Can 10,000 new GPs save general practice?

Crumbling morale and rising workload have left general practice on its knees. Nick Bostock looks for a glimmer of hope.

For all that depressing headlines about general practice have been two-a-penny in recent years, the past 10 days or so may have topped the lot.

The BMA's quarterly opinion poll, which found that nearly 60% of GPs planned to retire early because soaring workload has crushed morale, followed hot on the heels of a similarly doom-laden RCGP survey.

Low morale

GPC chairman Dr Chaand Nagpaul said the profession's morale had never been lower in his 25 years as a GP. RCGP chairwoman Dr Maureen Baker went one better, warning that GPs face 'extinction'.

The findings came as the dust had barely settled on the astonishing Doctors' and Dentists' Review Body (DDRB) advice - gleefully backed by the government - that GP practices should receive a funding uplift of just 0.28% in 2014/15.

The logic behind this was that staff costs had fallen in the past year, the legacy of a decade of constant pay freezing and real-terms cuts that have forced many practices to slash their main cost - employees.

Just as the DDRB recommendation suggests the profession's finances may be locked into a terminal cycle of decline, with cuts perversely used to justify further cuts, the constant bad news is taking a similar toll on the workforce.

GP morale has been ground down by a toxic mix of media sniping since the 2004 contract, falling profits and rising workload - fuelled by an ageing population, rising demand and growing bureaucracy.

The BMA poll found 57% of GPs plan to retire early, while a decline in applications for GP training posts shows that young doctors are being put off careers in primary care.

All this is happening at a time of profound change in the profession. On top of NHS reforms and sweeping changes to GP contracts, official data released this month show that for the first time, female GPs outnumber their male counterparts.

The data also confirm the rise of a new generation of salaried GPs - whose numbers have swelled 435% since the 2004 GP contract cut the tie between practice income and partner numbers.

So amid all the gloom, where can GPs look for a glimmer of hope?

The number one factor that GP leaders across the spectrum say must change to restore optimism is funding - enough to deliver at least an extra 10,000 GPs by 2020.

Funding

The share of the NHS budget spent on general practice has fallen to just 8% - a figure the RCGP says must rise to about 11%.

Dr Baker says: 'The real solution lies in long-term investment in general practice.

'All four governments of the UK must heed the RCGP's call for an urgent rise in funding to 11% by 2017. This would allow us to create more GP posts, part-time and full-time, so we can provide more appointments, longer appointments and safe care to all our patients.'

Although the transfer of funding has yet to materialise, both NHS England and health secretary Jeremy Hunt have made positive noises about moving funds to primary care. NHS England's London region, for example, says: 'We know practices are facing a financial squeeze and shifting more resources into general practice is a key priority.'

Plans to hand CCGs more power to commission primary care services could increase GPs' influence over this transfer in coming years.

Meanwhile, NHS England's demand that CCGs put aside £5 per patient - potentially more in future - to invest in and around general practice to support GPs' role in caring for vulnerable elderly patients could yet set the ball rolling for investment in primary care.

However, GPC deputy chairman Dr Richard Vautrey says moving enough funding to primary care to create more GPs and allow them to spend longer with patients with increasingly complex problems will require a 'major NHS management culture shift'.

'It also needs brave decisions to not only move work from hospitals in to the community, but the funding too, to enable sustainable community services,' he says.

Group working

'Working in groups of practices could help practices bid for and deliver wider community services above the practice, but they will not work if all that happens is that we try to spread a currently overstretched service more thinly. That will just lead to the service breaking completely.'

Sections of the media, Dr Vautrey adds, must move beyond 'tired, inaccurate stereotypes' that undermine GP recruitment and morale.

News that more than half of GPs are now women is likely to bring more lazy stereotyping. Dr Baker says it will 'be seized on as another excuse to criticise women GPs who work part-time'.

But the RCGP chairwoman says general practice should be congratulated for 'leading the way' on gender equality. 'It is encouraging to know our profession is seen as a stimulating and progressive career option for women and men. This is one area where we are streets ahead of the corporate world.'

Women may be more likely to take career breaks than men, but general practice is a profession that a diminishing number of people feel they can handle full-time - and many men are also moving towards flexible and part-time work.

Northumberland LMC medical secretary Dr Jane Lothian says: 'Portfolio working is not just something women GPs do. The full-on clinical days, which not uncommonly extend to 12 hours or more, four or five days a week, are unsustainable. I can think of very few colleagues who haven't started to take on other roles - across salaried GPs and partners.

'That is pushing people towards part-time working, irrespective of their gender.'

Put simply, women, and others who want to work part time, are a good fit with the high-pressure primary care of 2014.

Moving to a model where less than full-time work is the norm, or a diverse working life spread across general practice and other specialisms or areas of interest, can help to build the broad-skilled generalist workforce the RCGP and others want for primary care, while offering GPs an escape route to avoid burnout.

In a world where an increasing number of GPs want to work part-time or across a portfolio of activities, locum back-up is vital.

Dr Richard Fieldhouse, chief executive of the National Association of Sessional GPs and medical director of an 80-GP locum chambers organisation, says a 'symbiotic relationship' between locum groups and federations of GPs is the key to a sustainable future for general practice.

Partners and salaried GPs can spend more time on complex patients with long-term conditions, with support for the rest of their patient list from a well-organised supply of highly trained locums.

Locum GPs

Dr Fieldhouse says that the NHS fails to take account of the huge role the five-figure locum GP workforce has in easing pressure on practices.

NHS census data fail to count locum GPs as part of the total workforce, he says. 'How can you work out the future of the profession if you don't count a third of them?'

Although the census suggests there are just over 40,000 headcount GPs in England, Dr Fieldhouse says this data should be 'shredded'. About 15,000 locum GPs are excluded from the census count, he says.

'We need to ask how we make best use of the GPs we have. We have 15,000-odd locums - all self- employed independent doctors organising their own work.

'I bet there are lots out there who are not fully booked. They are not managers, and it's a bun fight out there. There are inefficiencies you see all the time.'

That said, Dr Fieldhouse agrees there is a clear need for more GPs.

He says: 'In the last 18 months, we have had GP practices asking us to cover 16,000 half-day sessions. But we have only been able to cover 9,000. There just isn't the workforce. We are fully booked.' Nonetheless, he says there are huge improvements to be made to the way in which the existing workforce is managed.

This is an area where the profession can take the initiative, as it can in making greater play of the fact that working five 13-hour days each week is not the only option, and celebrating its diversity.

So can 10,000 new GPs save the NHS? Perhaps, but only if future governments take a long, hard look at the profound malaise hanging over the current generation of GPs and support the next wave with long-term funding.

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