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Evolve or die

As I was driving my 15-year-old son to his climbing lesson this weekend, I told him I was under pressure to write a blog before Monday and would do it while waiting for him. His response? ‘GPs’ jobs are changing from their intended purpose, and they need to embrace this or they’re going to become obsolete.’

I was floored by this statement and demanded an explanation. He proceeded to talk about artificial intelligence and econsults, and described a future I can only describe as transactional medicine. 

Unsurprisingly, I don’t come home every night and talk to my kids about the crisis in general practice. My son has proofread the odd blog, but his all-too realistic insight was truly uncanny. His words came two days after my own reflections, at a GPC England meeting, about the future of general practice. 

Despite what others may say, I strongly believe our future depends on the £££ attached to funding us. I reject any notion that funding will not fix the problems associated with workforce and workload. These platitudes are usually spouted by commissioners who don’t wish to stick their hand in their pocket to pay us our market worth. It is disingenuous to ignore the correlation between funding and workforce, and workforce and workload. 

If the global sum was tripled overnight, we could double the number of GPs and offer them an hourly rate commensurate with their worth, while ensuring a manageable workload. I could also offer a more family-friendly working day, which was my driver for proposing the contentious ‘Dolly Parton’ LMC motion of a 9 to 5 core contract. The pool of GPs for this is right there under our noses – in CCGs, in appraiser roles and in the private sector, where the hourly rate is far greater than at the emotionally draining coalface. 

But you know and I know that this is never going to happen. Not via the global sum, and not via a PCN or federated scheme. The current starvation of funding means that we will continue to haemorrhage GPs and the Government can hide behind the workforce as a cause for the crisis. 

So, how does general practice survive under the current funding structure? Simple – as my son implied, it will no longer be general practice as we know it. 

I predict that in as little as five years’ time, an NHS GP will never be the first person who sees a patient. The few of us that remain will function at the pinnacle of a pyramid model. Patients will be digitally triaged into large multisite call centres (whose management could be outsourced to other countries) and directed to the clinician who deals with that part of the body. A mental health specialist for the brain, a physiotherapist for the joints, a practice nurse for long-term conditions, a specialist nurse for children or gynaecology, an advanced clinical practitioner for undifferentiated symptoms. 

Where will GPs fit into all this? Part of our role will be as consultant to this multidisciplinary primary care team. The other part will be to step into the space that is the increasingly complex area of interface medicine. We will be elevated from community house officers to community registrars and formally take on the mass of work that sits between primary and secondary care. 

The question is, will this make general practice more or less attractive? I will let history be the judge.

Dr Shaba Nabi is a GP trainer in Bristol. Read more of her blogs here

READERS' COMMENTS [8]

Patrufini Duffy 7 June, 2022 4:27 pm

To all of those in a cosy PCN, you are right, they are coming for your appointment book, and will soon create a nice accessible “working together” call centre outside of your reception staff. Probably in 2024 if you’re still awake. Good luck in seeing other surgeries’ patients from October on an evening and weekend and delivering fake access as a trial run. You should now be coding all patients using a Babylon, Livi or whatever GP app as “Family using private General Practitioner” and wake up to your forgotten cheapened role.

Jonathan Heatley 8 June, 2022 7:47 am

how depressing.
We manage to run the traditional pattern at our surgery with mainly full time partners and we manage to be on top of our workload despite lists of 2400 each. Fortunately we still enjoy our work and feel we are well paid. Its a shame no one is interested in a surgery that actually thrives and is extremely popular with patients as a result. To us the PCN is an extra add on with some benefits but not the answer in my opinion.

Darren Tymens 8 June, 2022 10:59 am

But it’s not evolve *into the proposed model*, or die.
The proposed model will fragment care and lead to a service that is less safe, less effective and far less efficient. Patients will like some aspects (the convenience for simple single-issue transient problems) and hate absolutely everything else.
There are only really three possible ways forward:
The government and NHSE (in their willful ignorance of the real value of general practice) continue to push the model that Shaba describes. The Fuller Stocktake proposes a big and significant step towards this. A few GPs may be left delivering a very unsatisfactory and unrewarding service, I suspect mostly dealing with complaints, but most will either leave the profession or switch into a private service where they retain autonomy and can continue to deliver a high quality service to those who can afford it and who are willing to pay. This is obviously against most of our values and will be painful – but may be the only option left to us as a profession (see: dentists). The BMA needs to prepare for this possibility.
A second option is that the government and NHSE changes direction and works with us to evolve the service in an appropriate, evidence-based, patient-centered way in order to continue NHS care free at the point of contact. But this would involve a complete change in their attitude to general practice (especially with regards to trust and funding), and a complete change in their values, and there is no sign and little likeliness of that happening.
The third option would involve the profession digging its heels in and being willing to undertake industrial action in order to assert our voice and compel NHSE to agree a future acceptable to us. But there is no sign and little likeliness of that happening either, it seems. I don’t think the BMA has won any form of industrial action in almost 60 years? And GPC appears to be being treated as an irrelevance by NHSE.

Esmat Bhimani 8 June, 2022 2:22 pm

If these are the options the government wants, I have no problems with it.

Patrufini Duffy 9 June, 2022 4:02 pm

Well said Jonathan.

Nick Mann 11 June, 2022 10:30 am

As GPs’ future, or lack of it, becomes apparent, the need to fight against this destructive political meddling should gird our loins.
Fight for the system we know will work for patients. A new GP Charter has been compiled by Doctors in Unite:
https://doctorsinunite.com/2022/05/16/primary-care-and-public-health-vision-for-revitalising-primary-care/

Steven Hopkins 11 June, 2022 1:01 pm

It is interesting to see how the NHS mindset thinks so differently from private business. We look to funding from Government and plan for e-consults and further distance from the patient. It doesn’t cross our mind to ask what our customers want. How much public criticism are we prepared to accept before we question ourselves and our practice?
One other thought. How do you buy more doctors? In the absence of doctors, more funding usually equates to more administrators and more bureaucracy to justify their employment.
The NHS model has failed. It’s time we acknowledged this and discussed a future in which we have a direct relationship with our patients.

Nick Mann 11 June, 2022 4:40 pm

Yes, the “NHS mindset” thinks differently from private business, because we understand public service and what is needed to run it effectively and efficiently, without the distorting effect of the profit-driven corporate priorities. The failure was entirely a lack of strategic planning to support the model, not a failure of the model itself.

We do know exactly what patients (for they are not and never will be “customers”) want: to see a doctor who has the infrastructure and time to resolve or manage their problem. Government’s vision of remote call centre Medicine is a dissembling corporate narrative, promoted on the back of a firefighting plague-ridden NHS.

The NHS has endured, not failed. The failure lies squarely with a government obsessed with corporate control, governance and profit; who see contracts and not patients; and who will consistently and consciously defund a vital public service to the point of dysfunction in order to achieve its predetermined ends.

Doctors and Nurses have been driven out, not vaporised. The hostile environment has driven them to retire, reduce hours, emigrate, work in management roles etc. Yes, we need rapid expansion of professional education and training placements.

We already have ample evidence that the NHS is an excellent and fair model for healthcare. You cannot make any reasonable analysis of the model itself when its component parts have been eviscerated.
Read the Charter. With an adequate workforce, beds and funding, patients will be very well served in a publicly provided NHS.