Victoria Tzortziou Brown: ‘Increasing GP capacity must come before arbitrary access targets’

In our latest podcast episode, Pulse editor Sofia Lind caught up with the new RCGP chair Professor Victoria Tzortziou Brown to discuss her priorities for her term, as well as the college’s role in negotiating the new GMS contract, the unemployment crisis, and how increasing access alone is not enough.

Q: The first question I wanted to ask you was about the prioritisation of UK graduates for GP training, which is becoming legislation. Given the context of your own background as an international medical graduate (IMG) GP, what do you think about that?

Victoria Tzortziou Brown: I think it’s an important issue. It’s important to start by recognising the reality of the situation that we are in right now because we are seeing record levels of competition for a limited number of GP training places. And this is at exactly the same time as demand for GP services is growing and patients are finding it harder to access care. So as a college, we understand why the Government is looking at emergency measures and why prioritising graduates from UK medical schools is being considered as part of this. Because when competition is this intense, it’s reasonable to ask how public investment in medical education can best support a sustainable NHS workforce.

But at the same time, it is absolutely critical to be clear about the role that IMGs play, and especially in general practice; over half of our GP registrars are IMGs. They make a huge and vital contribution to the NHS and to general practice in particular. So, any conversation about prioritisation has to acknowledge that reality and avoid sending a message that their contribution is somehow less valued.

I think that’s why implementation really matters with policies. Any changes must be delivered fairly and transparently in a way that protects the highest standards in general practice – which we try to maintain as a college.

Within all of that, I would like to say strongly that prioritisation on its own is not really the solution. We urgently need to increase the number of GP training places overall, and that means tackling the real barriers to expansion, which are: shortage of trainers; lack of space in practices; and the pressures that practices are already under. Finally, we need to think what happens after GPs are trained – there must be enough appropriate roles for newly-qualified GPs. We need to remove any unnecessary barriers there. For IMGs, there can be inconsistent visa arrangements, which can make this very difficult. Addressing these issues is important if we really want to grow the GP workforce and retain those that we train.

In summary, we understand these proposals, but they have to sit alongside a much bigger, more ambitious plan of growing the GP workforce.

Q: And the college is going to be helping to advise the Government on the implementation, alongside the BMA?

VTB: Yeah, absolutely. We are very keen to work in collaboration to address all these issues that I mentioned.

Q: You touched upon GP work already, and one thing that the RCGP has asked for in the past is for the updated workforce plan to include a strategy for GP retention. What do you think could incentivise experienced GPS to stay on?

VTB: When we talk about retention, first of all, I think it’s important to listen to what GPs are telling us. The college runs surveys and in a recent survey, one third of GPs said that they are unlikely to still be working in general practice in five years’ time. Over half of those planning to leave said that a reduction in administrative workload would make them more likely to stay. Also, reducing a sustainable clinical workload is an important factor for them, as well as making the role of GP partners less risky. So, if we are losing too many highly-trained GPs now – very experienced GPS – it is important to address those issues that really matter to them.

I think that’s where the upcoming workforce plan really matters. We need to see targeted retention initiatives within that plan including commitments to: reduce unnecessary bureaucracy; improve interface working – we know this creates so much tension and affects our everyday working lives; and improve flexibility, which matters at all the career stages, but especially in mid- and late careers. Retention initiatives should also offer opportunities for portfolio careers, and what I mean by that is opportunities to combine clinical practise with research, education, training, leadership and specialist interests. We know that these aspects give more variety to our roles and make people more likely to stay long term.  

Q: You make two key points there. There’s admin – both bureaucracy and clinical workload – and then there’s the other side with flexibility and liability.

In terms of the unemployment problem, we talk a lot now about how GPs can’t find substantive employment. The obvious solution would be to give money to practices so that they can afford to hire more GPs, but the Government seems very unwilling to do that. Are there any other tangible solutions – or is that the one which they’re missing?

VTB: For me, underemployment is the clearest example of a system not working properly because we are training all these GPs and then are unable to retain them. It’s not just that they cannot find any work; there are GPs that want to do more work – that’s when we talk about underemployment, when GPs cannot increase the number of their sessions.

Again, we need to listen to what our practices say. In our survey of practice managers, 61% said that their practice needs to expand its workforce within 12 months to meet patient need. But more than 90% of those said that the lack of core funding was the main barrier preventing them from doing so. So ring-fenced funding would definitely help.

We keep hearing that there is no new money available – if this is the case, then funding will probably need to be found by redistributing the allocations across the NHS a bit more fairly. Care is increasingly being shifted from hospitals into the community, but funding does not follow patients. Clinical pathways are continuously being redesigned, but they are not properly costed and resourced. I think if we really want to deliver more care closer to home, we cannot just keep transferring work in an unfunded way.

So, it is a matter of funding, and we need to think how we can allocate the existing resources more appropriately and fairly if there is not new money.

Q: You talked there about ring fencing. Your predecessor, Kamila Hawthorne, talked about getting rid of the ARRS. Is that a position you share?

VTB: At the moment, the ARRS is used as a solution to the current shortage of doctors, but I don’t think this is what it was there to do. It is important that we have urgent improvement to the current ARRS, which should include widening the eligibility criteria and addressing the generally low pay scales that make recruitment and retention quite difficult. But what practices are telling us – very clearly – is that the biggest problem is lack of core funding.

As a college, we have consistently called for practices to have the funding that they need to employ GPs within the core funding. I think this is important if we want to see the GP-to-patient ratios going to safe levels and also provide the access – that is so important to policymakers – going forward.

Q: So instead of ring-fencing funding to non-GPs, you’d be OK with funding being ring-fenced to hire GPs?

VTB: Yes, it needs to be ring-fenced for GPs. We need more GPs, and we have GPs out there who are unable to find work.

Q: The RCGP has been invited to take part in the consultation of what should be in the 2026/27 GP contract. So far, I’ve been very impressed with how you’ve handled that politically because it was a little bit sensitive. Were you surprised at being invited to be part of the process?

VTB: We were surprised. We didn’t expect it. Saying this, we have always asked for more collaboration and involvement into how care is being designed and planned going forward. We didn’t expect this to come for the GP contract, but when we got the invite, we were quite clear on the our role. We saw our role as a college in terms of ensuring patient safety, that we support quality of care and being honest about the growing gap between patient need and the resources that are currently available within general practice.

Our role is not to negotiate the terms and conditions of the contract; that is rightly the role of the BMA. We were quite clear on that, and I think this has helped to engage in a constructive way because everybody knew where we stood. We have tried to draw on evidence from what our members are telling us: what are the issues, and what is and isn’t working on the ground so that we try to address this through the upcoming contract.

Q: What are some of the key messages?

VTB: Of course, I cannot go into much detail because the whole thing is confidential and we have respected this. But what I can say is that there are some clear principles that we have been quite vocal about, ones that we think are important to shape not just this future contract, but any future contract going forward.

The first is that capacity must come before targets. We think that in order for there to be sustainable improvements in access, there must be an increase in the existing GP clinical capacity. No amount of contractual ambition can really compensate for a workforce that is already very overstretched.

Secondly, access must go hand in hand with quality and continuity. We know that fast access is important to some patients, but it cannot come at the expense of continuity of care, patient safety and a GP’s clinical judgement.

The third principle is that equity must be built in by design. Contractual mechanisms sometimes disadvantage practices serving more deprived or complex populations, and we know that there the workload is a lot higher and need is greater. We cannot afford to further widen health inequalities.

Fourth, reporting needs to be proportionate. So far, we have experienced excessive micromanagement, box ticking and performance management which does not just reduce the time that we spend with patients but also affects GP morale.

And finally, workforce well-being and retention must be central because people are tired. Contracts that increase pressure without addressing workload, I think, will simply accelerate people leaving the profession, so we need the contract to be a conduit of improving quality of care rather than increasing pressure on the ground.

Q: You talked about future contracts there. Do you know if the RCGP will also be asked to take part in the consultations for the wholesale new GMS contract or not?

VTB: We hope we will be involved. This process so far has been constructive and helpful, and we would like to be involved. But again, our role will be very clear. We come from the angle of quality and standards and bringing our members inside; rather than having the role of the negotiator on the terms and conditions and the actual funding allocation, which is very much the BMA’s territory. So, we will work with the BMA on the wholesale new GMS contract as well.

Q: The NHS is currently working towards realising the 10-year plan. Do you think that GPs A) are being sufficiently informed about what’s going on and brought along; and B) will be leading these new teams?

VTB: Well, as a college in principle we have supported the ambition – both of bringing care from hospital to the community and also this kind of neighbourhood working. But what we mean by neighbourhood working is essentially bringing services closer together; community services in general practice to support our communities and patients.

But as you said, what is critical is clarity of purpose – being clear on what neighbourhoods [are] really trying to achieve. We haven’t seen that clarity as of yet and this can create issues with engagement. As I said before, in every policy implementation it is important that any new or redesigned pathways must be properly costed and co-designed with the relevant clinicians. Of course, GPs should be leading a lot of this work – as well as patients.

It should also be quite clear what is it that we are trying to achieve – so that we can allocate adequate resources, but also agree on outcomes that then we can monitor and evaluate and understand whether what we are trying to do is working or not. This has not happened in a systematic way. It may have happened in the existing pilots that are there at the moment, but we haven’t received much information on those. So, it’s quite difficult to say whether good progress has been made.

What I will say is that: if neighbourhoods are to be successful, GPs need to remain at the centre of care – with continuity of care being preserved and us shaping how services develop locally. Any redesign needs to be evidence based and co-produced so that any extra services in the neighbourhood meaningfully add to the care that is provided by general practice – rather than result in increased complexity and fragmentation to what we already have.

Q: The BMA is currently in dispute with the Government about the 10-year plan and access targets – which we have already touched upon. Where do you stand on that? How have the changes to online access gone in your practice? Do you do you feel supportive of taking action? Would you be willing to take collective action at all?

VTB: As a college, we don’t really comment on collective action because this is very much a BMA decision and we wouldn’t want to interfere or shape the way that things are moving, because I think clarity of roles is important.

However, access versus continuity is a very interesting debate. A lot of the time this is framed as a simple choice between the two when in reality, we know that patients want both. However, the political focus has tended to prioritise rapid access above everything else, and that often comes at the expense of long-term continuous care that many patients need; especially those with complex needs and long-term conditions.

We know that there is a strong body of evidence on the benefits of continuity and within that evidence it shows that continuity actually helps us to control demand – so it can improve access! So, although we absolutely agree that every patient should be able to get a timely GP appointment when they need one, we need to be careful about arbitrary targets that don’t solve the underlying problem; the fact that we need to have enough GP capacity. If we have enough GP capacity, continuity, access and quality of care, all will be better.

So, I think by playing with contractual targets, we are not necessarily addressing what the key issue is there, which is that we need more GPs.

Q: Absolutely. The Labour Government itself has also talked about the importance of continuity, but it seems like their actions are not in line with their ambitions on that. So how can GPs get through to them? How can the RCGP and BMA successfully get through to the Government on that issue?

VTB: We keep mentioning it to them and keep bringing more evidence to make the case. Policymakers seem to have started to understand its importance. I think the link between continuity and demand management has not been understood very well yet, and that the economic efficiency benefits for the rest of the system probably have not been understood at policy level either.

I think we need to make a much stronger case for that and hopefully there will be a lot more evidence coming to support this as well. Then I think it will become clear that just quick access care-fragmenting ‘taskification’ is not really the answer. We need to provide meaningful care at the end of the day and we need relational care in order to do that.

Q: Those seem like some really solid points to put forward. How have the consultations gone so far – has it been as you had hoped?

VTB: We submitted our report and have had meetings with the DHSC and NHSE. We discussed the proposed changes, and now we are waiting for any next steps. So, it’s a little early to say. But I think from now on, the GPC will probably have a bigger role to play in terms of negotiating the detail.

Q: I’m going to pivot a little bit now: you are a GP with a special interest in exercise and sports medicine. Do you still have time to focus on that role? And are there any interesting new developments in the area?

VTB: Up until now, I worked within the interface service, a musculoskeletal service, and I’m still involved in research within sports and exercise medicine. I’m very interested in the subject, especially as there is increasing evidence on the impact – not just in elite sport, but with everyday exercise – of physical activity on health. Therefore, I think it’s very relevant to GPs.

We are seeing high-quality studies show that exercise can have a meaningful impact on mental health, cardiovascular health and mortality. And I think this is important when there is so much polypharmacy and over-medicalisation. What all of this highlights is that we need to invest more in research, but also the delivery of these non-pharmacological interventions. A lot of the time our main kind of management is medication, and we know that a lot of our patients are on many many medications and this has its own unintended consequences. So, the whole area feels a lot more relevant, and I think it will only become more so as we progress.

This interview has been edited for clarity and length.

Professor Victoria Tzortziou Brown is a GP in London and chair of the RCGP council.

You can listen to Professor Tzortziou Brown’s interview on the latest episode of the Pulse in Focus: The Podcast for GPs.