2020 is a metaphor for perfect vision, and as the new decade begins we certainly need a clear vision for UK general practice. The RCGP's Fit for the Future blueprint for general practice sets out its view of the current GP crisis and potential solutions - with further detail emerging in its workforce roadmap last week.
As a full-time GP since 2001, based in the same practice, I have seen many changes in the NHS during my career. This article is simply my reflections on the #GPcrisis and some simple ideas to help.
The five-year GP contract framework published in 2019 says: 'General practice is the bedrock of the NHS, and the NHS relies on it to survive and thrive.'
Value for money
However, although we provide around 90% of all NHS contacts on a daily basis, the funding allocated for general practice was 7.1% of the total NHS budget in 2018/19 and falling.
General practice is quite rightly recognised as both the entry point and gatekeeper to the NHS. By providing safe, accessible and evidence-based care in the community - using just £7 in every £100 spent on the NHS - it supports people to be independent and manage their lives, prevents the need for patients to attend A&E or see a specialist unnecessarily. The cost savings this delivers are key to enabling the health service to afford the high-cost, specialist, hospital-based care most of its budget goes towards.
Given the rising costs of running a safe, compliant practice - for example staff pay rises, increased employer pension contributions, increased costs for insurance, mandatory training and regulations to name a few - it should come as no surprise that GPs are feeling stretched. Take-home pay for GP partners has stagnated for the last 10 years at least – despite spiralling workload.
It is this mismatch of chronic under-funding with rising expenses, increasing demands, and a diminishing workforce that is causing an overstretched and increasingly demoralised environment.
What are the solutions?
Small steps can make a huge difference. The 2019 changes to indemnity allowed many GPs to increase their sessions without worrying about the associated professional insurance costs, and has been a huge boost to the profession. This shows that with professional lobbying and political will things can quickly improve.
With that in mind, here is my list of 'suggestions from the coalface' to help general practice:
1. Keep the patients at the centre of everything
Always think ‘what is best for patient care’ and the patient's ‘journey’ through the NHS. This is particularly important as we move towards system-wide population health management, in which the GP is critical. Do not impose politically driven, non-evidence based or untested schemes – we have seen this time and time again in general practice where huge amounts of time and energy are spent on unproven schemes and incentives.
The current draft PCN proposals seem to be a good example of this. Make sure that all new schemes are discussed and approved by the BMA and RCGP, and tested on the ground by grassroots GPs before being rolled out nationally. While many advances in IT can improve patient care - the current obsession with use of Skype consultations does not fit in practically to the GP day and would be costly to implement with unproven added value. On the other hand screening and monitoring for pre-diabetes, or the safe prescribing and monitoring of high risk medications (DMARDs, Valproate, NOACs etc ) are conspicuously absent from QOF (and the draft PCN plans) yet would be excellent for patients and the NHS.
2. Invest in GPs and their staff
Once again start paying some form of seniority / time in service awards to help retain senior GPs. Bring this in line with the secondary care system - just as has been achieved with indemnity. The previous seniority payments for GPs were phased out several years ago and are due to be removed as of 2020. This means that a newly qualified GP earns the same on day one as those more senior. This cannot be imagined in any other profession and provides zero financial incentive to remain in post. Surely a small pay rise per full year of service (pro rata) would encourage at least some GPs to stay on?
3. Reduce administrative burdens
Free GPs for patient care and clinical work. Examples could include simplifying the numerous highly complex existing incentive schemes - both locally and nationally imposed - and investing further in allied health professionals to work in primary care networks (PCNs). The NHS is trying to bring in new staff through PCNs but both the funding for this and the local flexibility needs to be greater.
4. Encourage the partnership model
We are losing a partner-led workforce who would stay in post for a career and be the traditional ‘family doctor’ running their practices. We have a shift to salaried and locum GPs who work on sessional rates and arguably do not have the commitment or responsibility required to run practices, which often erodes continuity of care - something we know is very cost effective and good for patients’ health, wellbeing and overall healthy life expectancy.
It should also be noted that the infrastructure of traditional general practice has always been maintained by the partnership model in running premises, recruiting staff and ensuring all the mandatory training and regulations are in place. If the partnership model dies, who will take all this on?
The importance of the partnership model has been recently highlighted by a formal review. Financially encouraging this model is an easy solution to reverse its decline. In the past there was a payment per partner to each practice and when that system ended, not surprisingly practices employed fewer partners. There is no good reason why the current general practice contract could not bring back a financial incentive per partner (pro rata) to incentivise and re-invigorate partnerships once again.
5. Rebrand general practice?
Maybe rename GPs as ‘consultants in family medicine’ or ‘consultants in primary care' to recognise in both name and job description the highly specialised and complex care that we are providing. Giving GPs consultant status and recognition would bring various benefits in both public opinion and professional regard.
6. New rules for medical negligence claims
Bring in specific data protection rules for medical negligence claims that allow a fair charge for access to records when this is being made specifically for a legal claim. GPs and their staff are spending huge amounts of time copying and reviewing notes for legal claims requested under GDPR rules. This is all provided for free, and a GP must carefully read through bundles of paperwork to ensure that no confidential third-party or harmful information is released. This whole process is a huge time drain for GPs and their staff, and since GDPR there has been a rise in requests.
7. Create a separate home visiting service
Perhaps once a patient is classed as housebound, or in a permanent nursing or residential home, their care would be best provided by a specialised team of paramedics, pharmacists, physios, occupational therapists and care of the elderly doctor or specialist GPs? Such a team would remove a huge workload from the average GP day, would probably provide safer, better care to elderly frail, vulnerable patients, and would allow GPs to focus on their clinic based work more effectively.
8. Sort out the pension fiasco
This is forcing early retirements/reduced hours, is taking the most experienced clinicians from the frontline and removes training and support for more junior staff. The government is reviewing the problem but the solution must work for GPs as well as other NHS doctors.
9. Focus on retention
On a final note, recognise that training or importing more GPs will take years and there is no guarantee they will work under the current situation - maybe consider focusing on retention of existing GPs and encouraging more sessions from working GPs with improved pay and conditions. It can take many years to fully integrate into the culture of the NHS and UK general practice. These options are not a quick fix.
Saving general practice
Being an NHS GP has to be one of the most varied, rewarding, and interesting jobs available. On a day to day level most of us love what we do, and simply want to help each and every patient that we have contact with – which is usually why most of us became doctors in the first place.
Many of the issues currently facing general practice have relatively simple solutions, however implementing them requires sustained political will and focus.
- Dr Simon Hodes (@DrSimonHodes) has worked as a GP partner in the same Watford practice since 2001, and is also a GP trainer, appraiser and LMC rep. The views expressed above are his own.