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‘It’s not sufficient to have 5,000 doctors’

When announcing the independent workforce review, Jeremy Hunt said: ‘We tasked HEE to do an independent study on what exactly do we need, area by area. We need to know exactly where we are underdoctored and by how much.’

Why isn’t this in the report?

That’s very simple – if you look in the terms of reference of the commission, that was never in our Terms of Reference. There was a lot of discussion about whether at ought to be, or not, and a decision was made – not by me – between Health Education England and DH that that was not going to be part of our terms of reference.

We would look at new models of care and somebody else would look at numbers.

It’s not sufficient to have 5,000 doctors in the areas already over doctored. There do need to be initiatives to attract doctors to come and work in some of the parts of the country that are less attractive at the moment. We know from evidence, from this and other countries, that financial incentives are part of that – you’ll be aware that the Government recently announced financial incentives for doctors to move to under doctored areas. But non-financial incentives are also really important.

So that means providing doctors with a feeling that they will get good working lives, that they won’t be isolated, that they’ll be supported and there will be good ongoing education and opportunities.

How do you provide guarantee they won’t be working in isolation?

We haven’t got any specific examples on things like working in isolation, I know from the literature there are examples from abroad. Other countries have a much bigger problem than we have, you know Australia and Canada getting people to move to remote or unpopular areas, but I think there are plenty of things that Health Education England particularly could think about in supporting doctors – especially in their early years as a GP.

The other thing on numbers, and some people have said to us ‘why are you suggesting more pharmacists, and the possibility of physician associates? Why not just more GPs?’

Our answer is two fold: firstly some of these roles have things to offer – particularly pharmacists for example – are doing things that would complement work that is done by GPs.

But the reality is, even if the Government was successful in recruiting 5,000 GPs by 2020 – which is far from certain – that’s not going to meet all of the workforce requirements of the future. Saying ‘oh well GPs could just do it all’ is not the right way to be thinking.

We visited a practice in Yorkshire which is employing two physician assistants. They’ve done that very simply because they’re unable to find replacements for GP partners who had left. And that arrangement was working very well.

There clearly is a tension between access and continuity, and we think the Government has, over many years, put too much priority on opening hours and too little on people being able to see a doctor of their choice. Which is in danger of becoming a considerable problem.

It’s not just a danger for patients, because patients like to see their own doctor, but it’s increasingly a problem for doctors because as our population gets older and we have more and more multi-morbid patients, then the problems of dealing with someone you don’t know in a ten-minute consultation becomes increasingly difficult for doctors – and potentially a patient safety issue.

So we think that needs to become a much greater priority.

Is the continuity issue completely down to raw numbers of GPs to take workload?

The RCGP has published a reference on this.

There are some quite straightforward things that the college recommends that can make continuity easier for patients  and also for doctors. It is a common complaint from patients that they can’t get to see their doctor, or they see someone different every time.

I’ve been in surgeries frequently where patients said they couldn’t get an appointment with the GP they’ve seen before. It’s almost as though patients don’t realise now that continuity of care is an important issue for us.

The Government has pushed initiatives to bring about seven-day working to improve health care outcomes . Can you improve health outcomes with seven-day working if continuity of care suffers?

I think as opening hours get extended more and more, it becomes more difficult to provide continuity of care. So our view is the Government needs to put more focus, relatively speaking, on continuity of care and somewhat less focus on access.

Clearly there is a push, including from patients, for GPs to be seen at more extended hours. But we need to distinguish between people who don’t particularly mind who they see and are happy to see a doctor from another practice if they’re a group of practices or a federation providing care in that way. And there are those people to whom it really does matter that they’re seeing a doctor that they know.

We can see benefits in future to primary care organisations holding the contracts for providing out of hours care, rather than it being hold by somebody separate. I think that will make it easier to provide for these very real tensions between continuity and access.

So what do we need 5,000 or 8,000 new GPs?

We quite deliberately didn’t express a view on that because we don’t think we’ve got a reliable figure to give. The 5,000 is a commitment and we just noted that the college has said 8,500.

It’s something that needs to be under constant review – if the NHS is able to provide more of these roles, physician associates etc, to what extent will they be able to successfully fill in the gaps where we can’t get GPs.

This might be something that needs to be taken much more locally, rather than saying 8,000 and they all go to the wrong place.