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Dr Chaand Nagpaul: ‘Pressures on general practice have sunk to new depths’


RB, since we last met sadly pressures on general practice have sunk to new depths. Demand escalates relentlessly, with a growing ageing population with expanding multiple complex needs.

Meanwhile, the explicit wholesale transfer of care out of hospital continues unabated. It’s GPs who’re absorbing this burgeoning workload, with 70m more patients seeing us annually compared to 7 years ago and with fewer GPs per head which is drowning our capacity to cope. A record 201 surgeries closed last year – the tip of a much larger iceberg of practices on a cliff edge. Unfilled GP vacancies are at their highest, with half of practices struggling to recruit locums to provide essential services. This has led to a toxic mix from which existing GPs can’t wait to escape, and which many young doctors will not join

That’s why in our crisis LMC conference in January, GPs across the UK declared they can no longer work in an environment of unmanageable workload that prevents us providing safe, quality care.

RB indulge me by stepping into GPs shoes for a moment, to understand how we care for Doris, aged 75. Doris has heart failure, COPD, diabetes and severe knee arthritis. Her entire ongoing care has been transferred from hospital to her GP. She’s on 10 different drugs, and today asks her GP to change the large blue tablet she can’t swallow to a smaller one, how to obtain a disabled car badge, complains her hearing aid needs repair but the clinic insists on a new GP referral, and that she hasn’t received a date for her knee replacement and on calling hospital was told to see her GP to write a letter. And that’s before the whole point of her appointment which was to review her uncontrolled diabetes and heart failure. Her four conditions would previously have taken 4 hospital appointments totalling an hour and a half, yet GPs are forced to juggle this multiple complexity in 10 min. It’s not possible. Not sustainable. Unsafe.

Far from the being thanked for working against all odds, there’s an unforgiving climate of blame. Litigation against GPs has rocketed no doubt contributed by us not being able to work safely. CQC adds further insult by crudely judging practices rather than recognising our impossible context. Why do CQC reports not explicitly acknowledge that GPs work within constraints that compromise quality care, and highlight specific practice difficulties such as GP vacancies? How callous to name and shame practices for not having the capacity to tick boxes when those struggling the most are rightly spending their time attending to patients rather than producing reams of policies to satisfy the clipboards of inspectors.

On the back of our crisis conference, GPC produced our Urgent Prescription rescue plan “responsive safe, sustainable”.

The fundamental problem is that demand runs roughshod over our skeletal capacity. Our solution is clear- we need to increase capacity and reduce demand.

On reducing demand, NHS England estimates a quarter of GP appointments are avoidable. Patients who could have seen another professional, patients who didn’t need medical advice at all, or appointments wasted on bureaucracy. That’s why we need a national campaign highlighting that overstretched GP services must be used wisely, signposting patients to other professionals where appropriate, and empowering patients to self-care. But the entire system must pause before uttering the proverbial “go and see your GP”, since each additional avoidable appointment is breaking our backs, preventing GPs caring for ill patients who need us. From the filling of forms, GPs chasing up tests they didn’t request, through to Doris seeing her GP because she didn’t receive her follow-up hospital appointment.

On increasing capacity, with thousands GPs short today who won’t suddenly appear tomorrow, we need upfront funding for skill mix now to support GPs to free up our time – from practice pharmacists, paramedics to advanced nurse practitioners. Because it’s only by relieving our pressures will we attract new GPs, and retain those already working.

We can also increase capacity by maximising the full working potential of the existing GP workforce. Unmanageable workload is fuelling GPs turning to part-time work, with 1 in 5 intending to reduce clinical sessions further. Making the job doable will reverse this trend and itself expand capacity now.

We must equally retain the current workforce. With government figures showing 38% of GPs intend to quit in the next 5 years, mass resignation is not a threat –it’s an emerging reality. That’s why government must tackle the pressures driving GPs to throw in the towel, such as crippling indemnity costs of up to tens of thousands of pounds annually, which GPs bear personally, and leading many to reduce work or leave altogether.

Our urgent prescription proposes putting an end to GPs working to unsafe open-ended demands. If you were seriously ill, would you want to be the 60th patient to see an exhausted GP at the end of the day, a GP who has worked non-stop, skipped lunch, squeezing in home visits and dizzy reading 100s of hospital letters and test results before seeing you beginning to end in ten minutes?

In England the government finally responded with the GP Forward View. In fairness, in belatedly recognises the pressures in general practice, and proposes investment which for the first time in years will increase general practices’ share of NHS spend. GPC will work to ensure that positive elements in the Forward View are delivered to support GPs. However as LMC conference last month declared it doesn’t go far enough. We need immediate support and funding to reach the frontline to prevent practices imploding. Our conference gave government a three-month ultimatum to accept GPC’s urgent prescription, or else to assess the profession’s willingness to take action. This is a tragic reflection of the unsustainable strain on GPs, from a profession which by its very nature is forever accommodating given we care for people not conditions, and where our goodwill has been actively exploited to a point where it’s threatening our profession’s future.

The elephant in the room is of course money. As a supposed rich nation it’s shameful we spend less on GDP on health than most of the developed world, where we have a fraction of the hospital beds of France and Germany and lag behind most other OECD countries in our doctor and nurse numbers. General practice desperately needs more resources, but not by robbing Peter to pay Paul, but from a larger NHS pot that provides the level of care that befits a civilised state. This is everyone’s fight, from doctors to patients and the public as taxpayers, to challenge politicians who are irresponsibly trying to squeeze a quart into a pint, while savagely slashing NHS funds under self-proclaimed austerity.

GPs will play their part in this fight and we’ll fight every day until we resurrect our proud profession. Because if general practice fails, the NHS fails, but I’ll turn that to a positive – if general practice succeeds, the NHS succeeds. I move.