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How can we fight when we don’t know what we want?



To say it’s been a challenging time for general practice would be an understatement. I am writing this two days after that NHSE ‘support package’ dropped into my inbox. Once the immediate shock and tears subsided, my most prominent emotions were confusion and despair.

It is likely my practice will fall in the bottom 20% of many of the performance targets, which include GP appointment numbers, attendance at A&E and NHS 111 callouts. Of course, NHSE has no desire to examine the evidence that suggests A&E attendance is associated with deprivation and proximity to the emergency department. In England, we have been living in an evidence-free zone since before the start of the pandemic.

Many will think of this as a watershed for general practice, but I see it as a Sliding Doors moment. In the first scenario, we miss the train and our subservience to NHSE continues, until we sleepwalk into a salaried service resulting from partnership resignations. In the second, we stand together on that train, side by side, and we say ENOUGH. We carve out our destiny and we continue riding the train for many years to come.

The problem is we seem to have no clear idea where we want this train to go or how to get there. Do we have a strategy, a vision, or a mission statement for our profession? Do we have any notion of how we wish to practise in the years to come, or are we allowing ourselves to be mis-sold the illusion of the expert medical generalist because we believe it’s the only option?

I have been writing for many years now about the risks of being a conductor instead of a musician – of constantly working at the top of your license supervising multiple allied healthcare professionals who act as gatekeepers for the gatekeepers. For me, general practice is about treating a patient’s simple ear and throat infection while she is a student. It’s about being there when she plucks up the courage to attend for that lump she has noticed. It’s about helping her navigate her breast cancer journey and then seeing her with her kids once she has recovered. I no longer want to be the voice at the end of the phone, or the message on the screen, dishing out instructions to the myriad of others looking after my patients.

I know there will be many who will deride the aspiration of continuity from a GP who doesn’t work every day. These will be the same people who insist that working three 12-hour days a week in general practice is ‘part time’.

Continuity is our USP, and I believe we can still achieve it without being present in the practice for every single core hour.

Despite being dual qualified in medicine and general practice, I don’t wish to be an expert medical generalist – aka risk sink. I joined general practice for the variety it brings, and I want to be a bog-standard generalist. I do, however, believe it’s unsafe to force GPs to practise conveyer-belt medicine and, for my patients’ sake as well as mine, want my contacts to be capped at 30 per day.

Is this really too much to ask?

Dr Shaba Nabi is a GP trainer in Bristol

READERS' COMMENTS [11]

David Mummery 22 October, 2021 6:12 pm

Totally agree – GPs need to *be* the orchestra , not the ‘conductors’ of an orchestra

Patrufini Duffy 22 October, 2021 10:04 pm

Work smarter not harder.
I want the orange smartie because it’s the only flavoured one. That makes my life exciting currently. And potting spring tulips and hyacinths. In nature you can reap what you sow, not currently in General Practice. The door keeps revolving with flashes of aggression and vilification, and the rabbit hole turns back onto your desk___ **I calculate for every 15 minutes extra you give to NHSE per day, that could equate to 3,600 minutes/year = 7.5 extra 8-hour working days. For free. Work smarter. Less follow-up, straight to referral and test, the system then clogs (and maybe Javid loses his job), less signing up to non-core schemes, get out of PCNs and play more golf like the public say you do.

Decorum Est 23 October, 2021 1:13 am

Thanks Shaba. A beautifully written and insightful commentary from a deeply committed and knowledgeable practitioner.

Jonathan Heatley 23 October, 2021 10:22 am

I would fight for traditional general practice with personal lists and medium sized GP owned surgeries where the GPs are responsible for their own business and working practice, similarly to the franchise model in the service industry. This model has worked very well for the last 70 years but seems to have fallen apart with the rise in part time working and portfolio junior doctors, who only want to do their clinical shift and avoid any running of the business. In the absence of them running it, all sorts of other entities have stepped in such as private groups and most recently PCNs. We have brought this disaster upon ourselves.
Some are still fighting to keep it alive- probably more than realised as they tend to keep a low profile and just get on with the job. We need to explore ways to resurrect this tried and tested model that made UK general practice so popular 20 years ago.
I’ll be hated for saying this, but I absolutely love this job- you spend all day helping people with varied interesting problems and we are paid well for our efforts.

Philip Cox 23 October, 2021 11:41 am

I recognise everything that Shaba has outlined.
The importance of continuity is ignored by the powers that be. Less admissions, referrals , better patient satisfaction and I dare say doctor satisfaction.
The mantra about working at the top of your licence is rubbish. By all means let our nurses do what they are trained to do, but if a patient needs a quick dressing and no nurse is available the doctor should offer a temporary dressing. If an urgent blood test is needed the doctor should do it etc .
I’m afraid that the 2004 contract was a disaster ooh co ops worked well GPs were respected. The loss of the basic practice allowance which paid a practice to have partners encouraged the use of salaried GPs.
GPs no longer control the list of patients . It is hard not to believe that there is a long-standing plan to disempower GP.
I don’t think industrial action will take off. GP has been dissected up , palliative care, Obstetrics , ooh are all shifting away. Repeat prescribing will go to pharmacies.
Look what happened to the miners. “ the miners united will never be defeated”
We arent a united profession!
Sorry to be negative .

Saffron Koupparis 23 October, 2021 1:08 pm

I agree entirely, a capped number of consultations would be a big step in the right direction.

Slightly off piste, but how about selling our services to the pharmacies? I think it might work out more favourably than the current GP terms and conditions. For example, see https://psnc.org.uk/services-commissioning/advanced-services/community-pharmacist-consultation-service/cpca-funding-and-claiming-payment/ – £14 per patient seen by a pharmacist for minor illness. As a salaried GP with 40 patient contacts per day, this equates to a fee of £9.77 per patient, except we are expected to deal with complex cases as well as making referrals, dealing with administration, test results, prescription requests and reports in addition. Even if consultations were capped to 30 per day, this would still fall short of pharmacy rates at just £13.04 per patient.

While we greatly appreciate the help of pharmacist colleagues in meeting patient demand, as a GP pondering on the figures, it does seem that the role of the GP is rather undervalued by the government or that the volume of our patient contacts is not truly appreciated.

Steven Hopkins 23 October, 2021 5:34 pm

You are correct. We all of us want different things out of General Practice. There will, indeed, be those who want a sausage factory approach to the consultation. There are those of us who want a humane and personal approach. Equally, there are those of us who have strengths and I interests in one specialty or another. And those, like me, who recognise weaknesses in their practice.
As I see it, the NHS insists we do everything and in a set way. The administration is in constant Flux and we are governed by algorithms set by somebody else to a degree that, we do not treat our patients as we feel best but according to someone else’s narrative. This begs the question, who is the patient being treated by, the doctor in front of him or the bureaucrat behind the doctor.
If we all went private, we could act independently and treat ” our” patients the way we would wish.
Our problem is that we want the independence of thought and action, but are wedded to our role in the NHS. This is the very dilemma that the BMA foresaw in 1948.
What a shame we have allowed politics to cloud our view .

Josef Kuriacose 24 October, 2021 6:41 am

Shaba, we do have so many opinions, as you say. But the common thread is the workload. It has become impossible to do safely to the satisfaction of the public. The primary reason for this difficulty is that though the contract is list based, consultation rates have trebled in the past twenty years. If we continue to provide list size based contracts, then the workload will just increase each year. Like you, I have argued at BMA ARMs without number to restrict consultations/ day to 28- 32. But that does not dovetail with the contract which is open ended. I hate to repeat myself, but we do not define safety as we should. 30 is a safe number, 50 is not. If we leave the contract as it is, that is what will have to do to provide GPS for patient demand. We promise patients to give them a consultation within a reasonable time. If we do not because of severe workloads, we are defined as lazy. Public perception is not related to our workloads, but their waiting times. This contract has to go. It has to become an appointment based safety contract. Safety for patients in that they get a fresh doctor and safety for us in that we do not make mistakes because we are tired. This change is going to be difficult.

David Banner 25 October, 2021 9:51 am

Many surviving partners have stumbled across an imperfect solution to some of these issues.
In the absence of any replacement GPs, and the ruinous cost of locums, surgeries are increasingly staffed with teams of ANPs, PAs, CPs etc., who are cheaper and (if selected and supported properly) extremely effective. This has allowed much more effective triage, reducing the surgery stampede, and allowing the few remaining doctors to act increasingly as “Consultant GPs”, with capped surgeries and increasingly fewer home visits, with a reduction in paperwork and prescriptions.
The payoff is more supervision of nursing staff, but this can be incredibly rewarding and boosts team building.
A return to a world of lots of GPs and few nurses is now out of reach. A mass resignation from the NHS will simply not happen. After years of bemoaning our inevitable decline (as I have done repeatedly in the last decade), we must either walk away, or try to rebuild a better future for ourselves, because it should be blindingly obvious that nobody else will.

Andrew Jackson 25 October, 2021 4:35 pm

We have to have a system of workload control which is essentially a maximum limit of appointments in a day- there is no other meaningful way of limiting workload.
The Government won’t confront this as it will decimate capacity hence all the platitudes about reducing bureaucracy in other ways which never make any difference.
Solve this and most of the other stuff will fix itself.
We also need to reward continuity of care as the article states as most of us with a long career know the importance of it.
If this isn’t recognised and supported to be achieved soon then we run the risk of having GPs coming into and through a system where they have never seen the benefits of this and why GP is different to A and E.
Once the generation that knows about continuity has gone then it will never be recovered.

Jamal Hussain 26 October, 2021 8:59 am

How can you fight when the profession as a whole isn’t inclined to make the tough choices i.e. it’s unwilling to fight. Talk is cheap. Plenty of people are happy to have a good old moan on various forums. Nothing comes from that. The BMA have suggested moving to 15 min appointments and closing practice lists. Will that get traction. Nah. The personality types going into general practice these days has agreeableness as too prominent a trait for that to happen. As many have said the current contracts sucks. A contract with a fee per item of service is the way to go in my view as moving forward workload will continue to skyrocket and it’s a fair way to get paid for what we do. But again the current personality traits moving to GP land now and over the last decade would find this sort of risk unacceptable.