Careers in general practice are a hard sell just now, the BMA’s top GP admits. Dr Richard Vautrey says seasonal pressure on top of the existing GP crisis has made this winter the worst he has seen in 30 years in the profession.
‘Over the past decade,' says the GPC chair, 'funding has not kept pace with rising numbers of patients, and rising numbers of elderly patients who are frail and vulnerable, living with multiple conditions. The disparity between funding and workload inevitably means that every year is worse than the last.’
The cancellation of thousands of elective operations and a surge in flu cases early in 2018 have turned up the heat on practices when many already felt their workload was intolerable.
Signs of the crisis are almost too numerous to list. Dr Vautrey warned last week that recruiting GPs was so hard in some areas that many practices had simply ‘given up’ trying to fill vacancies.
Meanwhile, practice closures are at record levels, partners’ income in England is now in real terms lower than it was in 2003/4, and three GPs a day have been coming forward for help since the GP Health Service began offering support for doctors facing burnout.
Can anyone say that general practice is still an attractive career?
‘At the moment it’s very difficult to say that,’ the GPC chair admits. ‘But I do believe - and I wouldn’t be doing this job if I didn’t believe it - that the future is very positive for general practice.
‘I think it is somewhere that doctors can use their skills, have the ability to be flexible in a way other careers are not - we can be flexible in our hours and ways of working, also in the opportunities that doctors can develop through portfolio working, developing different skills, having specialist skills alongside generalist skills, having a degree of independence and long-term relationships with patients in a way that many other doctors don’t have.'
The NHS has been talking for years about shifting more work into community settings, and Dr Vautrey is clear that this expansion - with GPs at its heart - is the only sensible way forward for the health service.
Retaining independent contractor status over the past decade counts as a major success, he believes, allowing GPs 'almost a unique ability to to be flexible, to be responsive and to shape how they operate'.
'I think we underestimate our ability to shape our working arrangements and the way that we provide services to patients. Being an independent advocate for my patients is a really important thing. It’s one of the reasons GPs are so often the ones able to speak out and to say it how it is whereas increasingly hospital colleagues are unable to do so because their managers restrict them from contacting the media or speaking in that way.We need to maintain the role that we have and build on it and use it.
‘So I think there is a lot that is positive around general practice. I hope that the career and the job itself is one that doctors want to aspire to - what we need to do is make the job doable.’
Making general practice ‘doable’ will inevitably centre to a large extent on whether the BMA can persuade ministers to back larger, faster investment.
Politicians aren’t completely oblivious to the strain on GPs - promises of 5,000 extra GPs and a £2.4bn rise in annual investment by 2020/21 through the GP Forward View came as a direct acknowledgement of the crisis facing general practice.
But since Jeremy Hunt promised in September 2015 to increase full-time equivalent GP numbers to 39,500 over five years, numbers have not risen - they have dropped by around 1,300. And even if the GP Forward View cash is delivered in full, the BMA says general practice will remain £3.4bn short of the share of NHS funding it needs by the end of the decade.
There have been wins for the GPC on funding in recent years, with GP investment rising in real terms over the past four years, even if not at the rate the GPC would like. And there have been additional packages of funding to cover CQC fees, and support on indemnity.
These have been firefighting measures, however - not enough to make general practice manageable, something Dr Vautrey defines as ‘dealing with the workload pressures and making sure that all doctors feel that they are using the skills they have to best effect, and not feeling so overwhelmed that they feel stressed and burnt out rather than supported and encouraged to do a good job for their patients’.
The GPC chair is not prepared to consider proposals aired by previous health ministers to cap the profits partners can take from their practices in return for a funding injection. There is an argument that capping the amount partners can take could enable major investment without the risk of headlines about colossal increases in individual GPs’ pay.
‘I don’t think a cap would be helpful,’ says Dr Vautrey. ‘The inherent status of the independent contractor arrangement and the practice contract does allow flexibility in the way you use the resource you have. NHS England and the government has a clear cap on the resources they provide to practices through global sum payments - the taxpayer is secure in terms of the resource that is used.
‘It is then up to practices how they provide the services and practices should be judged on the outcomes that they deliver. If we were to see an increase in funding we could anticipate - particularly with the workload burden as it is - practices starting to take on more staff to be able to provide an increased service to their patients.’
He’s convinced the existing GMS deal remains fit for purpose. 'Unless there was additional money, changing the contract would still leave us with the same problem that we don’t have sufficient funding to do what we need to do. One of the great advantages with the GMS contract is that the funding is nationally prescribed and has to be delivered to practices - it provides a guarantee of a foundation on which general practice can be built.’
Dr Vautrey is clear that practices should not give up the security of these deals - risking their own and their successors’ future - to join emerging new care models.
But in the absence of major investment over the past decade, the attraction of partnership roles has been significantly eroded. GPonline reported last year that numbers of GP partners had slumped by around 2,000 in the two years to September 2017. This change is tied to perhaps the greatest change in the GP workforce in recent times, with a huge drift to locum roles.
Dr Vautrey is clear that choosing to work as a locum is a valid career choice for a GP, and that partnership may not be for everyone. ‘Every GP will choose the way of working that suits them best,’ he says. ‘We need to recognise that general practice is dependent on a pool of locums.’
But he adds: ‘I personally think being a partner is a great role and one of those things that provides you with the opportunities that many other roles in medicine don’t provide.’
A logistical problem that has emerged with the rise in numbers of locums is that the system for counting GPs has failed to keep up. It is unclear whether the government would know if it hit its 5,000-GP target at all if most of the extra workforce became locums.
Dr Vautrey says it is simply very difficult to measure this part of the workforce, and that maintaining and increasing numbers of GPs in ‘substantive’ roles - salaried and partnership positions - remains a good benchmark of the state of the profession.
Ultimately, all GPs’ fortunes are bound together, the GPC chair argues. ‘It’s in the interests of locums themselves that there continue to be viable practices in which to locum. So it’s in the interests of everyone that we maintain a strong general practice base with partners, salaried and locum roles.’
The best way to encourage locums into those ‘substantive’ roles is to ease the pressure - both financial and workload-related - that is at the heart of the GP crisis, he argues.
‘One of the keys to encouraging doctors to work a salaried GP or as a partner is to address the workload issues and reduce some of the risks around indemnity and premises ownership. If you do that, more of the doctors may choose to take on a substantive role. We know that there are a number of salaried GPs who have been invited to become partners but have decided they don’t want to take on the risk. We need to look at those risks and see what can be mitigated against - particularly issues such as indemnity and premises ownership.’
Dr Vautrey admits that elements of the new GP contract agreed for Scotland have caught his eye. The Leeds GP describes measures in the Scottish deal that will gradually strip away responsibility for premises from GPs as ‘very interesting’ - and suggests discussions on the 2018/19 GP contract for England will look at this.
Talks on the state-backed indemnity deal offered by health and social care secretary Jeremy Hunt are ongoing, and Dr Vautrey is ready to take the government's word that it will deliver a solution that levels the playing field between hospital and primary care doctors.
Health Education England hailed 'the highest number of people entering GP training in NHS history' last year. Dr Vautrey is clear that if he was at that stage in his medical career, he would make the same choice and join general practice.
To make sure the next generation match his 30 years in the profession and that a good few opt for partnerships, however, he'll need some help - starting with major investment in the next few GP contracts and a game-changing deal on indemnity.