Dr Katie Musgrave says the state of general practice is enough for her to consider industrial action
There has understandably been a lot of discussion in recent weeks about the GP contract imposition and insulting funding offer; alongside scepticism about the model of practice being trialled in NW London (the so-called Fullerisation of general practice).
It does rather appear there is a trajectory being followed. This involves a reduced dependence on GPs – in favour of a scaled up model, employing fewer of us but more allied health workers (and under greater NHSE control?).
But does a model of primary care without GPs at the centre becomes extortionately expensive and inefficient? Will it produce higher rates of secondary care referrals, repeat consultations, urgent admissions, and less satisfied (and less healthy) patients and doctors?
From where I’m standing, the UK cannot afford to make the career of a GP any more difficult than it currently is. Many of my colleagues are teetering on the edge: thinking constantly about taking early retirement, moving abroad, or simply doing something else. NHS England may like it or not – but GPs are rather fundamental to the running of the NHS. (That’s why so much work gets dumped on us – because we sort things out with minimal fuss.)
I’ve had the interesting experience in recent months of doing more locum work. The contrast between those practices which use online triage (such as Klinik), to determine who needs a GP appointment, versus the traditional model of using a receptionist taking on the day slots, is stark. If I were newly qualified, the prospect of doing full days of pre-triaged FTF appointments, where the simple cases have been given to an ANP, would be frankly terrifying. Unless the number of appointments in these sorts of sessions is significantly reduced (e.g. almost halved), they will prove a recipe for burnout.
As pressure on many surgeries builds, with increasing patient demand and reduced access to secondary care, more and more work is being passed to fewer GPs. The extra tasks, action points, squeezed in appointments, phone calls that should be FTF, text messages that should be phone calls – we are creating a pressure-cooker of a system that cannot continue. General practice will not survive with fewer GPs. We cannot be designed out of the system. Our leaders need to recognise that the politicians were right when they said the NHS needs more GPs.
We currently have a situation where NHS England and the government have given up – and now seem in cahoots to dismantle traditional partner-led GP surgeries, in favour of super practices using hubs and online triage. This is hated by many GPs and patients alike. (Perhaps only popular with those who get to sit behind a screen clicking the buttons – but not actually seeing the patients in the interminably complex clinics).
I think I just wanted to write something somewhere, in black and white, which spelt out that this is all madness. Practices desperately need adequate funding. Dr Claire Fuller’s proposals are not the solution. Our leaders are inept and misguided. Patients will suffer. GPs will leave in their droves.
I’m not a paid up member of the BMA, but even I think enough might finally be enough: and I would seriously consider joining industrial action.
The working conditions of GPs, and financial stability of GP surgeries, are of fundamental importance to the health of the nation. We need to make things better, and more sustainable. Tearing apart general practice is not the way. Perhaps it’s time we found our collective voice, and did something about it?
Dr Katie Musgrave is a GP in Devon
READERS' COMMENTS [12]
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You are quite correct – but will be disappointed – the writing has been on the wall for long enough – there will be no ‘collective voice’ – if any voice, it has been, is, and will be ‘a cry in the wilderness’.
KM – I believe you’re spot on that this Govt over the last decade has intentionally infected general practice with a disease that may cause its extinction, by underfunding.
No doubt the idea was that their oily, ready and willing private friends would step in and buy out the rescue of a mutated general practice, which would still be underwritten with taxpayers money.
The question to ask yourself is how would you feel if you did nothing?
Or you could vote (albeit in a weak BMA ballot) for IA and send the next Govt a strong message re funding. And for a slower evolutionary pace of change rather than the ugly mutant general practice we’re witnessing – when even Lord Toad sees fit to make ill informed pronouncements.
https://www.bma.org.uk/pay-and-contracts/contracts/gp-contract/gp-investment-in-england
Can you join industrial action if you are not a member of the BMA?
yes indeed you can.
I would agree with the premise that GPs are the backbone behind an effective and efficient Primary Care in the UK.
I would however disagree with online triage creating more complex patients and burnout. Since we introduced online triage 2 yrs ago it has been a massive blessing. If nothing else the significant stress reduction on reception staff and the clearly archaic way of making people mass telephone or wait at reception at 8am is a strong enough why to make that change. However we have also found seeing the correct patients much less stressful and more satisfying. We do not use PAs but were early adopters of CPCS and value Pharmacy First and other services to help with the simpler or certain specific issues.
Maybe it is because we adopted the 15mins per appt ( telephone or F2F) and limit appointment numbers to BMA recommended numbers. Maybe it is because we allow the Triage Doctor to decide if an appointment should be double or even longer. However I think it probably most importantly because we only allow the GPs to do the triage each morning and these same GPs see the patients so that the system autocorrects quickly and the GPs discuss amongst themselves where issues are and solve them quickly. GPs should always retain autonomy on how they work if they wish to avoid stress and burnout and also maintain a good service, and the loss of autonomy is the biggest risk in all these vague and top down attempts at change such as Fuller and Integrated neighbourhoods.
“I think I just wanted to write something somewhere, in black and white, which spelt out that this is all madness.”
I understand this feeling. Since the contract announcement, the thought of ‘What the bloody hell are they thinking?’ has been on repeat in my head. The one idea that I keep coming back to is that HMG and NHSE think that GPs are too costly to provide undifferentiated state funded primary healthcare.
The tricky thing is that individually and as a profession there is an element of sense in this. I have certainly had consultations where I have looked in an ear to confirm wax or felt powerless to solve a purely social presentation, and I have certainly questioned whether I was the best person to be doing this. Fundamentally, GP time is rightly expensive, given the training requirements and expertise provided. From a spreadsheet model, getting a GP to confirm ear wax would seem like asking a Kings Counsel to contest a parking ticket; they can do it but expensive.
For so many reasons (most of them explained by Katie above), I do not agree with this direction. The ability to effectively triage undifferentiated health needs is one of the most sophisticated skills within the whole of healthcare. I believe it is no coincidence that general practice and emergency medicine are the two areas that have struggled most in recent years. My impression is that healthcare needs are exploding, but that pathology is not (clearly there are areas of exception such as metabolic syndrome and low level mental health, but these demands are mostly shouldered by primary care anyway). Against this backdrop, general practice is seeing and filtering more than ever. Locally, referral rates are almost static, versus primary care activity which has climbed significantly. The ignorance of this situation, the enormous number of people being ‘held’ in primary care, is, I believe, driving a silent belief that GPs are mostly seeing trivial health problems and worried well. Sadly, the only way that I think this will come to light is when primary care is no longer a GP delivered service and secondary care becomes even more overwhelmed by the patients who fit the algorithm for referral, but might previously have been managed effectively by GPs.
The reduction in GP numbers, as a result of a hostile contractual environment, poor planning for training places and a well briefed media campaign is the real agenda. They think we cost too much. I think they are wrong.
Apologies for the splurge. I am furious/utterly confused by this situation. Katie, I very much appreciate your articles, which might not give answers, but demonstrate that we need to keep on asking questions.
Agree with you. If only our trade union had stood up for us – as they are paid to do – and our royal college had been more relevant and less tree-hugging then general practice would have not come to this
The ‘gatekeepers of Primary-Care’ have been purposely destroyed by ignorant carpetbagging politicians and gutter press journalism. ‘Secondary-Care’ need to brace themselves for the tsunami coming their way?
Divide and rule, NHSE has been very successful. Locums and salaried are struggling to get jobs, Partners for the time being enjoying support from ARRS, soon they will be hit hard too. Not sure how many locums and salaried will be up for industrial actions !
We keep turning the other cheek, knowing that it’s well insane to continue doing the same thing and expect different results.
Enough now.
I completely agree with your article Dr Musgrave and I completely (vehemently) disagree with posters continually pushing total triage as some kind of solution. To these people I say this is not the solution, its a sticking plaster, its the problem. YES Drs up and down the country are doing this, they have to. And YES for some of the Drs and managers in the practices doing it, its wonderful. But NO for the system as a whole its an feckin disaster. You don’t ALWAYS get it right, the times you don’t get it right don’t ALWAYS end an in obvious easily rectifiable observable “safety net-able” tragedy. Patients just get fed up, they don’t bother, they get angry, they turn up in A&E , ‘trivial’ attendances are delayed until they turn into emergencies, under qualified staff over refer, they get it wrong, they miss stuff, they over prescribe, the junior colleagues you are using to see these clinics of concentrated misery with the ‘trivia’ removed burn out whilst you are attending “important” system coordination meetings. You haven’t magically eradicated a lot of unnecessary work to concentrate on the important stuff..you’ve just shifted it somewhere else, be that in place or time. You are NOT as clever as you think. You cant not second guess the undifferentiated chaos of real life. YOU are the problem, destroying your profession with blinkers blinding you to all the nonsense you’re too “special” to deal with..that simply ends up somewhere else. The system is drowning in the crap you are filtering out. You have got it wrong. There is immense value and efficiency in first contact being with someone with top tier skill. You are not clever enough to design a protocol that fully encapsulates every possibility at presentation. You just aren’t.