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The crisis in general practice is unprecedented

Dr Kailash Chand

Dr Kailash Chand

 

It's a big day for general practice - in the press. But for GPs, it's simply a snapshot of the many problems that are enveloped tightly within our profession. 

Which headline are you going to read first? If you work in general practice, you don't need to be picky - we live and breathe the realities behind the words. Day in, day out. No-one's under the illusion that any form of medicine has ever been easy - but today's coverage reiterates just how much the issues are escalating. 

Pulse's exclusive reveals that over half of GPs say they're working beyond safe levels, generally dealing with a third more patients than they believe they should be. The public's safety is, of course, every healthcare practitioner's priority, but this could seriously damage it. 

In a survey of 1,681 UK GPs, the safe limit of patients to see in a day was decided as 30, but in actuality it's more like 41. And one in ten deal with 60 or more patients in a day - which is typically 11 hours long, comprising of eight hours of clinical work and three of admin.

The intensity of workload pressures is similarly high, with 29% deeming their patient contacts 'very complex' and 37% 'fairly complex'.

This may be the first study of its kind, but I doubt GPs will be particularly surprised by the findings. And in a similar vein, the BBC are focusing on figures compiled by the Nuffield Trust that show that the NHS is seeing the first sustained fall in GP numbers for nearly 50 years. Strikingly, the number of GPs per 100,000 people dropped from 64.9 in 2014 to 60 last year.

Numbers haven't declined like this since the late 1960s. Despite a government commitment in 2015 to create 5,000 additional general practitioner posts by 2020, recent figures suggest a further deficit of over 1,000 full-time equivalent GPs. The crisis in general practice is unprecedented, with GPs increasingly leaving the profession due to feeling ’undervalued’. The NHS is haemorrhaging more general practitioners than are entering it.

You probably need no reminder as to why this is - but as this news shines a spotlight on, factors include intensity of workload; administrative burden; lack of recognition of the value of general practice; and the fear of litigation. A combined financial and staffing crisis could cause chaos in primary care for years and ultimately kill off general practice for good. Add to this discriminatory and confusing pension regulation that punishes GPs who take on more work, and it’s a recipe for disaster. GPs are in their role because they want to help people - but in these instances, it's we who need help ourselves. 

Unless GP shortages are substantially reduced, the NHS Long Term Plan can only be a wish list

Across the board, GPs are underpaid and overworked, and this subsequent demoralisation explains why the NHS is losing good people. They haven’t had a pay rise in seven years - even 1% uplift this year - a real-terms pay cut. The entire crop of GPs is undervalued, with consistently more work and expectations placed on them. The overall amount of GP consultations has increased by 15% over the past five years – three times the rate of increase in the number of GPs. The unprecedented pressure on primary care is undermining GPs’ resilience. If morale collapses, it will hammer retention. The workforce crisis consuming primary care could soon eclipse funding as the most serious problem.

We’ve known for several years that the NHS is short of GPs and nurses. Current figures suggest 10,000 extra nurses and almost 3,500 GPs are needed to meet the existing demands. On current trends, this will rise to nearly 30,000 nurses and over 7,000 GPs within five years. Unless GP shortages are substantially reduced, the NHS Long Term Plan can only be a wish list.

In my view, the new GP contract with fresh restructuring of primary care, like Andrew Lansley’s reforms, is not a panacea and will end in tears. Primary Care Networks (PCNs) will mean the end of GP autonomy and the partnership model. PCNs too, like its predecessors, PCTs and CCGs, are set up to fail by taking on too many tasks too quickly without trained staff. Overinflated expectations, as well as time-limited funding and support, would leave general practice in a worse position.

General practice is facing a ‘triple challenge’ of increasing demand, growing workforce shortages and pressure on finances, and I fear it may never recover from this crisis.

Dr Kailash Chand OBE is a retired GP in Tameside

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Readers' comments (30)





  • Maybe the solution is to have an honest appraisal of the current way we are employed.

    Partners are suffering (see last week’s report). This is because we are the only professionals in the health system who have to bear the increased costs of locums, cost-of-living increases, meet all demands for more work with less resource and so on.

    An AE consultant does not take home less money because their department is having to rely on locums or fill the shifts him/herself to dangerous levels. Yet GP partners do. I think we are still being punished for having the pay rise in 2004 and for the ill-judged comments made by some of those who negotiated the pay rise.

    Sensibly, this generation of GPs are voting with their feet - they are not becoming partners (many are not even becoming permanent salaried doctors).

    And before I am shouted down - I said this in 1991 when i first became a partner and wrote about it in an RCGP publication in 2008 - well before my own practice became a 'super practice'.

    I think we should be all salaried to PCNs - with funding matched against a hospital consultant with a Bronze ACCA (or whatever they are called nowadays). We should have our face to face clinical time capped at maximum 5 sessions and the remainder of the time should be management, teaching, training and so on. We can still work in small 'partnerships' but within the PCN and if funding is not enough to meet the salary requirements then it is not our responsibility to box and cox and work harder. It would be those who provide the funding to the PCN - so the CCG I suppose or NHSE or whoever are our pay masters at the time.

    F/T should be capped at 8 sessions per week (as it is with hospital doctors) and we could even decide that one of these sessions is an out of hours one (maybe with hospital doctors also helping us deliver out of hours care).

    Just some thoughts

    Clare


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  • Cobblers

    Lovely. Salaried servitude to the PCNs who are in the thrall of the DoH. No comments about managing patient/political demands and the GMC, CQC, Societal venom, Appraisal, Revalidation, Pensions and the host of the other shite that descends on us?

    You are tinkering Clare with what is now. It will fail. Ask all the Hospital doctors, who are mostly salaried, if they are happy?

    We need to do a dentist. Get away from the dead hand of Government. People will pay to see a doctor at a convenient time. A lot has to happen however and that includes allowing private GPs access to the NHS FP10s and referral to NHS hospitals.

    A good deal of thought needs to go into how the chronically ill, older and lower incomes would manage but it is not insuperable. Not least would the feckless have to put aside some money just in case. (My old grandmother born 1895 used to keep half a crown in a pot for that purpose even though the NHS had been running 12 years by then)

    However a sensible conversation is going to be next to impossible to have with Red Jerry and the MayBot in charge and Brexit still on the horizon.



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  • So if partnership were so great - why is it the current generation are not becoming one.

    PS I speak to hospital doctors every day. Their stressors are different. And there is a general malcontent amongst all doctors.

    GPs though - are suffering +++

    We have had 5% of all GPs in England through our service in 2 years.

    What does that tell you?

    The vast majority are partners - struggling to make ends meet. The other group are locum GPs, feeling isolated and lost.

    What is the current advantage of partnership ?

    We cant open when we want, have curtains we want, change our hours, change our referral criteria - we cant even decide who we team up with as we are forced into PCNs of CCGs or Federations making.

    Please tell me where the autonomy is?

    C

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  • The sensible thing to do would be for GPs to escape the NHS as many dentists were able to do and regain control over their workload. The NHS is the problem.

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  • Private dentists are having a tough time. Many are employed by large conglomerates. They have to do production line dentistry. It’s best to be in the NHS family.

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  • Research shows that the happiest professionals are those that have a skill that is in high demand and can charge a relatively high amount per hour worked. They also need to have control over their working hours and prefer self-employment. Interestingly they tend to be happiest when working by themselves, not with others. Guess who these people are?

    Plumbers and in particular those working on boilers and heating.

    “June 1, 2018
    It seems plumbers are guaranteed not to get that sinking feeling every time they go to work…

    A survey has revealed that Britain’s plumbers are the happiest professionals in the country. In fact, 55% of plumbers said they were ‘very happy’ in life.

    It seems tradespeople are way ahead in the happiness index because builders were next on 38%.

    The survey was commissioned by Boundless, an experiences company with a 94-year heritage.“

    “Those in the public sector are less happy than counterparts in the private sector”

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  • As Cobblers, Stelvio and Tony have said. The time to save Primary care was when the pay rise came in 2004 , but as many painfully learnt, doors were tightly shut and only the ' Of course my friend, this ' With a view jobbie will lead to a Partnership ' kind of empty jabber was what was flying about. Having learnt from the experience of others, the current generation of new GPs are voting with their feet when asked to carry what has now become a poisoned Chalice.The way things are going, can anyone sincerely advice any medical student to join a VTS? I cannot .

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  • We need to drastically reduce the work load of GPs.

    GPs are happiest with continuity of care looking after no more than 600 patients, as it is impossible to deliver the higher modern standards of care with any more. Payment should be per consultation, utilizing their full hospital experience. GPs have to be able to access nearly all investigations without referral. They should choose who they wish to work with and most importantly there HAS to be co-payment for numerous reasons, but obviously not for all patients. e.g. Canada

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  • The partnership model will die slowly as : hardly any young GPs will be partners, there will a joint and several liability 'crisis' for many partnerships mainly related to premises leases, super-practices which are run by corporate type, patient avoidant GPs are not real partnerships, PCN mean effectively the independent contractor model no longer exists, service charges after Brexit will go up exponentially due to struggling landlords and will bankrupt some practices, GP is totally over-managed and over-regulated mainly due to the power dynamics of the 'management class' GPs in Primary Care, who pay themselves large amounts of money to sit around in endless stupid meetings ( which could easily be done for free in lunch hours) who really should get down onto the frontline NOW and starting seeing some f****ing patients. Rant over.

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  • Cobblers

    Clare, we are agreed. In fact almost all of the GPs who post here would agree that GPs are suffering ++ and that young doctors are not choosing GP within the UK.

    What I was suggesting was to explore options for the future. Employment within the NHS as a GP or a Specialist is toxic and has no future as is.

    If not "Do a dentist" then maybe Dr Jonathan Reggler's Guernsey option from some time back is worth a review. GP Chambers? Having a debit card "Tap and see the GP" option, mind you £30 limit won't cut the mustard.






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  • There has been a war of attrition against partners since 2004 when market conditions dictated a correction in their favour.The mess should have been sorted then.Instead we have been serving a penance partnership has been starved of funding, over regulated, over managed.Going salaried will not solve this the same manager class that bully harass and abuse us now will do that to us as a salaried profession.The youngsters can see this is hospital and in gp land hence the increasing portfolio career.If being salaried is so good Claire look what they have done to junior Drs.Outside London there are massive holes in Hospital rotas due to the damage done to our Junior Dr corps.Claire the relationship between the medical profession and state in the UK is broken the last 15 years have well and truly done that.Your solution suits the Hurley group et al(conflict of interest methinks).Bridges have to be built with the whole of the profession there is a recruitment retention crisis across the whole of the profession at all grades.In general most of us do not trust the establishment(sorry but that includes you as a 'leading GP' at all.I do not know how you(the establishment)are going to fix the damage they have done.I for one can never forgive,and will leave the profession a decade of more before I should have.Ditto most of us I bet.Well done the establishment trying to make a compliant workforce you may well have destroyed it.Who will look after us when we are infirm and end of life!!!!

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  • I think the conversation here sums up the current state of UK practice. There is a huge gulf between the GP leadership/management and grass roots/ coal face GPs. There is a lack of faith that our leaders will achieve anything, and all GPs are seeing on the ground is everything getting worse, despite a string of constant policy announcements, reorganisation, funding tinkering- its all very reminiscent of Neville Chamberlains negotiations. Whether true or not, we perceive too many self-interests at the top and too many cosy relationships. Basically as grass roots GPs 'we aint buying' the message from our 'leading GPs' a term that makes us scoff here at the 'bottom', I hope that doesnt offend anyone. I left the UK as I could see the road ahead. I cannot see a future there. You will not be able to negotiate and meaningful change in terms and conditions with a softly softly approach. The best negotiation methodology in my opinion is to simply say nothing, stop talking, stop training more victims, and for us to quietly pack up, hand over the contracts and slip away. Let the politicians sort out the mess they are responsible for. A meaningful response from the government would be a 'statute of limitations' for the NHS to cut out the ridiculous legal fees, full government indemnity at no cost, and a 10% immediate uplift in the global sum with no strings attached..NONE.........if this pre-requisite wasn't met I wouldn't even bother responding and continue the exodus. The UK needs us more than we need them. I cannot see our RCGP leadership doing any of the above.... We need a Churchill type figure at this moment in time....and I don't see one so I'll stay down here where I am self employed, control my workload, my hours, I can charge as I see fit and I don't have to work with anyone I don't want to, and no I am not a plumber..... I also locum and I don't feel isolated or lost..... my phone has GPS...I'm in Canberra for training this weekend, Melbourne next weekend for another course, and excited about the next couple of years as there are numerous opportunities for keen and motivated doctors around here (None of which involve medical politics- its all clinical)....but sadly none of my UK colleagues with whom I remain in contact feel the same about their futures, they are all just counting down the days or looking for a way out. Given these people are some of the most intelligent and talented people in the UK this is a very sad state of affairs indeed.

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  • NHS partnership crap, NHS salaried crap
    What word links the 2?

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  • Spot on Curious.

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  • whereabouts are you, mr curious? whats life like down there?

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  • Cobblers

    Thank you Curious accurate comments. However "Let the politicians sort out the mess they are responsible for." That's a forever job. There is nothing a politician cannot make infinitely worse.

    On that hopeful thought.....

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  • I used to be married to a dentist Dr Gerada, I know how hard they work, how much they earn and how much regulatory nonsense they suffer. That's why I know GPs would be better-off out of the NHS.

    GP is in a crisis in large part because GP "leaders" like you are committed to saving the NHS at whatever the cost to GPs.

    Of course you would like to see an end to all those pesky Partners obstructing the expansion of the Hurley Group. Partnership is ok for you, but everyone else should be indentured Labour.

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  • This issue could be sorted out overnight if there was a real political understanding of the engulfing problems on the way and a consequent will. There are two solutions- income and autonomy. A 25% pay rise and abolition of the cqc. Stopping usually penny pinching interference from ccgs and blocking incessant gmc meddling.
    Clare Gerarda’s idea of salaried service would be better than the current worst of both worlds but wouldn’t be as good as the long-standing successful role of a well funded truly independent independent contractor status.

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  • And compared to what’s coming 25% is cheap.

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  • Denplan Denplan Denplan repeat after me GPplan GPplan GPplan

    For the price of a monthly mobile sim only plan of $25 think what we could provide

    The ppg was crap, the pag was crap, the pct was crap, the cig was crap the PCN will be crap. It's all bollocks

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  • Cobblers

    $25? 7:42.

    Make that Pounds maybe, but Guineas would be better. :-)

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  • Dear QB
    I am mostly in Tasmania but about to head up to WA for some rural and remote medicine. Tasmania is gorgeous... main barriers for new Drs coming down is the DWS restriction and a glut of their own medical students down here so you would need to move on this quickly . The advice I would give would depend on your own family circumstances. You ned to be wary of some unscrupulous clinic owners, stay away from the big cities which are over doctored. I would always do a short contract first to test the waters and dont move your family over until you are happy. Working salaried for a health board is a safe bet so you're sure of income and you can get accommodation provided - but these jobs entail a degree for ED work . If you are willing to go remote and work some antisocial hours then I am aware of GPs making in excess of $700k AUD / £375k GBP (£250k a year AFTER tax)but these will be in hot and dusty locations... and not great for a young family. Next week i will earn £6000 for a 6 day week..... but I finish at 3:00pm every day....indemnity is a lot cheaper down here, but you'll need the savings to pay for your medical insurance. Canada is also worth a look. If you are later on in your career New Zealand is fabulous, but pay not as good....

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  • Needless to say for me working salaried for Hurley Group is not an attractive offer..... I am my own boss here..... and love working alongside other 'own bosses' - and most people work collaboratively rather than subserviently, yes there are those who want you to work 'for them' rather than with them, but those are the types to avoid. I've found out about a few more interesting courses.... check out 'unconventional conventions' for your CPD! There is an enthusiasm for the job down here, more so in the rural areas. I've now a long list of places to go and work, Norfolk Island, King Island, Lord Howe...... you get paid to visit and work in some of the most beautiful, remote and ecologically interesting places in the world...... I can't think of any GP here who would go back to the UK unless forced to by family circumstances..... the schemes to attract GPs back are a complete waste of time....

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  • Apologies QB Im supposed to be one of those negative doomsayers / conspiracy theorists etc in the eyes of the RCGP so I didn't mean to let my enthusiasm slip out there...... I nearly made it sound like you can enjoy being a GP again....... I'll stick to more negative comments in future :-)

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  • If, knowing my state of health, you heard I was entered to run a marathon you would think I was mad. If you heard I was doing an unlimited and increasing amount of work for patients for a fixed payment you would think the same

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  • but there is one thing I want to save about the NHS: the lack of a link between what treatment or investigations etc I advise for my patient, and my remuneration. Can you get that in a private or insurance-based scheme?

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  • Clare Gerada is London centric like most of our “leaders” and has no idea what life is like beyond the boundaries of the Emerald City ( as do most of our useless politicians).
    She talks to doctors.....
    We’ll try talking to doctors in Plymouth or Blackpool for example where their professional life is unbelievably tough, yet they keep going in order to look after their patients despite no promises of gongs or garlands or airtime.
    Try listening Clare....

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  • 'Just retired' where in the country are you? Do your colleagues maintain their RCGP membership? Be interesting to know what the true figures are. Whats the picture in General practice like where you are? It would be interesting to hear the thoughts of your colleagues too......Jaimie (Ed) can you do a map of the UK and get GPs to put feedback, both good and bad as to whats happening in their locality? It would be good if we could get a more representative picture from all the readers so we can all see more clearly the state of general practice across the country to look for regional variations..... is there a London/ everywhere-else divide? What are RCGP membership levels like? There must be plenty of GPs who still keep it on as well as plenty of those who have ditched it.... are there age/gender /geographical factors between members and non members? Id love to know more.....

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  • I got the MRCGP in 1997 (7 years after taking a partnership) so that I could take my turn being a trainer. I paid the compulsory first year's subscription, and after reading a couple of the journals I ditched my membership.

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  • RCGP membership rising, unbelievably. Perhaps people daft enough to fund these parasites deserve to be dumped on.

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