The truce is over between GPs and hospitals

Amid the hurly-burly of the covid crisis you could be forgiven for missing the sounds of some old battle lines being redrawn following two recent public statements on primary care.

Last week the prime minister held the last daily covid-19 press conference and fielded a question from a member of the public about when primary care and dentists were going to return to normal working, because patients were starting to fill up emergency departments as their primary physicians were refusing to offer them face-to-face appointments.

Suzanne from Chesterfield

This touched off GPs who took to Twitter to voice their bewilderment and anger. This turned to invective in some quarters when it emerged the member of the public – Suzanne from Chesterfield – is also a professor of emergency medicine.

GPs said they have been working hard throughout the pandemic, having transformed primary care from carrying out more than 80 per cent of consultations face-to-face to now doing remote consultations as the norm.

They also pointed out some acute trusts continue to reject GP referrals and consultants running digital outpatient clinics are asking GPs to pick up key tasks, such as blood tests.

But this heated episode speaks to more than just the long-standing beef between GPs and hospital medics.

Demand for health services is now rising after activity plummeted across the health service in the early weeks of the pandemic. GPs are already reporting their workload is back to normal levels, yet also it appears many patients are still staying away.

GPs have told me the service cannot and will not go back to how it was before. Even if the will was there, many practices are not set up to cope physically with an influx of patients seeking face-to-face interactions while also adhering to social distancing rules. Primary care will increase the number of in-person appointments it offers as time goes on, but it will not swiftly return to previous levels.

But, will patients continue to be as accommodating of this as they have been?

Many stayed away during the pandemic out of fear of the virus or a will to do their bit to protect the NHS. There has been lots of positive feedback from those that have engaged with the new way of working in primary care but, as more return, will they continue to be satisfied with a phone call or a Zoom?

A systematic review and modelling study published this week added an uncomfortable component. It found digital-first primary care models “are at least as likely to increase as to decrease workload pressure on general practice”. A workload dividend depends on how systems are implemented.

We are only partway through the digital transformation of primary care. GPs have moved mountains in three months but there now needs to be a time of consolidation and refinement, with GPs and colleagues figuring what has worked and where there are gaps.

There is the potential to revolutionise general practice, and dramatically improve integration between primary care and secondary care. But there is also the risk it merely moves the same activity from the consulting room to the telephone. Clinicians would still be overworked but through a different medium; patients would end up waiting online as long as they did in the surgery.

The potential therefore for patients to default to their local emergency department instead should not be dismissed.

Bonfire of the Regulations?

In mid-June another GP bête noire popped up online: the Care Quality Commission declared it was going to gradually start inspections again.

The response was swift with senior figures in primary care pushing back, clearly eyeing the changes wrought by the covid response as an opportunity for some major pruning of the regulatory regime.

The British Medical Association’s GP committee called for primary care to be taken out of the CQC’s remit altogether. The Royal College of GPs was a bit less trenchant, instead seeing this as an opportunity for substantial reform of CQC inspections, moving to a process focussed on “trust and proportionality”.

One senior London GP outlined to me how the CQC should have its budget dramatically reduced and reorientated to focus on a “forensic approach to problems that arise in practices, care homes, and units in hospital”.

He said the duplication of regulation across multiple statutory and NHS bodies that oversee primary care has stifled innovation and historically been a push factor keeping young doctors away from taking on GP partnerships.

For its part, the CQC has been far from bullish. The chief inspector of general practice told me the pandemic brought about changes to how care is delivered and “just as many providers will be working in new ways, we will need to be more flexible and responsive in the way we regulate”.

There is a long way to go before the dust has settled and we see the full make-up of the post-covid health and care system. But with NHS England beginning its promised reform of the primary care regulatory regime, we could well see an NHS with a little less red tape.