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GPs buried under trusts' workload dump

GPs, it is time to face the elephant in the room

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I recently stated that I had hope about the future of general practice. But let me try and manage expectation, this is no silver bullet, no matrix blue pill movement and no road to Damascus revelation.

We are past the tipping point in general practice, a recruitment crisis, a retirement crisis, a patient expectation crisis, a morale crisis and practices are failing daily. Those of us old enough to remember will know we have been here before. In the mid 1990s, GP post lay empty, the magazines were full of the word ‘burnout’ and general practice was destined to fail due to the burden of out-of-hours work.

GPs were working one in four rotas for generations and this position was no longer tenable; general practice was a ghost town. Then the unthinkable happened, we came together as co-ops and started to share on call shifts. This happened almost overnight and the effect was transformative both to morale, recruitment and retention; there was renewal. Make no mistake a seismic change is about happen again. 

Here are some bitter truths

They say truth is like poetry, and everyone hates poetry, so here are some bitter truths. General practice will continue irrespective of what happens: even if there is no more money or GPs to recruit. The crisis we face is not about money it's about ‘work-life balance’. Working in a hospital currently is a lot more appealing to young doctors than a chaotic general practice. Offering more money will have a paradoxical effect; doctors will simply work less for the same money. To think otherwise is denial.

My solution is elephant in the room, a solution so blinding obvious it is crushing us against the wall. The only solution is scale. We need to merger together. Federations won't work as the bonds are too loose. Now many will simply stop reading, thinking: ‘I am off to cloud cuckoo land, on the back of a flying pig to see a screening of “La La land”. But read on.’

For scale means more cross cover, on-call systems, more consistency in clinical practice, more holiday cover, less administration, flexible working, financial security, diversification and that it's easier to attract and recruit staff. It means better life work balance.

Doctors will work in a well paid and well organised environment, they won't work in a highly paid but chaotic environment. If the working environment is better, then older doctors may decide to work longer. In the short term this could ease the workforce crisis.

I should be honest about the problems of a large practice. We currently manage nearly 40,000 patients. Patients don’t always like large practices because of reduced continuity, (but because of ubiquitous part-time working and out-of-hours organisations, traditional continuity is dead). Doctors also sacrifice some control and feel they are being ‘managed’. There is also a potential divide between the partner and the salaried doctors. Larger practices are not ‘super’, and no medical nirvana, but they are better than the current choke-hold most practices find themselves in.

Scale also gives you a voice. The BMA and the colleges have no vision and do not reflect the views of many working doctors. They have been unable to resist the largely pointless appraisal system, unable to rebut the CQC, unable to prevent the endless cycle of reorganisations, and unable to challenge NICE’s mindless guidelines. We are voiceless small units that have been divided and ruled to our detriment for decades.

If we allowed the current situation to continue then practices will fold, pass to the local health board, then corporations will step in as the only alternative. Doctors will have very limited control or input. This corporatisation is currently butchering the pharmacy and vet professions. We either elect to do something now or wait the inevitable.

Local practices are subject to historical petty jealousies and vanities, but we have more in common, than that which divides us. I would not presume to tell people how to merge, but merely say our practice has two themes: an administrative mantra (‘today’s work today’) and a clinical mantra (‘less medicine is better medicine’).

Brothers and sisters open your eyes see the reality elephant, don’t let your future be written by someone else. The only logical evolution of general practice is at scale. It’s time to change. 

Dr Des Spence is a GP in Maryhill, Glasgow, and a tutor at the University of Glasgow

This is the second of a two-part blog from Dr Spence as part of our ‘Great GP Debate’ season. Read the first here. If you would like to write a piece on how you see the future of general practice, then please email the Editor at editor@pulsetoday.co.uk.

 

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Readers' comments (22)

  • Bob Hodges

    I agree with you Des. 100%

    Why to colleagues continue to conflate 'scale' with 'lack of continuity' and the 'end of General Practice'?

    Whether you are part time or full time, if less of your time is spent (pro rata) on admin and being 'on call' dealing with trivial nonsense, then you have more time (pro rata) to devout to your usual patients providing continuity!! It's obvious.

    I suspect that the increasingly shrill protestations about 'continuity' are from GPs who don't want to admit that continuity is currently a product of goodwill and only possible because we're all doing 50% extra unpaid overtime to achieve it, and that's not sustainable.

    THAT is why no one who isn't already a GP wants to be one.

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  • "The second law of thermodynamics can't be broken!" -- but it is in general practice, as it does not follow the usual rules of economics, I've seen it in my own practice. Its all about work/life balance. Pay a GP more and it finances more leisure time, so they drop sessions. Try paying them less and they just leave the profession. Either way, there is less.

    There are too many GP tribes, each with their own self interests for us to be able to act with unity. I am just hunkering down and waiting for the inevitable.

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  • At scale will lead to a salaried service for most and a salaried experience for partners. Voices calling for this are leading future generations into the wilderness and doing them the greatest possible disservice.

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  • "Scale" is about avoiding the big issue: not enough money is being spent. If we opt for scale, then we are admitting that we can only flourish by making economies of scale and not allowing the Gov't to feel the heat of its cheap and transparent ways. The public and the profession will be so distracted by the re-organisation process that this follows that it will not push for better resourcing too. STPs want GPs to "go to scale" as it provides a venue for dumping hospital work into the big, new teams in their shiny, converted car showrooms. Oh and if it fails financially, it is our liability! Keep an eye on the bottom line: don't fall for it. The funding has to be obscenely big (like when services are tendered out to other Private Providers)or we should just walk away.

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  • The challenge then is to build in rules and constraints that preserve continuity in a large organisation and protect the influence and involvement of partners when inevitably some
    Managerial and administrative functions are carried out without an enormous meeting.

    Also helpful to consider the new gp cohort, I believe they are over 80% likely to want part time working and at presently are 50% likely to completely leave the profession by age 40.

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  • For once I disagree with you Des. In a big organisation staff are not valued as individuals, morale is low and staff turnover is high. If I wanted to work in this sort of environment I would have stuck with working in secondary care. There are benefits but the cons outweigh the pros for me.

    If you want to stay small/medium sized and compact I think the only long term solution is to diversify your income e.g. Teaching medical students, commercial research, private cosmetic work etc

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  • I've been a portfolio doc towards the end of my career for the last 7 years (after almost 30 years as a full time partner).

    Three of my portfolio jobs have involved visiting GP practices (no I didn't and wouldn't work for CQC). I've clocked up meeting doctors at about 300 different sites.

    I have the greatest respect for Des's views but he is absolutely wrong about this one. Very big practices mean very big problems.

    General practice without some options for continuity of care for the 'elderly, the seriously ill and the hopeless' is completely pointless. Without some long term relationship with individual punters the job is meaningless, even more soul destroying and medico-legally impossibly dangerous. We will just end up playing pass the parcel like our hospital colleagues.

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  • Vinci Ho

    Interesting debate from both sides of the argument. As I said long time ago : the strategies to fight this war were (1) Going for the jugulars on the negotiating table (2) anti-spinning against the government propaganda machinery (3) not the least , grouping together to increase our defence against the common enemy.

    The interesting question here is ' has our enemy actually changed?' or ' otherwise , has our enemy only changed its face with the same secret( well , not so secret anymore) agenda?' Read the full interview with Bruce Keogh about GPs would all become consultant physicians in the community (read my comment if you want as well).
    Defending against your enemy could mean changing the tactics of war but not necessarily changing who we are and the values we hold . I accept the point we might have been a bit obsessed with this continuity but then I would refer to my favourite Michael J Sandel's definition of justice : '
    ''Arguments about justice and rights are often arguments about the purpose, or telos, of a social institution, which in turn reflect competing notions of the virtues the institution should reward and honour .''
    Perhaps , we have to redefine our telos and virtues of general practice in this country ??
    Like everything else , work by scale will have both advantages and disadvantages but I also believe one size does not fit all.
    But the bottom line is the indisputable lies behind the government's claim of how much money it will put into NHS and hence general practice by 2020 , as quite rightly exposed by the Health Care Committee in House of Commons. And of course , you now know the true meaning of STP.
    I also agree that the problems cannot be solved simply by paying each GP more as I stand by the definition of resources as money + manpower +expertise + time, one for all , all for one. But fundamentally, if there is a political will to sustain NHS and general practice, there must be a political ,but also honest ,way to face the reality of establishing new , secure channels of recruiting funding . Whether it is a left(taxation) ,right(private funding ) wing or somewhere in between solution, we need to have a transparent, democratic debate. The problem is this government is ,with an excuse, too busy dealing with Brexit and Article 50 that all domestic issues are left to rot and wither.
    One thing I also like to point out is agreement to work by scale universally has a potential danger of giving our common enemy the opportunity to claim general practice has substantially increased its 'capacity' by merging together , more capacity the bigger. This of course , will certainly fit its agenda of pushing for 7 days opening , at current level of recruitment and funding .
    I respect the author's modesty not to presume how practices should merge but my ideology of grouping together is a mentality of fighting a war instead.
    Exactly what is the colour of this elephant, I will leave this to the readers to decide and by the way , I always believe second law of thermodynamics .You probably already know that anyway .

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  • Not everyone hates poetry. I love poetry. What's wrong with poetry?

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  • I agree with Des, the advantages of working at scale outweigh the perils of trying to cling on to small and unstable "corner shops". Continuity and quality of care come from having good operating models that ensure patients can access their preferred clinician, that the notes and care plans are clear and accessible so that when an urgent issue dictates, patients can access a primary care clinician who has access to all of that information rather than being told that there is no one available and therefore left to go to A+E or OOH. Scale allows us to work differently and develop more productive MDT working with community colleagues, with other clinicians who are also able to see patients on the front line (Nurse Practitioners, Chronic disease nurses, physiotherapists, mental health workers, pharmacists). Small units cant employ alternative clinicians or integrate effectively to change their model of working, larger single units can. We can free ourselves to be more effective as the consultant physicians in the community that we already are.
    The current contractual arrangements we have create high risks, small partnerships where care is dependent on 2-3-4 individuals, where patients' care is dependent on those individuals being fit, able, willing to continue, maintain their investment, recruit their replacements creates a massive risk to the partners' health and finances and to the population they serve, we are seeing practices fold, partners can go bankrupt, populations loose their primary care, bad for everyone.
    It is true that the lack of funding is partly to blame but Des is right in saying that higher pay would not in its self fix the problem as unless we work in a different way we will simply be paid more to endure the misery we have now so will opt to shorten the duration of the pain and do fewer days. We need both reform in the way we work and more adequate funding to solve the problems.
    Larger units do have a stronger voice. Put simply if a practice that cares for 40000 patients is threatening to fail there is no way that commissioners can ignore it and rely on being able to disperse the list. That voice is also much stronger in other commissioning forums, Primary Care has had such a small input to the STP's, this is in large part due to our desperate small units not having a single voice. Commissioners are clearly anxious about investing in primary care as they worry that any investment will disappear as profit and not lead to a tangible change in outcomes, they are also hamstrung by having to hold multiple different negotiations with multiple small providers. This leads to Primary Care being overlooked and investment passing us by in favour of secondary care where the conversation is often much easier, their pressures far easier to see due to their size and the relationships between commissioner and provider, far simpler.
    If you want what you have always got, stay small and pray the GPC can do something that they have been unable to do for the last 20 years and negotiate a GMS (General Medical Slavery) contract which works, fat chance, probably lots of tinkering round the edges as we have seen this year without addressing the open ended workload, decreasing reward, increasing risk and imminent collapse of the workforce.
    There is no option but to change. We have just merged and crated a 36000 patient practice, it's not been easy and there is a lot to do to make it work properly but we can see a future together that we could not see as 3 separate practices.

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