Some time ago, I found myself explaining to my dad why general practice was in crisis. ‘People don’t like the job anymore’, I told him, ‘it’s become too hard’.
My father (a trusty accountant) couldn’t believe that this was true. What about his friend Tim? He was still practising at 60. What about Brian’s daughter? She seemed to enjoy her locum work in London. Fast forward three years, and I hear that Tim retired earlier than planned, and Brian’s daughter moved overseas with her husband’s work. She’s staying at home to look after the kids.
You see, if you make a job too difficult, people will find ways not to do it. It really is that simple.
We’re told that GP numbers are falling, that we can’t keep pace with patient demand for appointments. But why? The headcount is rising, yet individual GPs are opting to work fewer clinical sessions. As the job becomes more undoable, less enjoyable, and the profession is ever more demoralised, GPs make choices to protect themselves. As the job gets harder, we all choose to do a little less.
So is the problem the people, or is it the job itself? For many years, GPs have manfully held the fort. They’ve shouldered more and more work, propping up a faltering NHS. But as these GPs fall ill, burn out, or retire (exhausted) from the effort, how can we hope to keep the system afloat?
If we want to fix the crisis in general practice, we need to take a long, hard look at the job, and make it better. GPs need to start speaking more honestly about their struggles. Pretending everything is OK is no longer safe or acceptable.
The number one priority must be to reduce the demand coming into the service. Whether this is by an almighty investment in parallel community support services (unlikely to be forthcoming), fees for GP consultation (unpopular with many, especially our leaders), or by urgent workload review and reassignment (who will bother when the GP contract offers a free-for-all?), something urgently needs to be done to address the spiralling demand. While the demand remains, the supply of GPs will never keep pace. No-one can manage the job anymore – so it’s the job that needs to change.
A cap is needed on our appointment availability and a reliable system in place for diverting patients when our safe capacity has been met. Continuous extra funding to employ additional doctors and nurses (offer part-time and locum staff protected sessions and they would do more work). Across each region there should be paid time in educational programmes for GPs, where staff from different practices could meet and learn together, while decompressing and encouraging one another. The current status quo is exhausted GPs with no time to learn, reflect, or develop new skills. We too easily become isolated, demoralised and overwhelmed.
An uplift in investment to support the proportion of NHS work delivered by GPs is well overdue. GPs have been skating on thin ice for far too long. The danger is that the system moves into chaotic free-fall, which could easily bring down the entire NHS. This is no longer a theoretical risk or hyperbole – it will happen if changes aren’t made. If general practice is allowed to collapse, the health impacts will be truly catastrophic.
The interventions needed are actually relatively small, but they will take significant investment. An end to the limitless workload we’re drowning in. Time for education and camaraderie. Reduced bureaucracy in appraisal, and less interference from the CQC. Stronger defence against complaints and litigation. Fewer of the interminable ‘guidelines’ we increasingly feel bound by.
It’s not the case that ‘bigger is always better’ (can increase workload and reduce job satisfaction) – PCNs are proving largely ineffectual (aren’t these simply a route to encourage mergers?), and a salaried model won’t improve our conditions over the longer term (but would erode efficiencies). Online triage or artificial intelligence won’t provide the answer either, but may add extra layers of complexity leading to a bloated and inefficient system (see 111 for a case study). Simply give GPs autonomy, funding, a manageable workload, and leave us to do the rest.
It’s our job that needs fixing. But will anyone do it?
Dr Katie Musgrave is a newly-qualified GP in Devon and quality improvement fellow for the South West