I am now into my fourth week of leading this review – a positive start but it feels there is so much to do and so little time.
I have taken a sabbatical from my practice and am committing at least two days a week to the review and will continue to do so until the end of the year, when the conclusions of the review and recommendations need to be submitted to health and social care secretary Jeremy Hunt and Simon Stevens, the chief executive of NHS England.
So what have we done in the last 4 weeks? We have established our formal governance structures for the review, with the DHSC, NHS England, the GPC and the RCGP. We are also building a virtual reference group with membership from a wide variety of people, in terms of organisations, geography and experience.
This group is growing to ensure we get the views of as many people as possible. We will use this group to test out our assumptions and potential recommendations.
We have started a series of visits to various parts of the country to see what is working well, where things are very difficult, and listening and learning from local GPs, practice managers and other to help us shape the review.
Last week we visited Devon which is a county that I know well as my parents lived in Plymouth for many years and I spent much of my childhood there. On our visit we were able to look at three very different situations: a practice that has gone into partnership with an acute trust; a super partnership with a registered population of over 30,000 with a number of mergers; and hearing from practices within the city of Plymouth where a number resigned their contracts due to difficulties with recruitment and retention.
Partnerships 'not dead'
There are some really important lessons to learn from all of these. This week we are visiting Birmingham, with plans over the next couple of months to visit Humberside, Sunderland and Newcastle, Nottinghamshire, London, Cambridgeshire, Liverpool, Kent, Yorkshire, Dorset, the Isle of Wight and Suffolk.
What are the key messages we have received so far? The partnership model is not dead. Many still believe it is a model that serves the patients and population well, but it is at significant risk. For most practices the daily workload in terms of both administrative and clinical work has become too great to manage within existing resource.
The funding for general practice has not kept pace with the work associated with the ageing population, the increase in long-term conditions and greater complexity of multiple-morbidity.
The workforce - the good news is that we are training more GPs than ever before, yet the number of GPs working in practices - excluding locums and trainees - is falling. We are therefore not recruiting younger GPs in sufficient numbers to the permanent workforce.
Older GPs are getting fed up with the pressure of work and the perceived unnecessary bureaucracy and are opting to leave practices to become locums or retire prematurely. But this is not just a problem with GPs - there are also issues with an ageing workforce with practice nurses, and the role of a practice manager has become more challenging.
Liability and risk – we all carry a degree of liability in the work we undertake, but with the current structure of GP partnership, GPs carry unlimited personal liability, and this is compounded by the partners being joint and several liable. Younger GPs are less willing to take on this personal liability. The risks of being a partner are now seen by some as being greater than the benefits.
One example of these risks is premises, whether you are responsible as the owner of the estate or as a leaseholder. Both can be a significant risk if the practice ceases to hold a GMS or PMS contract.
Lack of career progression – contrary to popular myth, many younger GPs would consider joining a practice as a partner, but not immediately after completion of training. They would like to gain more experience in working in different practices and be able to develop wider interests that would be valuable in their future careers, for example, in leadership, or clinical areas.
Many are also looking for greater flexibility – including GPs wanting to develop portfolio careers, and also GPs with young families.
Uncertainty about the future - how can we expect the younger generation to commit to a partnership for the medium to long term if the majority of messages they get are negative and full of uncertainty?
So, it seems our challenge is to make general practice a better place to work, to ensure the working day is manageable with a sufficient workforce to meet the demand (AKA workload), to reduce the personal risk and liability, to introduce greater flexibility for those who want it and to create a positive future for general practice if we are to reinvigorate the partnership model.