Is general practice really at its lowest point?
in Pulse’s 60th birthday month, Léa Legraien looks at whether the job is really worse than it has ever been
‘It was better before, you could do what you wanted,’ says Dr Greg Roberts, a GP who retired last year.
‘You didn’t have to fill in loads of unnecessary paperwork, certainly not appraisals where you have to sit at a computer for hours filling in forms and ticking boxes, which you haven’t got the time to do. You want to look after patients, not tick boxes on a screen. There is more admin work now.
‘When I started in the early 1990s, you would apply for a job and there would be many applicants for each job. There was competition. Now, you can walk into any [GP] job you want and it’s the other way around, there are hundreds of jobs for one applicant.’
Many GPs would agree with Dr Roberts’ assessment, regardless of when they started out in the profession.
Many believe pressures related to the current recruitment crisis,practice closures, modest funding increases, 11-hour days, increased demand and mistreatment at the hands of the press have left general practice in its deepest rut.
A Pulse survey of 800 GPs last month revealed that 19% of GPs say their morale is ‘very low’, with a further 34% saying that it is ‘fairly low’.
Even more shockingly, 54% believe their morale is ‘much worse’ than when they first started practising.
When I started in the early 1990s...there was competition. Now, you can walk into any GP job
Dr Greg Roberts
And it seems all generations feel the same. Around 70% of those who started their career in 1991-95 rate their morale as ‘much worse’ now, with 65% of GPs who began working in 1996-2000 saying the same. Even among the older cohort, around 50% of those who started practising before 1985 agree.
But could there be an element of selective memory at play? Because there has always been fluctuating morale in general practice. In 1965, job dissatisfaction led to around 18,000 GPs – around 70% of those in the profession – handing in their undated resignation, with the support of the BMA.
And there have been problems ever since then. In 1990, then health secretary Kenneth Clarke imposed a contract on GPs, despite the profession voting against it in a ballot, with the intention of linking remuneration to performance. This led to his infamous comment that ‘GPs should stop fumbling nervously for their wallets'.
In 1993, one of Mr Clarke’s successors Virginia Bottomley admitted that stress among GPs had ‘increased’ and morale had ‘plummeted’ following the release of the 1990 contract.
It was only in 2004 that GPs won the ability to opt out of out-of-hours care. Dr Paul Frisby, a 52-year old GP from Eastbourne, recalls: ‘Before then, we would be getting out of bed several times at night and we were using our own car, visiting on our own, sometimes in dangerous areas. We were happy to give that up.’ So how does today’s crisis compare to those of years gone by?
First, it may feel that today’s recruitment crisis is worse than ever. But a recent analysis of data from the Office for Health Economics by the Nuffield Trust1 shows there are now 60 GPs per 100,000 patients; the figure was 46 per 100,000 patients in 1964.
Such were the problems in those days that in 1965, the BMA produced the family doctors’ charter, outlining a list of requirements by the profession, such as higher remuneration for out-of-hours work, a maximum patient list size of 2,000 and funding to make improvements to premises.
But these figures do not tell the full story. The Nuffield Trust points out there are issues around whether registrars, locums and retainers should be counted, while the extent to which GPs work part-time is also sketchy and has changed over time.
However, one thing seems undeniably true – that the UK has suffered a sustained fall in the ratio of GPs to patients over the past decade, since the 2009 peak of 67 GPs per 100,000 population. The Nuffield Trust estimates that for the overall number of GPs to have kept pace with the number of people in the UK since 2014, ‘we would have needed some 3,400 more GPs’.
Not only are GP numbers falling, the work is much more intense. Although there is no official reporting of such data, last year Pulse asked GPs to describe the daily workload pressures they face as part of a first major survey highlighting the conditions under which GPs work.
A total of 1,681 GPs submitted responses, revealing the average working day comprises 11 hours, including eight hours of clinical care. And the findings also showed that, on average, GPs working full time have 41 patient contacts a day – far beyond the 30 contacts respondents regarded as a safe limit.
Former RCGP chair and leading GP burnout expert Professor Clare Gerada says it is much harder to be a GP now than 30 years ago.
She says: ‘GPs are now expected to do far more. I used to start at 8am, finishing at 11am and going back for my evening surgery at 3.30pm. Now you start at 8am and you barely finish your morning surgery before the evening one starts.
The big problem we’ve got now in general practice is...very little continuity of care'
Professor Clare Gerada
‘There’s a lot more that we have to do. We cover a lot more and patients are more complex, with more comorbidities than ever before. When I started, it was unusual to have somebody over 70 let alone over 90.’
Professor Gerada believes there has also been a loss of continuity, mainly due to a more mobile profession and the pace at which things have evolved.
She says: ‘I think the big problem we’ve got now in general practice, which we certainly didn’t have 30 years ago, is that we have very little continuity of care.
‘We have a sizeable peripatetic workforce and the expectation is that people will work in this way, either as locums or moving around different practices, and that creates work and it loses the satisfaction a bit.’
There have been numerous studies showing burnout is a growing problem.
Pulse’s ‘Battling Burnout’ campaign highlighted this. It found 50% of GPs in 2015 were at ‘high risk’ of burnout. It seems unlikely things have improved – a GMC report in 2019 found 45% of GPs were at risk of burnout (see box, further below).
This has often been countered by the idea that GPs are being paid more. And, on the face of it, life may seem a little rosier than it did decades ago. In 1960, the intended average net remuneration was £2,425 – in today’s money, £56,000. NHS Digital statistics suggest average GP earnings were the equivalent of around £113,400 in 2017/18.
But this is way off the 2005/06 peak, when GP earnings reached £165,000 in 2019 money. Former BMA GP Committee negotiator Dr Peter Holden argues that peak is down to the 2004 contract.
He says: ‘If you look back in history, there were several dates when GPs got big pay rises – because our pay rises have been a history of falling way behind the game, getting a massive rise to catch up, falling way behind again, before another massive rise to catch up. This happened in 1953, 1966, 1971, 1980, 1990 and 2004.’
However, Dr Holden says this has had negative consequences for today’s GPs: ‘Since 2004, in the view of government ministers, you earn too much then it’s payback time and you’re doing penance. And yet our workload is fantastically bigger in volume and in complexity. That’s why no one wants to be a GP.’
Former health secretary Jeremy Hunt said as much in 2015, saying: ‘Labour signed a disastrous contract in 2003 and since then, in penance really, the NHS has not really wanted to put extra money into general practice and it been has starved of resources progressively.’
In the past few years, NHS England has committed more money to general practice. However, this has often been linked to new work, with the current contract a typical example.
Retired Tameside GP Dr Kailash Chand says: ‘Before we only had GMS contracts. Since the 1990s, more funding has become available but with more strings attached. The same thing happened in 2003/04 due to PMS and APMS contracts.' In addition, he says, the QOF became ‘increasingly a policy agenda, not a clinical one’.
In terms of patient satisfaction, since 2007, Ipsos MORI has run a GP patient survey on behalf of the government of the day. Usually sent to more than two million people in the UK, it looks at various aspects, such as the level of confidence and trust in GP practices.
Last year’s survey, completed by 770,512 patients in England, showed 96% had trust and confidence in the healthcare professional they talked to or saw during their last GP appointment– the same proportion as in 2018.
This is not too different from the 2009 survey, which found 94% of more than a million respondents had confidence and trust in the doctor they saw.
GPs are trying to manage a situation with inevitably limited resources but infinite demand
Dr Peter Swinyard
Family Doctor Association chair Dr Peter Swinyard says GPs have maintained high-quality services to keep patient satisfaction at high levels, despite a lack of resources.
But he adds: ‘The generation of patients who were around when I started in general practice were grateful to be treated. They were people who had either individual memories or heard memory of a time before the health service in 1948, when you had to think twice before going to see a doctor because you had to think whether you could afford to.
‘Now people don’t have to worry about whether they can afford to be ill, they will be treated according to need. That puts significant extra strain on doctor-patient relationships, where you’re trying to manage a situation with inevitably limited resources but infinite demand.’
One completely new phenomenon in the past few years has been practice closures. In 2013, there were 18 – and that was considered a lot. Pulse revealed there were almost 140 closures in 2018, affecting half a million patients.
Given such pressures, Dr Holden believes general practice is now at its lowest point. ‘I think there are a few green shoots but we’re around the bottom at the moment. I do wonder if the Government is trying to kill general practice.’
Eastbourne GP Dr Paul Frisby agrees: ‘General practice is, without a doubt, at its lowest point. In 25 years of full-time practice, I’ve never known everyone to be under so much pressure and so demoralised.
I don’t think it’s a great job, I think it’s a deadly job and I expect it to kill me
Dr Paul Frisby
‘I don’t think it’s a great job, I think it’s a deadly job and I expect it to kill me.’
Dr Phil Hammond, medical correspondent for Private Eye, says GPs need a more targeted message: ‘Moaning about morale will never engage the media or politicians. GPs need to frame their arguments in terms of patient safety. If the service cannot safely cope with demand, we need to spell out how patients are harmed as a result.
‘The 2015 Conservative manifesto promised to make the NHS “the safest and most compassionate health service in the world”. Five years on, they need to be held to account relentlessly for failing to deliver.’
But Professor Gerada says despite today’s unique pressures, the profession is not at an all-time low. She says: ‘Over the years people have said “this is the end of general practice as we know it” and there is a big laugh because we’ve heard this since the 1950s when we had the Collins report and it was in a terrible state then.
‘But it’s nowhere near its lowest point. The problem is people believe it is so we get into a terrible cycle of discontent. It’s at a point where I wish it was better but, there are good things on the horizon.’
Cheshire GP Dr Louise Davies agrees, but sums up the feelings of many GPs: ‘General practice is not at it’s lowest point, but I do think it’s in crisis.’
2 Sutherland V and Cooper C. Job stress, satisfaction, and mental health among general practitioners before and after introduction of new contract. BMJ: 1992 13;304:1545-8
4 Gibson J et al. Ninth National GP Worklife Survey. Policy Research Unit in Commissioning and the Healthcare System Manchester Centre for Health Economics, 2018
Sources for bar chart on GP pay:
- The Review Body on Doctors' and Dentists' Remuneration, via Hansard for years 1960, 1965, 1970. Each year includes slighty different data, eg excluding GPs aged 70 and over in some cases.
- The Review Body on Doctors' and Dentists' Remuneration via Hansard for 1975. Data represent the intended average remuneration.
- The Review Body on Doctors' and Dentists' Remuneration via the BMJ's copy of records for years 1980, 1985, 1990 and 1990. Data for all years are based on actual net remuneration, apart from 1990 which is the intented average net remuneration.
- NHS Digital data for year 2000. Data are based on GMS net income.
- NHS Digital data for years 2005, 2010, 2015, 2016, 2017. Data are based on GMS and PMS income.