Are we seeing the decline of general practice, or its rebirth? – with Professor Katherine Checkland, Dr Rebecca Fisher and Shaun Lintern Episode 14 of the Health Foundation podcast

Jennifer Dixon: For years, public satisfaction with the NHS has been highest for general practice – the jewel in the crown of the service. But even before the pandemic rising workloads and workforce shortages have left many GPs dissatisfied, stressed and planning to quit in the near term. Then add the pandemic into the mix with GPs instructed to move rapidly from face to face consultations, to total triage with telephone or digital advice first. Despite digital-first primary care being NHS policy pre-pandemic, the government has threatened to hold winter funds from practices having less than 20% of consultations face to face. So is all of this a sign of general practice crumbling? Or is it all about the rebirth of general practice as the old model of care enters the digital age, albeit with birth pangs? Well with us today to navigate this thicket, I'm delighted to welcome Professor Katherine Checkland, who is Professor of Health Policy and Primary Care at the University of Manchester. Shaun Lintern, who is Health Correspondent at The Independent. And finally, our very own Dr Becks Fisher, who part of the week is a GP serving a deprived area of Oxford, and the other part of the week is Senior Policy Fellow here at the Foundation. So a very big welcome to all of you, thanks for joining. Can you just tell us what it's been like for you, particularly Becks, during the pandemic? How's it been in general practice?

Becks Fisher: It's been in some ways a fascinating experience, being a doctor in a pandemic. We've had to deal with a whole new disease, we've had to learn about it as we go along. We've had to change our guidelines constantly, work out how we keep people safe, both people with COVID but also people with long term conditions that needed to be managed in a whole different context. And we've done that in some really interesting and innovative ways. So for example, right at the start of the pandemic, a load of WhatsApp groups that we were using to connect people over primary care networks got repurposed as a way of sharing clinical guidelines and information. Organisationally, there's been a freedom to innovate as well. Certainly early in the pandemic I was interested to kind of observe that when bits of bureaucracy got suspended some of the operational monitoring bits – CQC inspections, QOF – necessary in lots of ways, but their suspension really did give surgeries freedom to redesign their systems to try and fit with primarily the infection control precautions we needed to take. The pandemic has been challenging in lots of ways too. There won't be a GP out there who hasn't lost patients and had deaths, particularly in care homes, that they feel very, very sad about. There have also been moments of real pride, our first vaccine clinics were amazing, like a real joy. And I think kind of a light in the middle of a pretty grim winter. The last few months have certainly been really grim in general practice, and things feel precarious, in a way that I haven't experienced in my 10 years in the service so far.

Jennifer Dixon: And why has it been particularly grim in the last few months?

Becks Fisher: I think, for a number of years, there's been a fundamental mismatch between demand for care through primary care in the NHS and the supply, so particularly in terms of GP numbers, and demand has gone through the roof. I think there are probably different things driving that demand. Part of it is sort of pent up demand, perhaps people not seeking help at points when COVID prevalence was very high and people weren't vaccinated. I think part of it is that health is kind of foremost in people's minds at the moment, we're living through a pandemic. I suspect that changes the way that people feel about their own health and wellbeing and perhaps, therefore, things they want to consult or ask for advice on. And I think the waiting times in secondary care are certainly ricocheting back into primary care. So those waiting lists, they're not a kind of arbitrary thing to me, they are people ringing in day in, day out saying, I've still got a problem, can you help me more, can you help me more? And we simply don't have, we can't increase our workforce to meet that increase in demand. We're losing GPs, we're finding it really hard to recruit more GPs. So we just have this kind of open door on demand and no way of increasing our capacity to meet it. So we're all working extraordinarily hard. And ultimately, probably not getting as much satisfaction from the work that we're doing either.

Katherine Checkland: Can I just come in there? I'd like to ask Becks a question because I have a feeling that digital access, so filling in forms, filling in online forms and asking for GP advice. I've had several colleagues say to me that they feel that that lowers the threshold for help seeking behaviour. And I don't think you remember but there was a whole row a few months ago about whether or not GPs were allowed to turn off their online forms overnight, because people were getting things coming in at two in the morning. Let's just ask the GP that question and I wondered whether you felt that. I do have a sense that we never talk about the threshold for help seeking behaviour anymore. We used to, a lot. But we don't talk about that anymore.

Becks Fisher: I completely agree with you, Kath. And we are really struggling with it. Our experience of using online consultations is really mixed. For things like sick notes, it's fantastic. Someone can say I need a sick note, our admin team can deal with that and it really does kind of ease those types of things through the system. We certainly see a lot of people who will fill in an e-consultation on Saturday, that gets picked up by the practice on Monday morning, and you ring them and their problem has resolved. I think it's also difficult, you ring a patient and they often don't answer. So it's not as simple as before, when a patient didn't turn up to see you that was just 10 minutes that you perhaps got back and could use to catch up. Now you're ringing patients again and again, trying to get hold of them. There are lots of quirks in the system. It doesn't mean they'll always be there, but we certainly haven't got it right.

Jennifer Dixon: So Shaun, you've been reporting on the pandemic and the health service over the period and looking at general practice. From your perspective, what have you seen is going on in general practice?

Shaun Lintern: Most recently, I think we've seen the strain beginning to show on GPs actually. In conversations I've had with GPs up and down the country they are exhibiting to me, I think, signs of quite severe burnout. We ran a big story earlier this summer about the level of aggression and attacks that were coming at GPs and the demand that they were seeing. And certainly there are wings of the media that have really inflamed some of this without necessarily discussing some of the the broader issues and the things that are feeding into this. For example, the failure to really plan the workforce around GPs to meet the demand and the government are clearly risk of missing their targets, again, for recruiting numbers of GPs, and we are actually losing full time equivalent GPs, I think the latest data showed we were down by 100 full time equivalent GPs while the population is growing, and the demand is growing. And I think as Becks referenced earlier, electronic access has actually increased demand as well. So there's all these pressures coming to bear on GPs, in addition to the usual demographic challenge of an ageing population, deprivation, and the pent up illnesses that were there during COVID and perhaps haven't been seen and people haven't come forward. We're not really having a very sensible debate about general practice at a national level. It's very simplified. And I think to be honest, government ministers have played to that really along with some wings of the media, to really kind of give the public a flawed view of general practice and where it is.

Jennifer Dixon: Shaun, that was very interesting. And I mean, everybody looking at the papers will be seeing the campaign in The Mail, for example, to have more face to face consultations and also over the Conservative Party Conference that some of this blew up, didn't it, with MPs facing in their mailbags some quite, quite a lot of frustration. If you look at the sheer number of face to face consultations, you see it's pretty similar pre and post pandemic. It's not quite back to what it was, but it's not far off. What has increased is the number of telephone consultations. So Kath, I'm returning to you as an academic in health policy. What's your understanding of the trends? Do you think that the current sort of discussion in the press certainly that Shaun is talking about is just ill informed?

Katherine Checkland: It's difficult, isn't it? Because I think that, you know, people's experiences of trying to get care are real, as Beck said there's an avalanche of demand, and we're not meeting it. GPs are not very good at recording what type of consultation they're doing, for example. So quite often things which are actually face to face are recorded as something else. Because you do actually have to manually set exactly what it is you're doing sometimes. There's quite a lot of activity that goes on that's not recorded. So I think there's certainly a sense among the profession that the headline metrics, which are being sort of bandied about, are potentially problematic because of that difficulty in capturing the myriad things that GPs are doing. And as Becks says, you're doing things all in the minute, so you respond to an electronic thing and then you do a phone call and you might then look at a blood result which then leads you into making a phone call to a patient but that might not be recorded as a consultation and so it's quite – I think people feel that being hit over the head with, you know, how many, what proportion of your consultations are face to face on the basis of what we know to be flawed data is part of the problem, I think. But then we've got the real life experiences that people are struggling. And of course, the more people who, as Beck said, if you've got people who are waiting for months and months and months or years sometimes for for secondary treatment, then they're going to fall back... I can remember that from, you know, in the late, in the 1990s, I can remember that, that managing people on long waiting lists was quite a big part of general practice. And it's so sad to see us back there again.

Jennifer Dixon: Just to process for a minute, because total consultations the same, pretty much, face to face pretty much the same, telephone consultations have gone up from 3 million a month to 10 million across the country, pre and post pandemic, and the same proportion of people receiving care on the same day, one to two days, two to five days, etc, similar sort of. So if you really look at the headline data, the patterns are not looking as if they're flashing red. And actually, if you look at the latest GP patient survey about patients' experience of general practice, it's really good. And yet on the other hand, you hear testimony from general practitioners and friends of mine who, they've never been so stressed. They never been so over-worked. Do we just say that the data are flawed? How do we interpret the bald figures that I've read out?

Shaun Lintern: As a journalist, I'm always conscious that you pick up and hear from patients and people in the system, they have an issue to raise and that's why they speak to journalists. And I'm always constantly reminding myself that the view I get of the world is not necessarily as it is, because of just the nature of my job. And I actually delved into some of the data on GPs, when all of this blew up over the summer, and actually, I was quite surprised that almost, I think it was almost 60% of appointments, were face to face. 14 million in July, I think, and nearly half took place on the same day. I mean, that that is not a bad service, I don't think. But on the other hand, I have to say, I do speak with nurses and doctors in A&E departments, and there is this almost constant comment that they see patients all the time who are telling them that they're there because they couldn't get seen by their GP. So there are clearly some patients who I think, they have a sort of expectation of service which is more akin to Amazon. And the instant get it now sort of service that they expect versus what we can we can offer and maybe some of those people as a subset of patients are the ones driving to A&E and calling ambulances and heaping pressure on the system.

Katherine Checkland: I think there's something there as well, Shaun, about how people are reacting, because I think that the headlines and the Daily Mail and those kinds of things aren't helpful because they raise the temperature. People are now saying they're getting quite a lot of aggression from people who don't get exactly what they want, that kind of Daily Mail story which is, you know, we're failing and we're not providing the care and then people get angry and then practices feel under siege and then that makes it all more difficult.

Jennifer Dixon: Yes, it doesn't take much does it to change the weather. And I mean, GPs have always been top of the pops with the public, haven't they? And it must be a real shock to find that suddenly, despite giving their all in the pandemic, feeling under siege, that actually they're facing some degree of public frustration, Becks?

Becks Fisher: It's been particularly difficult in the last few months. I'm really aware that our reception team bear the brunt of it. I think if somebody is being rather difficult with me on the phone, the chances are they've been even more difficult with our reception team. And there have been physical threats, there's been lots of verbal abuse, it's a deeply unpleasant environment to work in, particularly when that work is at some personal cost. I think I'm particularly sad by the approach that government has taken to this and the seeming creation of a division between patients and doctors, and a division between those groups and politicians. It sounds like a naive thing to say, but I don't really understand why we aren't all on the same side in this one, which is understanding that the pendulum, which was probably too far towards face to face consultations pre pandemic, swung too far towards primarily telephone first consultations and now needs to find an equilibrium. Surely we need to be working collectively, mindful of the back story to this – which is decades of underfunding, in the NHS in general and in primary care I would argue in particular, and a persistent workforce challenge – to see what the solution is because the rhetoric at the moment is just going to fuel the problem. I've got colleagues who have quit in the last couple of months who aren't intending to work in general practice anymore and just say, look, it's not worth it. And the government haven't got our back so who has.

Jennifer Dixon: If you think about elective waiting, there's 6 million people waiting at the moment on waiting lists, maybe a few millions more who are still not coming forwards for care. But if you set those numbers, sheer numbers against the volumes of people who see general practice, so that's over 300 million every year, it strikes me if primary care is in a precarious position that is far more risky and can go off far more quickly for the government, Shaun?

Shaun Lintern: Exactly, I mean I wrote a piece recently that the numbers of delayed transfers of care in hospitals are rising again. And we've seen some nursing homes, and the CQC has warned of nursing homes, closing their doors and effectively not taking referrals. And that's leaving those beds in hospitals blocked and of course that trickles down into the whole system. And we've got ICU beds that are empty because we don't have ICU nurses to staff them which, you know, considering we've got 6 million people waiting for surgery, and there are beds there that they could go to after their operation, and it's just empty because we don't have the nurses. The whole situation is actually quite serious at the moment. I'm not sure the government are fully recognising the danger they're in.

Jennifer Dixon: Exactly. One of you I think referred to the fact that over the last certainly two decades, growth in NHS funds have been really focused far more on hospital care than they have been on general practice care. That has been recognised and as we know, there is a strategy to improve primary care in NHS England. There's the Five Year Forward View and a lot of good stuff in there too, and an upturn in investment that happened around the same time in 2016. So I wonder if perhaps Becks and Kath you might just chart out what are the main features of the strategy forwards for general practice?

Katherine Checkland: A lot of it is around diversifying the workforce and moving in, a lot of the investment is towards increasing the volume of other types of professionals in primary care to diversify what we can offer. First contact physios, advanced nurses, pharmacists, those kinds of things. And then also, and I think this is one of the things, Jennifer, that I think might be slightly problematic, which is that. we're doing some research on primary care networks, they're almost like the solution to everything. And there's quite a lot of confusion, I think about what what they're mainly for.

Jennifer Dixon: Can you just chart out what they are for people who may not...

Katherine Checkland: Primary care networks are, GP practices are getting together, or asked to get together in their neighbourhoods, to work together to employ additional staff who will be employed across the network. So more than one practice, often 10 practices or six practices or whatever, will be working together in a network on a particular neighbourhood footprint, they'll be employing these extra staff, they will be receiving funding to do that, the staff will move between practices, they won't be employed by a single practice, there's funding for incentives, so there's some money, extra money if they can provide additional targets. And then there's also, they're required to deliver particular services across that footprint. And there's a sort of sense that to some extent, primary care networks are intended to rescue general practice, that the investment is coming in, the additional staff are coming in, and that's part of the aim for them. For practices struggling, the idea is that working together in a network would give you the mechanisms to support each other. And that, you know, that's obviously not a bad idea at all. But then at the same time, these networks are supposed to then be a player in the local system. They're supposed to work closely across the patch with community services, with social care. They're intended to look at population health management. They're intended to be a player in local places and the integrated care systems which are currently developing. So that's a big ask if you're also trying to do the day job and rescue yourselves. There's an understandable ambition around the notion of primary care networks, but at the same time we're fighting fires.

Jennifer Dixon: So Becks, I know you've written quite a bit about PCNs, what's your take on these primary care networks that are meant to scale up general practice?

Becks Fisher: I think they're a very interesting beast, Jennifer. They are in some ways, I think, a very clever policy device to deliver aspects of the NHS Long Term Plan that NHS England needed to be delivered through primary care. And they were put in as a kind of superstructure to the partnership model. So they're not an explicit challenge to the partnership model. They don't challenge the integrity of an individual practice. But for the first time, what you have is funding coming into general practice that is to be shared between a group of practices working together so it doesn't come directly to the practice, it comes to the network. That I think is a really interesting, subtle but quite major shift. Something that I've been interested in since the idea for PCNs was mooted is how do you know whether they're working? What does good look like? And possibly more importantly, what does it look like when PCNs aren't working? And something that continues to worry me is that I don't think we have any way of knowing what is happening. My experience, personally, is that in some of the areas of the city where I work in, PCNs are working really well, groups of practices are very genuinely collaborating. In others, it's really just another three letter acronym, it's not really going to affect the care that patients get at all. And I think the other thing to say is that a lot of it has been derailed by COVID. A lot of those things that PCNs were expected to deliver in their first couple of years had to be postponed, because general practice needed to swivel to focus on first dealing with a pandemic and secondly, how you vaccinate people to help us get out of the pandemic.

Katherine Checkland: And I think there's something as well about the amount of support they need, Becks. So they're being expected to work together in new ways, do new things, and develop themselves as they go along. But then at the same time, we've got quite a lot of churn in the system with clinical commissioning groups going, integrated care systems developing. And so one of the things that worries me is that, as you say, if PCNs are going to develop to deliver the things that are expected to deliver, they need support. And it's worrying to me where that support is going to come from as the system is in a degree of churn, as ICSs develop.

Becks Fisher: I think there are particular challenges as well that PCNs have thrown up for general practice. The idea of an expanded skill mix in the workforce isn't a new one, Martin Roland's commission, earlier last decade, was very pro it. But something that we're still trying to work out is what does a good multidisciplinary team look like in general practice? What is the role of a GP in that context as perhaps conductor of the orchestra, not just an individual musician? And some really basic things that we absolutely haven't got sorted out like general practice premises. Where on earth are we going to put 26,000 allied health care professionals? It's not appropriate to have somebody consulting from what was previously your broom cupboard. But it's, it's not a joke, we really don't have a general practice premises plan that is fit for this new purpose.

Katherine Checkland: And how do we supervise them and look after them? Because a lot of our research has shown that that's hard work, you know, integrating these new practitioners into the practice isn't simple.

Jennifer Dixon: If we kind of step back and say, what is the public going to be seeing in future as to the way that primary care is going? And where should it go? You know there's a whole raft of policies in there about digital first primary care, which is, of course, what we were talking about in the pandemic. Who is thinking about the very future shape of care? What do we need general practice for? Have we looked at that recently? Is it time for another review of it? Given the rapid access we are getting can we not funnel a lot more to specialists instead, as is the case on the continent?

Shaun Lintern: I think the time is probably right to start thinking about the model of care, generally, in primary care. And actually also while I'm thinking about it also in A&E, and I know the CQC in their State of Care report recently called for new models of care to meet the growing demand which the current system just isn't meeting. And I think there are practices where there are some really innovative things being done, and they work really well and it's a good collaboration between the patients they serve and the GPs. And then you've got, unfortunately, there are other GP practices who, single-handed maybe or small practices, and, you know, they're working very much in the way GPs did when I was growing up as a child in the 80s and they haven't really changed much. Again, it just really amuses me that we had a Health Secretary saying at one stage, Matt Hancock was pushing this digital first approach and we've reversed that now, thanks to some of the media coverage it seems, and ministers now rowing back on that. And actually, some patients will benefit from that approach and some patients won't. And we need to flex the service and the model to meet the patients. I would hate us to develop a model for general practice that in a way reflects the model we have in A&E care which is that we build the system or we try and bend the patient to fit the system we built as opposed to creating a system that is around the patient.

Katherine Checkland: I agree with you, Shaun, that we do have to flex the model. But on the other hand, there's elements of what we've got that we forget about sometime. So for example, there's lots more evidence coming out about the value of continuity, and certainly doing telephone consultations it's much easier to be safe if you know, if you've got a relationship with a patient already. And we really know that this is something that really works and really makes a difference to the care that patients receive. And yet policy for decades has been built around a transactional model of general practice, which is patient has problem, patient needs doctor, patient asks doctor for help, problem gets solved. It's how do you build a system which can do both, which can provide that ongoing continuity which we know improves care, whilst at the same time dealing with the volume of things. As Becks says, some things are really simple and they are transactional. But a lot of things aren't. And it's building the model for that that's really hard.

Jennifer Dixon: Should we have a more fully thought through guiding strategy here for the future? In a sense, we've been hurried towards the future because of the pandemic. And there's been a bit of a backlash, even if it's a storm in the Daily Mail. But where is the thinking on the nature of demand coming forwards in general practice? Who's doing that kind of thinking, based on the evidence looking at the demand profile, for example, is that something that isn't done yet needs to be, or are people groping towards it? I'd be interested in all of your views on that.

Becks Fisher: Number one, I don't think we know much about the anatomy of demand in general practice. We've already talked about how poor a lot of general practice activity data is. And that's just the kind of raw numbers of consultations that we can't even trust, let alone what on earth goes on within them. And then I think there are huge questions that we haven't really grappled with recently, you know, what is the future of the partnership model? The number of GP partners is at its lowest ever, the number of salaried GPs is at its highest. These aren't necessarily questions that will just go away if we don't answer them, there are trends that need to be addressed. We don't know what the right size of general practice is, we still as Shaun said have lots of single-handed GPs, we also have a kind of plethora of different models of delivering general practice at scale. And I think people are grappling with bits of that picture but I'm not sure that anyone is trying to put it all together and say, well what do we want general practice to look like in 2030, let alone in 2050?

Jennifer Dixon: Shaun, what's your view about the extent to which policymakers can and indeed are able to generate a much more intelligent guiding hand to primary care provision, is what we're talking about?

Shaun Lintern: If I can make one plea to any policymakers listening, please, not another five year plan, or long term plan or any other plan that by the time people look back, it's long into history, I don't think any of those have really delivered. And actually, for me, in my view, talking to people in the ICSs, is in the PCNs, there is an opportunity with these new structures, that the ICSs will have a population level where they could actually do some really interesting work to plan their demand in their region and what their sort of model of care might be. And then they should be free to do that differently, in different parts of the country. And equally at an ultra sort of place level, a PCN level of the system, they also should be able and free to do some of these system changes that we might need in primary care going forward.

Katherine Checkland: One of the things as well is that we need policy, I think policy has historically been fairly narrow in its focus. So it's been particularly, it's access policy focused on timeliness, the getting an appointment within 24 hours, or 48 hours or whatever. I would really hope that NHS England and DHSC take a very broad view of primary care, because I think Becks is right, the anatomy of the demand and the need. Yes, timeliness is important. But then so are other things and there's a big section of the population with multiple conditions, older patients who do need continuity, who need a trusted doctor that they know, and we need to do policy which delivers all of those things because what we tend to do is we design the system to do one thing. And of course it should be doing lots of things all at once. And it's really hard to design a model that does all of the things that we need general practice to do, and does them all well. But that's what we need to focus on.

Jennifer Dixon: Yeah, in a sense, there's almost two things, big things going on. One is a huge opportunity with digital and expanded access that we've got. But on the other hand, we've got injury to general practice and primary care because of chronic underinvestment in the past save maybe the last few years. One way of buying more time to allow more response to the digital challenge opportunity is to buy your way out of trouble by just boosting investment in the workforce, which of course the government have been trying to do but maybe not fast enough to offset the risks that they're facing.

Becks Fisher: I think one of the challenges we have right now, Jennifer, is that money can't buy what isn't available in general practice and what isn't available is GPs. So we are reaping the disadvantages of the failure of workforce planning, that has meant that over the past 10 years, the number of hospital consultants has skyrocketed relative to the number of GPs. And of course, if you think about where demand is in your system, overall, that doesn't make any sense. Fundamentally, I think what we have to do is actually a much much harder thing, which is make general practice somewhere that doctors want to work. Ironically, of course, that does take money and investment to do but it's about things like the transactional versus relational elements of medicine. When you look at job satisfaction in UK GPs compared to international counterparts, it's far, far lower. And the one thing that you can pick out from the data is that consultation lengths in general practice in the UK are much shorter than in other high income countries. Now, there may be a bit of a correlation causation fallacy in there. But I think we have to do a lot of hard work and say, well, actually, how do we make general practice a much more attractive place to work? And only then do we start to solve some of the challenges that we have.

Jennifer Dixon: Yes and indeed, at the same time, not taking the pedal off the digital opportunities that we've got to offer expanded access to more people. Perhaps I could finish with the question for each you, quick fire answers perhaps on, it's a big question, which is what is your top priority for the government to now focus on to derisk general practice and start paving the way to a more sustainable system?

Katherine Checkland: I guess that would be my focus, is what can we do to make primary care more attractive? And some of that is about messaging, some of that is about just getting wholeheartedly behind GPs. Because if GPs feel bashed, it just compounds the workload problems and everything else. That would be my top thing.

Shaun Lintern: I think the government's got to start looking at the issues of deprivation and the wider sort of social determinants of health that we all talk about, and know so well, but these are the things that are driving demand on health care, generally. And we need to be tackling some of those bigger questions to actually support not just GPs but the whole health system, it can't continue to be relied upon like it is at the moment with no real investment upstream I suppose is the common phrase isn't it to try and reduce some of that workload that's flowing down. And, you know, frankly, I think the CQC described it recently as a tsunami of unmet need. And I think that's what we're seeing at the moment, they've got to get more upstream and do something to help out, not just GPs, but the whole system.

Becks Fisher: So I'd have something you could do today and something you could do tomorrow. The thing I think that government could do today is to fix funding for general practice so that funding is more aligned with need. And this gets to a point that Shaun was making about deprivation. I think if government is serious about levelling up, that has to include health, within health it has to include health care, and in general practice we have a situation where practices in the most deprived areas are underfunded and under-doctored relative to practices in the most affluent areas. You have to fix the funding formula I think to do that, and you probably have to boost overall GP funding so no one loses out. I don't think that's a bad thing, either. And my something for tomorrow, which is more complicated, is exactly as Kath says. You have to make general practice a more attractive place to work. Again, I don't think that's about paying GPs more. I think most doctors are really intrinsically motivated by wanting to deliver great holistic care for patients. And so you have to feel that the system you work within permits that so if we improve the care general practice can offer patients. that will increase job satisfaction for GPs as well.

Jennifer Dixon: Wonderful. So that's a great place to leave it. Thank you all very much for a really stimulating discussion on quite a number of issues there. I hope everyone listening will realise the risk that is being faced at the moment with primary care and the pressures and strains in it that we explore today. For key links to reading for the things we did discuss today please, as ever, find them in our show notes wherever you find this podcast, lots of good stuff there. And also to advertise that next month we'll be doing a Christmas special, a roundup of the key things we should remember from 2021 and why. So join us with a mince pie or something stronger to listen to 'that was the year that was'. So in the meantime, I want to thank again our guests Becks, Kath and Shaun for a really great discussion. So thank you all and see you all next time. Thank you.

• Rebecca Fisher (2021) 'Levelling up' general practice in England 
• Rebecca Fisher, Ruth Thorlby and Hugh Alderwick (2019) Understanding primary care networks
• Martin Roland, HEE Primary Care Workforce Commission (2015) The future of primary care
• NHS England (2014) Five Year Forward View