Interview: Dr Nigel Watson – ‘If we are to tackle workload, it will cost money’

General practice across the country is ‘barely surviving’, with all regions vulnerable to a collapse of primary care due to practices having to hand back contracts or close patient lists.

This is the stark warning issued by the head of the Government’s independent partnership review as he reveals the initial findings of his work.

In an interview with Pulse ahead of publication of the review’s early findings this month, Dr Nigel Watson, who has been tasked with ‘reinvigorating’ the partnership model, says that ‘doing nothing’ is not an option: ‘Around the country in every place we’ve visited, general practice is fragile and it’s barely surviving.’

Ominously, he warns that towns such as Bridlington and Folkestone – where problems attracting GPs have left practices on the edge – are far from unique, saying this ‘could occur in any of our areas’.

‘Partners’ workload unmanageable’

Dr Watson has undertaken his review at a time when numbers of GP partners are falling and fewer GP are wanting to take on the role.

Official figures from June show the number of full-time-equivalent GPs in the workforce has decreased by more than 1,000 since September 2015 – when the Government pledged to increase numbers by 5,000 by 2020. But in terms of FTE GP partners and principals in the workforce the figures are starker – a reduction of almost 2,500 in that time.

Government efforts to expand the trainee workforce are ‘desirable’, says Dr Watson, but the priority is to retain those already in the profession.

‘We’re expecting in the next 10 years or so more people to come through the system who want to be GPs, but we need more people sooner than that.’

The review group has so far found staffing challenges to be one of the major threats to partnership.

The working day has become ‘to many extents unmanageable’, he says, resulting in GPs cutting down on their number of sessions out of concern for their own health.

‘You’ve got fewer quick, easy appointments and more complex ones, meaning the working day is getting longer, the workload you’re coping with is greater – and the prevalence of disease is higher.

‘Clinically, GPs are expected to pick up more and more work, and with the focus on improved access, other things are compromised.’

This is having an even greater effect on partners than their salaried counterparts, as they are having to spend longer trying to cope with the business administration. This is partly a result of having more complex patients with greater needs – but it also relates to ‘issues with things like NHS Property Services and Capita, where practices are unable to resolve queries and difficulties, which just generates more work’.

At the same time, the financial benefits of becoming a partner are now negligible in some areas due to rising expenses and too little funding to cope with rising demand. In some practices, he says, salaried GPs are paid more than partners.

All this is happening while a culture shift is occurring in the younger generation: ‘When I became a GP, partnerships were difficult to get. Your expectation was that was going to be your career, in that practice for the rest of your life. I think many now see a long-term commitment as five to 10 years.’

With all this in mind, it’s little wonder that partners are opting to become locums or salaried GPs in a bid to gain more control over their working day, says Dr Watson.

‘Fairer pay and more flexibility’

To tackle these challenges, he says the review is looking at ensuring partners have fairer pay and greater flexibility.

‘Many more people are looking for much more flexible working. They say “I’ve now got a young family so I want to work part time and reduced sessions but I’ll increase them in the future”. If you’re going to work potentially until you’re 67, doing general practice for 40 years, you’ll burn out.’

The solution could involve all GPs working sessions of four hours, as salaried GPs do, so that the workload is managed within the four-hour periods.

‘In which case, if practices are open from 8am to 8pm, rather than everybody coming in when the doors open and leaving after they close, perhaps GPs could look more flexibly at their working week.’

And as there is a need to make partnership more attractive to the younger generations, this also means more flexibility to pursue clinical interests.

‘They say “actually I want more variety, so I want to do general practice for three days a week and a day a week of doing something else that’s related to general practice but isn’t necessarily the surgery visits, paperwork”.

‘So this could be developing clinical interests, diabetes, frailty, etc, or it may be about education or research or other things that become available. Part of what we’re also looking at in the review is how to create career progression and create roles where younger GPs are attracted into it.’

‘Premises liabilities put off younger GPs’

It’s not just about flexibility and reducing workload, however. There is also all the perceived personal financial risks and liabilities that are putting younger GPs off partnerships. One risk is the prospect of being the ‘last man standing’ – where a single partner hands back their contract for GP services but is left liable for the leasehold of the premises.

‘Premises has been identified as one of the risk factors that puts younger GPs off joining partnerships, whether that’s signing a 20-year lease or buying into premises,’ notes Dr Watson.

‘One of the big risks for practices is, I hand my contract back because I can’t recruit and suddenly I’m the last person standing and left with the liability of premises. So we’re going to explore ways of mitigating that risk.’

This includes ‘looking at where the lease sits, who holds the lease, where the break clauses are, who would take responsibility.’

When asked how far the group was looking at government intervention in a ‘last man standing’ scenario, Dr Watson says that is ‘to be decided’.

Indemnity is another area that affects personal finances. ‘It’s really critical that the state-backed indemnity scheme comes into force as soon as possible and no later than the 1 April.’

For older GPs, he says, pension considerations are playing a part in decisions about cutting down on work.

‘Towards the end of a GP’s career the pensions issue has an impact, so people are choosing to reduce their sessions. We hear that because of the annual [tax] allowance and lifetime allowance of pensions, people hit their lifetime limit earlier, so they are either opting out of the pension scheme, reducing their sessions or leaving.

‘So although the NHS scheme is still excellent, it is not as flexible as others in terms of contributions, so we’re also looking at that.’

Considering Scotland’s reforms

Dr Watson is paying close attention to contract reforms in Scotland – where the NHS is offering to take over all GP premises – but says: ‘Their situation is quite different from England and I think it’s highly unlikely that we’ll go exactly the same way.’

The reforms in Scotland include a minimum annual salary of £80,000 for GP partners – something the review group is also ‘looking at’.

Pay is a concern for GP partners in England, in particular the shrinking gap in remuneration between salaried doctors and partners, he notes.

‘It’s not the number one issue but certainly people have brought up the status of general practice and whether GPs feel valued.

‘There has to be a pay differential between partners and salaried doctors to account for the risks partners hold. In some practices that differential has reduced and in some the salaried GPs are earning more, and that is not sustainable.’

‘We’re looking at what they’ve done in Scotland and what we can learn from it but we haven’t come to any conclusions,’ he says.

Costs of change

Overall, Dr Watson says the recommendations his review team expects to make will ‘inevitably… not be cost neutral’. It will not be sustainable for practices to pay for extra GPs by reducing the salaries of existing staff, he warns.

‘If we want to resolve workload issues, we need to expand the workforce, and that’s going to cost money. If we were to hit the Government’s target of 5,000 extra GPs that’s got to be funded from somewhere.

‘You can’t just divide the GMS pot up even more and just pay existing GPs less to pay for extra GPs. So, inevitably, there will be a cost to it and that explains the Treasury’s interest in what we do.’

Dr Watson says he is ‘not naïve enough to expect that everything we say is going to be supported by all GPs’ but stresses the recommendations must be ‘reasonable, practical and affordable’ to gain the support of not only the profession but NHS England, the RCGP, the BMA and the Government.

The review team expects to finalise its recommendations by the end of the year. So far, the ideas have been ‘well received’ and Dr Watson is hopeful real change can occur: ‘I believe general practice has an exciting future, it has an opportunity if that is unleashed and supported.’