Patients are increasingly being seen in healthcare clinics (including GP surgery clinics) by several different professional roles who are not doctors (both clinically trained and non clinically trained). Clinics at their GP surgeries, at out of hours/111 services and sometimes within hospital settings. These include nurses/nurse practitioners, pharmacists, paramedics, physios and non clinical roles (in General practice these include social prescribers and wellbeing coaches).

Increasingly we are finding patients do not know which healthcare professional or non healthcare staff member they have been seen by in their appointment which can impact on patient safety and choice.

Clear name badges with the staff role can resolve this.

In addition the government is now passing legislation regarding a new additional role called 'Physician associate' to include the professional regulation of staff to be by the GMC (the General Medical Council) which is the Doctors regulatory body  (despite these staff not having medical degrees or post graduate medical training). In addition the name causes confusion amongst patients who have thought they are being seen by a doctor which causes concerns around patient safety and choice. (There are also similar roles introduced in hospital with 'anaesthetic associates' also who are not medically trained; ie not got medical degree or post graduate training). We request the name is changed to 'Doctor Assistant' to improve clarity for patients.

Increasingly we find patients do not know who they have been seen by at the GP surgery or out of hours/111 service.

We request a requirement for all healthcare staff to have clear name badges stating their profession in simple consistent terms (ie doctor, nurse, pharmacist, physio, paramedic, nonclinical role) and that there is a specific professional obligation for the role to be stated at the beginning of the consultation and in all written communications to both the patient and other services.

We also request that the ring fenced funding allocated to General Practice that is only allowed to be used for these non doctor roles is brought back into the main GP contract (called the core contract) so it can be used to pay GPs, practice nurses and receptionists for the individual GP surgeries to use this funding as they assess will best benefit their patients' care.

In addition we request that the role of the staff member in General Practice who has seen the patient in the consultation is read coded so when data is assessed and presented by the government regarding access to primary care appointments, the data is analysed by the specific role of who the consultation is with. This is important because when patients and the government discuss access to GP appointments there is generally a concern regarding access to appointments with the GP themselves, not access to an appointment with a non doctor in their GP surgery (ie one of the other roles listed).

The different roles listed (nurse/nurse practitioners, paramedics, physios, pharmacists, "physician associates"/doctor assistants (as we prefer)) do provide important support and patient care. However they are increasingly being used for general appointment lists, outside their specific areas of training. Without this clarity patients do not have the information they need to ensure patient choice and the understanding of their care.

To add to these concerns, General Practice is on the verge of collapse, and as we provide 90% of all NHS consultations (for 8% of the NHS budget) that will mean collapse of the whole NHS. This is due to systematic underfunding for years and top down management by the government and NHS England-the government department that manages the NHS. We need the government (as well as putting the funding for the non doctors into the main GP contract) to increase the overall GP budget from 8% of the NHS budget to 10-12% of the budget, with GP surgeries left to manage how that funding is used. The drive to remove same day appointments from GP surgeries and transfer them to newly create large hubs, currently being implemented, must end now. This restructuring of GP services will take more funding away from the GP surgeries. The hubs are planned to be manned by non doctors supervised by single or minimal GPs which will further undermine continuity and quality of patient care. The non doctors do not have the training or experience to manage patients as GPs are able (and I am already seeing more and more coming to A&E where I work as GP 2 days per week to deal with escalating patient numbers). This restructuring will therefore put additional strain on hospitals and will divert funding that could go to GP surgeries, to hub services that can not provide the standard of care needed, with patients and other hospital services especially A&E set to bear the strain. The "same day hubs" plan must be halted and that funding put into GP surgeries main contract (ie core contract).

If the government insists on any associated stipulations/targets with the increased funding should it be given, this funding should be linked to allocated GP appointments/ patient contact time (ie time with the GP doctor themselves not an appointment at the surgery with another different staff member). Consultations and availability of GP surgery doctor care, is the only thing that can stop the rapid demise of the NHS and patient care that we are currently observing.

Finally the partnership model of General Practice, where small groups of GPs manage their services as a small independent business, must be protected by increasing their funding (stated above) and by the government underwriting the GP partnerships' unlimited liability. (GP partnerships are not unlimited companies hence if the partnership is sued or goes bust, (increasingly more of a risk due to underfunding and escalating costs eg energy bills which the government chose not to cover) all financial costs are borne by the GP partners as individuals; ie against their own property eg their family homes which they will then lose.

The answer is not to get the GP surgeries to run as unlimited companies. I've worked for some surgeries that are unlimited companies run by a couple of "entrepreneurial" GPs and these surgeries are run for profits. (By using cheaper non doctors staff in the main (ie doctor-lite) and providing compromised patient access (predominantly econsult, mainly appointments with non doctors, GP doctors few and far between, patient care not nearly as good). 

The answer is also not to have surgeries managed by NHS management eg by NHS hospital trusts with GPs salaried only. This has happened in Somerset, where many GPs were retiring, under Symphony which is managed by Somerset hospital trusts. This was a necessary initiative because GPs were retiring, they couldn't recruit new ones and surgeries were closing down. Again these surgeries run more on non doctors, some of the surgeries are have GP input entirely from locums and there less continuity of care and more of a feeling of a rudderless ship.

What the government and NHS England(-the quango composed of managers that manage the NHS) don't realise is that GP partners are the glue that holds General Practice together, and hence the NHS together, as explained above. They hold the responsibility for their patients, for patient care and for their services in the way that only committed individual doctors can, and in a way that NHS managers, NHS trusts and unlimited businesses never can. Low on bureaucracy and managers, low on red tape, high on medical training and experience and knowledge and thus high on efficiency and cost effectiveness. (Again I quote the stats; 90% of NHS consultations for 8% of NHS budget).

I don't care what the Fuller Stocktake or Lord Darzi says about how NHS care should be managed, about GP hubs or NHS spokes or networks or community networks or whatever. (Darzi is a surgeon; the government might want to ask GPs how General Practice works. The clue is in the name. The current BMA GP chair is excellent; the government should go speak to her. She says what I am saying in words politicians understand). We do not need any of that management speak.

We need the current system ie GP surgeries, hospital care, community services; with the patients' own GP holding the continuity and responsibility and coordination of patient care. With all the GP/primary care funding put in the main GP contract (for GP partners to work out how best to use the funding to optimise their patients' care). We need that funding increased from 8% of NHS funding to 10-12% (the more money you give GP surgeries, the better the NHS will run). The unlimited liability of GP partnerships needs to be under written by the government (like they did with our individual indemnity in 2019). If the government needs a target to tie funding to, choose one and one alone: 'the patient time spent with a GP at their practice-ie total appointment time (GP-not anyone else)'. Let patients choose telephone or Face to Face or econsult; they know best what they need. And then leave us GPs to do our job. 

I've been a GP for 10 years-waiting to become a partner. Will do so when the government changes the system as requested above. I'm not planning on becoming a Partner while we have unlimited liability so risking losing my house when surgery goes bust; while also having no control over what we are paid for our services and what we are demanded to do for that funding with the GP contracts unilaterally imposed by the government year on year. It's not a business model any sane person would choose. (FYI; when I studied law a contract is only legal if both parties agree to the terms so don't ask me how the current GP contract for services is legal when GP contractors don't agree to it).

Finally, and this is now finally, I promise; Anyone who has read this through to the bottom. Thank you for your time and patience.

Dr ONeill BACantab MBBS MRCP MRCGP LLM