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What is in the Conservatives’ in-tray for general practice?


Prime Minister Boris Johnson


The time for pledges is over and the newly elected Conservative government must now demonstrate how they are going to fix unsustainable GP workload pressures.

In his jovial pre-breakfast speech at 7.20am this morning Prime Minister Boris Johnson promised ‘the NHS is this One Nation’s Conservative government’s top priority’.

In scenes resembling a school assembly supporters responded in unison to Mr Johnson’s rhetorical questions affirming the Tories would deliver 50 million more GP appointments, 40 new hospitals and £650million a week extra funding.

But the devil is in the detail and just how these ambitious plans will materialise remains shrouded in mystery.

GP numbers

Health secretary Matt Hancock has promised to find an extra 6,000 GPs by 2023/24 to reduce appointment waiting times which exceeded an average two weeks for the first time earlier this year.

 

 

His predecessor Jeremy Hunt promised in 2015 to recruit 5,000 GPs by 2020, and 1,000 have been lost during that time, so this new pledge is actually an extension to Mr Hunt’s deadline.

Mr Hancock has admitted these 6,000 new recruits include 3,000 trainees, who will not be practice-ready in five years time.

And even counting trainee GP figures, recruitment would have to increase by a staggering 17% in that time frame, when currently numbers have only risen by 1.3% since 2015.

Back in 2015 there were 34,429 GPs and trainees and four years later the figure stands at 34,862 which is hardly a massive endorsement of successful Conservative policy.

In an exclusive interview with Pulse, Mr Hancock admitted that numbers were rising ‘slowly’ since he took over as health secretary 18 months ago but at that time total number of GPs were falling.

There has been some success. The number of GP trainee places beat the annual target for a second consecutive year in 2019 with Health Education England confirming 3,538 had been accepted. But the Royal College of GPs has warned that a steady flow of 5,000 a year is needed to avoid severe GP shortages.

And even if the Government does magic up an additional 3,000 trainees, there is very little guarantee that these will convert to full time equivalent GPs.

NHS primary care director Dr Nikita Kanani pointed out at Pulse Live this year for every three GP trainees only one will become a trained FTE GP.

Even more concerning is a new study by the King’s Fund revealing only one in 20 GP trainees see themselves working full time in general practice in ten years’ time – half the percentage of the 2016 cohort. Only a quarter see themselves working full time in general practice after a year which makes the Conservative targets even more unattainable.

GP retention

Even if by some miracle the government does reach its GP trainee target this is unlikely to offset the numbers of GPs leaving in their droves and surgeries being closed.

The Kings Fund has warned ‘the volume and intensity of GP workloads is driving many to either reduce hours or leave the profession altogether’.

Although more GPs than ever are being trained there has actually been a 2% decrease in the number of permanent, FTE GPs in the past year and 6.2% fewer in September 2019 than in 2015.

Around 30% of GPs have reduced their hours in the past year according to a report by the GMC.

In a letter to the Prime Minister following the general election result, BMA chair Chaand Nagpaul warned ‘while your pledge to increase workforce numbers reflect the dire situation, they fail to reflect the realities of recruitment and the time it takes to train new clinicians’.

RCGP chair Professor Martin Marshall agrees and said the workforce had been in crisis for a long time with ‘many of the more experienced GPs burning out long before retirement’.

Effective retention strategies are required to keep people in the profession longer such as reducing the ‘undoable workload’ which saw the number of GP appointments in England rise to their highest level October – 30.8m in a single month.

Your pledges fail to reflect the realities of recruitment and the time it takes to train new clinicians

Dr Chaand Nagpaul

But it is unclear from the Conservative manifesto just how this will be achieved. Mr Hancock made vague references to reducing pressure on GP staff through triage and technology and the party has pledged to invest £4.5bn per year in the long-term plan to general practice. However, the BMA believe the Conservative NHS commitment will fall short of £6.2bn per year by 2023/24.

There are also pledges to use £300m a year to increase non-GP staff in general practice by 6,000 on top of the 20,000 pledged as part of the GP contract. But other than an ambiguous assurance to reduce bureaucracy around the NHS visa to recruit international staff it is unclear how full time GP and related practice staff will be recruited.

Pension reform

The Conservatives have pledged that the NHS would pay for extra tax charges incurred by doctors who work additional shifts this winter.

According to the BMA, the most immediate threat to GP capacity is the ‘punitive pensions policies’ and the Government has insisted it will hold a review of the taper problem within its first 30 days.

An indignant Dr Nagpaul told ITV News today the best way to retain GPs would be to scrap the pension tax restrictions which prevent doctors from working extra hours.

In his letter to Mr Johnson he urged the Treasury ‘to take action to address the cumulative impact of the taper, annual allowance and lifetime allowance’.

’The BMA is absolutely clear that the only solution to the current unjustifiable problem impacting doctors and ultimately patient waiting times, is removal of the taper and annual allowance for defined benefit schemes such as the NHS Pension Scheme. This is in line with recommendations by the government’s own advisory body, the Office of Tax Simplification. Other solutions such as increasing the threshold income level, scrapping the taper and pension flexibilities will not completely solve the problem.

Without addressing this thorny issue it is highly unlikely that GP retention will remain stable, let alone improve.

Another notable absence in the Conservative manifesto were pledges for public health prevention measures. Whether the government intends to tackle obesity, smoking and rising mental health conditions, remains to be seen, but they are clearly not a priority.

Brexit and beyond

This was of course a Brexit campaign and the BMA has consistently warned about the impact on the medical workforce and patients if the UK leaves the European Union.

Mr Johnson is now full armed to push through a January 31 Brexit but, say the BMA, for the sake of the nation’s health, we had better avoid a no deal.