We must transform medical training to re-establish the pre-eminence of primary care
A failure to reverse the looming GP workforce crisis will wreck havoc across the NHS, Dr Mark Purvis warns
The news that GP vacancy rates at practices have doubled over the last year should concern ourselves, our patients and politicians. A GP shortage has an impact on the entire NHS because 95% of first contacts with it are resolved at primary care level. In particular, general practice teams deliver the bulk of NHS care for patients with long-term conditions.
A workforce crisis in primary care would have a catastrophic knock-on effect on secondary care too. Even a trivial reduction in primary care capacity would overwhelm A&E departments, create a bed crisis in hospitals and cause financial meltdown in the health economy. While the most recent GP patient surveys show high levels of patient satisfaction with access to primary care – suggesting we still, for now, have an adequate supply of GPs – I believe that a shortage is imminent.
Any GP will be able to describe what it feels like to be on the end of increased demand. A rising demand for healthcare is being driven by the needs of an ageing population, an increasing prevalence of obesity and the rise of psychosocial ill health during these times of economic hardship. This heightened workload coincides with a drive within the NHS for greater productivity, shifting even more work from secondary into primary care.
So we see bed closures, planned secondary care staff reductions and an emphasis on community-based and ambulatory care rather than expensive and risky hospital inpatient care. Meanwhile, the widening role of the GP in commissioning is taking us away from face-to-face patient contact.
Lack of career structure
An increased demand for general practice would be fine if there were enough newly qualified GPs to meet that demand. But there is now attrition during training, mirrored by significant attrition in the early years of a GP career – with the BMA's recent GP survey finding evidence of poor morale and frustration.1 The lack of a clear career progression in general practice, combined with international demand for UK-trained doctors and surveys showing young GPs are preparing to leave the NHS, sends a clear signal we ignore at our peril.
Those young doctors who do embark on a career as a GP are spending less time working in general practice than previous generations. This is not due to gender changes in the GP workforce, but is part of an ongoing trend for both male and female GPs to work less than full time, take career breaks and develop interests outside general practice. All this comes at a time when we are facing the imminent retirement of many doctors, with a greater percentage of GPs approaching retirement age than at any stage in the last 10 years2 and, according to the BMA survey, a large number of doctors contemplating early retirement in the face of pension changes, revalidation and the NHS reforms.
The NHS has been slow to respond. While we have increased GP training capacity, working-time legislation in recent years has resulted in an increase in training opportunities in secondary care specialties where there is workforce oversupply, resulting in reduced applications to GP training, particularly from UK graduates.
We should commission increased multi-professional training capacity in primary care so almost all healthcare workers can receive part of their training in a generalist, family practice-based context, increasing the potential for skill mix by widening the range of healthcare workers equipped to be able to work alongside GPs. We need a renewed emphasis on primary care in undergraduate training so our workforce is less reliant on international supply. And we must convince commissioners to reduce the number of doctors training in oversupplied hospital-based specialties.
GPs understand the difference we can make to the patients and communities we serve. The time has come for us to re-establish the pre-eminence of primary care, and recognise its value to the NHS.
Dr Mark Purvis is a GP in Bradford and director of postgraduate GP education at Yorkshire and the Humber Postgraduate Deanery
1 BMA. National survey of GP opinion 2011
2 Centre for Workforce Intelligence. Medical specialty fact sheet – general practice. 2011