Commissioning and trust bosses in north-east London have said the number of GPs needed would fall from over 600 today to around 400 in a decade’s time.
The area's NHS leaders propose to slash GP appointments by 24%, replacing GPs with cheaper, easier-to-train physician associates and hiring more nurses and pharmacists, while moving more activity into primary care. Plans set out for the area claim that physician assiociates ‘can safely assume at least 83% of primary care visits without direct physician supervision'.
GP leaders have sought assurances from commissioners that the projected reduction does not mean they intend to actively cut GP numbers. Health campaigners have warned the plans to shift more activity from hospitals to primary care are 'untenable' if GP numbers drop.
A spokesman for local NHS organisations said the figures were a projection of the future GP shortage, and that the transformation plans would help the health service cope.
The plans have emerged as part of theTransforming Services Together (TST) programme, established in 2014 by Newham, Tower Hamlets and Waltham Forest CCGs. With local trusts and NHS England, the programme is developing a system-wide transformation plan.
The TST is a forerunner and component part of east London’s sustainability and transformation plan (STP), 44 of which are being developed by health and care systems across England as part of Five-Year Forward View plans to move care closer to home, implement £22bn of cuts and ensure access to new funding.
In parts of England GPs have complained they have been excluded from the secretive STP process.
The north-east London TST, which was published for consultation earlier in 2016, proposes massive reforms to cope with increasing population and demand, workforce crises and a projected financial baseline deficit of around £655m across local NHS organisations by 2020/21.
The plan says the three north-east London boroughs face a population rise of 270,000 over the next 15 years, which under current arrangements would require 125 more GPs in five years and 195 GPs in 10 years. ‘This will be impossible given the national shortages and high retirement rates,’ NHS bosses admit.
The report adds: ‘We expect there to be 136 fewer GPs working in east London by 2020.’
Implementing the TST strategy, however, would offset the need for those GPs, the plans claim, with 58 more pharmacists, 25 more physician associates, and 49 more nurses.
GP practices could be reorganised under the plans. Consolidated primary care hubs could be set up, with integrated care services joined up with local authority services.
The current number of GP appointments delivered would be slashed by up to 24%, with services delivered elsewhere such as through pharmacies or self care. The ‘released capacity’ would allow GPs to spend more time with complex patients whose care will be shifted from hospitals.
Overall, under the plan, general practice will see a 0.5%, or 96,000 episodes, increase in activity by 2021 ‘as a result of a necessary shift from hospital or urgent care settings to primary care’.
The primary care workforce cost would be cut by around £7m a year, the plans claim, with savings ‘driven by the less expensive roles being introduced’ and average whole-time equivalent salary falling from £91,000 to £75,000.
However, the plan admits that its activity targets do not take account of rising levels of average attendances, rising life expectancy, rising levels of long-term conditions, or the more complex care being moved out of hospitals to primary care.
Hospital based outpatient appointments will be reduced by 184,000, or 20%, by 2020/21, the plan says. Elective inpatient length of stay will be reduced by 10% through the development of surgical hubs, while acute care hubs will cut unplanned admissions by 15%, leading to a 150-bed saving.
Overall the TST is expected to deliver savings to the local health economy of between £104m and £165m over five years.
A consultation submission by local health campaigners and clinicians, seen by GPonline, called the plans ‘untenable’ and a ‘threat’ to the health of the population.
The plans for greater access to primary care with fewer GPs were ‘unrealistic’, the submission said. ‘Despite the current crisis in primary care - largely due to underfunding - the whole [plan] is predicated on shifting demand from hospitals to primary care.’
Former GPC member and Newham resident Dr Ron Singer said the plan reflected local commissioners facing the reality of the GP shortfall. ‘They're just responding to a shrinking NHS,' he said. Local NHS leaders were being forced to respond to demands from central NHS leaders. ‘Which in this case is about cutting the NHS to shreds. They have no alternative. They produce plans, however ludicrous and implausible. And they have to go out and sell them.’
There was no way to fill the GP gap without GPs, said Dr Singer. ‘There is a way of getting other people to do bits of the GP job, but that leads to fragmentation and the potential for worse outcomes.’
Dr Singer said the ‘whole thrust’ of the TST, moving care out of hospitals towards more self care was ‘utter rubbish’ which would hurt those least able to look after themselves.
Tower Hamlets LMC chairwoman and GPC member Dr Jackie Applebee said local commissioners had ‘an impossible job’ to save millions of pounds.
‘I'm against physician assistants,' she added. ‘I think we are going to spend time supervising them, which we don't have.
‘It is a false economy, bringing in physician assistants who will not have the specialist generalist training of a GP.’
She added: ‘My worry is that physician assistants will aid privatisation, because you'll have this cohort of workers which private companies can employ instead of employing GPs - they won't be anything like as highly skilled as we are, but they will be cheaper. This is not good for patients.’
A spokesman for the TST said the plan would help address the forecast GP shortfall while commissioners will invest more in trying to attract new GPs to the area as well as training and retention. Under the plans the number of healthcare professionals in GP practices will increase, he said.
Physician associates, he added, would be well placed to deal with more routine aspects of GPs’ work, freeing GP time.
On self care, the spokesman said the ‘full needs of every patient needs to be taken into account when developing self-care’.