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The obvious solution to the crisis in GP workload

It’s heartening to hear the various calls for a solution to the GP workload crisis. However, there still appears to be a lack of any coherent plan.

Could I suggest one? 

Bring in a small charge for seeing a GP. Possibly only £5 or £10 might be all that it would take – perhaps more for higher-rate taxpayers. There should be reductions or exemptions for children, pregnant women, certain health conditions, the elderly, and most deprived.

I believe that the BMA and the RCGP no longer accurately represent the opinions of grassroots GPs. Likewise, our LMC representatives seem to belong to a certain ‘type’ of GP. At times, I fear these fervent reps would sooner see their colleagues get into real low points, than contemplate the prospect of offering GPs the chance to vote nationally on bringing in a small consultation fee.

I’ve heard the arguments – the policy would cost more than it would earn; the vast majority of appointments are taken by exempt groups; the disincentive to seeking medical advice would discourage patients from seeking GP input which would lead to delayed diagnoses and greater expense in the long run…

But this isn’t about earning money. It’s about controlling demand. If supermarkets announced tomorrow that bread was free, don’t you think there might be a national shortage?

What I see on the ground is patients who cannot get through to their surgeries, let alone speak to their GP. We must not kid ourselves that the present system is universally providing a satisfactory service. Demand is spiralling, and GP are numbers falling. The system is failing. Wake up and smell the coffee.

And still, in my day-to-day work, so much of what I see is dominated by trivia – minor health anxieties, conditions that would have improved without treatment. Not to mention the over-medicalised who trail around circuits of different hospital departments, from neurology, to rheumatology, to gynaecology… 

I don’t blame the patients. The system has encouraged increased dependence over many years. And the phone-first triage system and e-consults perversely teach them that their GP isn’t that busy. But we are. We’re drowning.

Unfortunately, without some cost for seeking medical advice, we’ve communicated that our time is of no value. The public surely don’t consult their accountant, solicitor, or dentist anywhere near as freely as their GP. The status quo may also sadly communicate to our patients that their health isn’t of particular value, either. This isn’t true.  

We shouldn’t treat our bodies like a beat up old car that we can take back to the garage at any time and trade in for a new model, at no cost. 

As GPs battle to provide a service (of deteriorating quality, with reduced continuity), I cannot help but wonder if the smallest of interventions might make a transformational impact. After supermarkets brought in a 5p charge for single-use plastic bags, the average number of bags bought by customers fell from 140 per year in 2014 to four per year in 2020. A little nudge in one direction can make an enormous difference.

In addition, if we had more time to do our job more thoroughly, I’m certain that our patients would reap significant health benefits. Many could avoid unnecessary hospital admissions, outpatient referrals, or prescriptions. We could redistribute resources towards the most deprived, rather than accepting that poorer areas remain disproportionately under-doctored and under-resourced. A charge need not be a negative step – it could be implemented to focus healthcare where it’s most needed.

We might also find that our job would become more satisfying. Knowing that I had the time to do a proper job, offer palliative care, or personalised holistic support, would be a great encouragement to stick at my career. Being a GP is hard and gruelling. If the pressure from our excessive workload was reduced, GPs would have more mental space to innovate and develop services, practicing creativity and autonomy. We might have time to eat lunch, attend training days, or upskill in special interests. Imagine!

GP practices are collapsing, GPs are retiring in their droves. The endless promises of technological solutions, or remote consultations, won’t make a jot of difference. Fundamentally, the public needs to realise that their health is important, that our time is valuable, and that medical care does have a cost.  

Then we might, at last, be able to get back to providing high-quality and accessible medical care. The alternative is that we plod on, lamenting the workload crisis and the inaccessibility of our service, but being too cowardly to tackle this once and for all.

It’s time the profession were given a chance to vote on the issue.

Dr Katie Musgrave is a newly-qualified GP in Devon and quality improvement fellow for the South West


Dave Haddock 30 March, 2021 8:44 pm

Careful Katie, the Cardigans are a vindictive lot, if you challenge their holy free-at-the-point-of-abuse ideology they will be out to get you.

neo 99 30 March, 2021 9:00 pm

Great Post and a true reflection of the feelings of grassroot GPs. However, if you go back to pulse comments 15 years ago, you will see the same comments and sentiment. Nothing has changed and things are getting worse. Having worked in General Practice for 22 years, mostly as a partner trying to highlight these issues and make a difference, it is sad to say it really is not possible within the current monopolistic health structure we have. We have no power, we have no respect as a profession, we take what we are given, our leaders consider maintaining the status quo as a victory and we will continue regardless until there comes a time when you really can’t do it anymore. I have never come across a more constrained career choice than working within the NHS; an employer of sorts which is abusive to its employees and working partners, ironically in what should be a caring profession. The NHS really is an oxymoron. Sensible view like this will never get far up the chain of command.

Patrufini Duffy 30 March, 2021 10:42 pm

Written with clarity and grounded experience.
I agree. This ‘trivia’, self-entitlement and detachment from self-cafe and responsibility is quite honestly mind-numbingly dry, needing grey, empathetic, made up explanations and mindless safety netting documentation as if we were scared of what we truly know is happening…which is nothing. The truth Katie is the NHS is a clever business, disease earns money. The more sick people you code, the more you earn. And this perverse medicalised demand encourages happy privatisation and contract giving. GPs have become the surrogate parents, friends and boyfriends of so many, patients are to blame at times, the mindless chatter, it is nonsensical and non medical…and starts at the cradle with the infacol, aveeno, amoxicillin, sertraline and touch of daktacort en route, persuading the customer that nature is fickle and trivia has a solution.

David Banner 30 March, 2021 11:32 pm

– no political party would ever propose charging to see a GP, it would be electoral suicide. So it will never happen.
– it would be an administrative nightmare.
– if you exempt elderly, low income et al, then impact on workload negligible whilst the 10% of patients who already struggle to see us will be punished further.
– patient resentment of us is already running high, this would put it into orbit.
– would anyone refuse to see a patient who wouldn’t/couldn’t pay?
– patient entitlement will rise, and good luck trying to get them out the door on time…..”I paid for this appointment, so stuff your 10 minutes, I’m getting my money’s worth”.

Helen Horton 31 March, 2021 9:38 am


James Cuthbertson 31 March, 2021 10:02 am

Economics dictates it’s all or nothing.
Token charges will lead to entitlement (read the article in “freakenomics” about a nursery who did this to discourage late pickups).
Sad fact is a significant minority of patients don’t deserve a taxpayer funded free at point of use health service.
All it takes is a brief amount of self control and respect for the system from patients and it would continue to work well- sadly not forthcoming.

John Glasspool 31 March, 2021 2:59 pm

BMA and RCGP never represented grassroots GPs.
It would never work in the UK for reasons given above. It does work in Australia.

Cameron Wilson 31 March, 2021 4:08 pm

You are of course totally correct, Katie, hopefully in your not too distant future changes will be made that you and your generation of GP’s deserve. Seems too sensible to adopt a system that works in other countries, that delivers better care and more satisfaction for doctors and patients! Our leaders have failed by not developing an alternative model and not surprisingly the system will implode. Something is wrong when educated, motivated individuals do not want to take on a well renumerated post. It used to be said pay and they will come however, I start to doubt this is indeed the case! You have a vision that older ones have sadly dismissed, I sincerely wish you every success should you attempt to lead!

Lee Blackburn 31 March, 2021 7:01 pm

Can’t remember the last time I commented. Make of that what you will. As much as I hate to admit it you are absolutely right. My respect for the NHS and GP in particular over recent times is at rock bottom. There are many forces at play but we should call it as it is- decidedly unsatisfactory. This is not the fault of GP I must state. I have finally jumped ship for, hopefully, sunnier climes, but I fear the worst for our patients moving forwards. This NHS really is a third rate service pretending to be otherwise, and I have had good reason to utilise both primary and secondary care recently and I am left disgusted with the service. Maybe others have a happier story to tell but on the whole I think we are in trouble. Third world service. There. I’ve said it. Good luck everyone. I’m headed to somewhere where people pay and receive what they expect. Change is needed, but not the usual crap.

Akan Eka 31 March, 2021 7:46 pm

Thanks for this. I am happy I am not the only one who thinks the exact same thing. The obvious solution to me.

Bettina Schoenberger 1 April, 2021 5:59 am

They tried the obvious solution in Germany, Katie.
10 Euro copayment, maximum quarterly ie 4 times per year. It failed.

Amit Sinha 1 April, 2021 10:59 am

I am afraid this would never happen. The NHS is like a trophy. It is now rusting and crumbling, but will remain a show piece in the cupboards of every government, which comes in power. It is a treasure for all the public, a huge minting machine for the GMC and the UK treasury, with thousands of foreign trained doctors and nurses together with the local graduates propping it up and ready to lay their lives for it. Asking for £5 for each visit to a GP is taboo. Don’t you ever mention it again.

Peter Morris 1 April, 2021 5:43 pm

Carrying your analogy with accountants and solicitors foward. Most will tell you that 80% of their profit comes from 20% of their clients.The rest for the most part don’t really need an accountant or solicitor at all.But without seeing 100% you don’t know who the 20% are. 80% of what GP’s do could be done by a social worker or paramedic.But you cant’t tell…… you get my point.

Samuel Liddle 3 April, 2021 11:12 am

I agree Katie, and I consider myself politically left of centre. I can’t see any other reasonable way to control demand and empower self management for trivia.

Nigel Rowell 3 April, 2021 11:15 am

We’ve had this debate for at least the 37 years I’ve been qualified, only now you have the complexities of phone triage, e-consults, videos and the rest. Charge for one and you would have to charge for all…
Unlikely for reasons clearly stated by other readers.

Nick Mann 3 April, 2021 12:11 pm

Access according to wealth not need. Checking patients’ earnings when booking appointments. Hidden unmet need. Dr Musgrave’s over-simplistic and flawed assertion will not help demand management, it will facilitate queue-jumping and also increase A+E attendances.
Charging is a regressive and short-sighted demand management scheme which will primarily disadvantage those who demographically have the poorest health. Devon is not London or Bradford.
The wide evidence that charging is invidious and harmful by excluding disadvantaged groups is ignored in favour of specious comparison with plastic bags.
Call me a cardigan if you like, but with 30yrs experience and attention to the evidence, I’d rather be wearing a cardigan than blinkers and earmuffs.

Jonathan Heatley 3 April, 2021 12:40 pm

I’m sorry to disagree with a lot of the above sentiments. Firstly I have worked up to the age of 65 full time and plan to carry on for another 10 years as I enjoy it so much. I will not dignify trivia with more than a minute or so, and patients soon learn either not to make trivial demands or if they do they get a quick reassurance taking a minute or so.
Nowhere in GP training does there seem to be any guidance on how to get through work load quickly and efficiently. There is the self righteous cry ‘all my patients deserve a gold standard appointment’- maybe even 15 or 20 minutes worth and those who claim this burn out and leave. I don’t think this serves the public. Its trying to give a gold standard service with brass funding. No wonder its adherents are disillusioned or that doctors are not keen to be partners
and full time GPs any more.
But don’t forget there is a type of GP out there who still enjoys the job and keeps going. Perhaps its time their way of working is looked at to see what new GPs can learn from it to help them in their career?

CAROLINE WARREN 3 April, 2021 5:59 pm

Surely it would be better to accurately monitor the demand through suitable telephony systems which show the number of abandoned attempts at contact, counting the time spent in responding to e-consult, reviewing results and other documentation as well as recording the appointment data to truly reflect the current workload and enable appropriate funding for the service. I am still not clear why the demand for locums is still not where it was pre covid if GPs have an even bigger workload now post covid.

Vinci Ho 4 April, 2021 8:51 am

Ok , let’s vote (again)😎

David Church 6 April, 2021 10:37 am

The real answer is not to force an extra administrative nightmare on GP surgeries, but to have proper Clinical Governance if patient education:- throw out the guys who produce endless TV adverts encouraging attendance for every sniffle or dicomfort, or normal appearance, and replace with GP-led proper patent education on how to use the system – and indeed proper sensible school syllabus for personal heatlh and hygeine at school, for every child who registers to attend: and as part of it, include to whom to turn to seek advice, family, priests, SW, etc, before GPs. (unless it’s actually a medical problem!

Patrufini Duffy 6 April, 2021 10:54 pm

The problem GPs have is they can’t get their head around money. It’s not your issue. The patient transacts with the Government. Not you. Like ordering a covid test, isn’t your problem.

Patrufini Duffy 6 April, 2021 10:59 pm

I printed this and shared with the office. Rare to see an insightful GP not on autopilot – sheep don’t want or like to see the NHS matrix, they keep giving out stale bread and feeding this “dependance” with their infacol, buscopan, amoxicillin and 10mg of citalopram.

Harry Franks 7 April, 2021 6:48 am

Better still – sever all links with the government. Doctors and patients were able to function perfectly well for thousands of years before the government became involved in healthcare a few decades ago. The inevitable socialist decay is what we are now all experiencing. Unfortunately most GPs are socialists so their dependence on more government will continue. “Going private” is a taboo