for the Government, but what does that mean for Plymouth, and the hon. Gentleman’s constituents? GPs know the needs of their patients best, which is why the long-term plan seeks to change the balance of how the NHS works by shifting more activity into primary and community care. That will be enabled by expanding multidisciplinary teams working within general practice.

In Plymouth, the funding linked to the new GP contract will create extra capacity, with a 25% increase in staff numbers expected over the next five years across Devon as primary care networks employ pharmacists, physician assistants, physiotherapists, paramedics and social prescribers. I commend the valuable work being undertaken in Plymouth to open a network of local wellbeing hubs, aimed at giving residents easier and earlier access to health advice and support.

I understand that in a meeting with the former Health Minister, my right hon. Friend the Member for North East Cambridgeshire (Stephen Barclay), there was a specific proposal for funding to develop a hub in Plymouth city centre. I understand that following that discussion the clinical commissioning group has undertaken further work on the case for investment with the local sustainability and transformation partnership, in anticipation of the next capital funding bidding process.

I am encouraged by the number of promising local recruitment schemes that Devon CCG has put in place both to recruit more GPs and to retain those already in the workforce. I am very happy to meet the hon. Gentleman, hopefully along with my hon. Friends the Members for South West Devon (Sir Gary Streeter) and for Plymouth, Moor View (Johnny Mercer), and some GPs. Other schemes include investment in portfolio careers for GPs, supported by funding from NHS England; investment in GP coaching to support retention, and a scheme to entice those who have left the primary care workforce to return to the profession, which will launch this year. It will also offer flexible working and alternative employment arrangements.