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Independents' Day

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


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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?


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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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