Looking at the results of our recent survey of London GPs, I can honestly say that I am frightened for the future of general practice in London.
We are sitting on top of a three-year timebomb. By July 2018 London could lose as many as 10% of its GP practices. For patients that is an unsustainable rate of loss.
We recently polled all of the 1,340 GP practices in our network to find out about the workforce challenges they face at the moment, and to gauge their plans for the future. The results were worrying: 70% of the 431 practices who responded have at least one GP who is planning to retire within the next three years; and 10% are considering handing back their contracts and leaving the profession entirely in the same timeframe. That means over 330,000 patients could lose their GP in the next three years if all 43 practices considering terminating their contract ended up doing so.
Rising GP stress
In London there are fewer and fewer surgeries trying to cope with more and more patients at a time when the population is growing. And there is increasing stress on GPs and practice nurses who have to deal with patients who have been displaced – nomadic patients – who end up moving around local surgeries and having to tell their stories all over again because a practice they have been with for many years has suddenly shut because the doctor has gone.
Patients are at risk of losing their GP services and relationships with family doctors built up over many decades in some cases. And each displaced or dispersed patient will get a new GP who they have to start to get to know: all of which takes practices time and money at a time when both are stretched to breaking point.
But why is this? When I began working in general practice, GPs felt fulfilled by their work and revelled in the mutual trust and respect between them and their patients, many of whom had been cared for by that GP over many years. Established GPs, as partners, invested time, money and commitment to their practices and felt ownership and belonging. They were valuable and felt valued.
How times have changed! Over the last five years, the GPs I meet who intend to remain in work a moment beyond the time when taking their pension becomes practicable are, on the whole, those forced by external (usually financial or family) circumstances to remain in work. I have been surprised by the numbers of my friends and colleagues whose commitment to their profession, partners, practices and patients verged on the pathological, who have decided to leave in their late fifties or early sixties, and who tell me they do not regret their leaving or miss the work.
GP workforce crisis
So what’s the reason for this volte face? Our survey found the most commonly cited reasons for leaving the profession to be de-professionalisation, workload, appraisal/revalidation, desire for better work life balance, overregulation, bureaucracy and perhaps saddest of all, that it is no longer fun.
This is all bad news for the government – which relies on general practice to act as a buffer in the community and for whom the contractual relationship provides "cover" whenever there is talk of problems with accessing primary care services. It is bad news for the profession – who struggle to bang the drum for, and recruit into, general practice whilst the incumbent GPs are vocal about the problems that they face day in day out.
And most of all, it is bad news for the patients who rely on their local GP and – for the most vulnerable of patients – have developed a relationship of trust with their local GP and rely on the continuity of care that provides.
We need more GPs delivering core services, not fewer. An ageing population with multiple morbidity needs increasing numbers of longer consultations and need the GP’s skills as an efficient co-ordinator of care; the days will soon be gone when a full time GP could reasonably manage the needs of about 1,800 registered patients and there are good arguments for the need to increase the GP workforce.
Support general practice
Younger GPs rarely have the business and management skills that older partners have developed over many years of running a practice and a business; such skills are ever more necessary in the current environment, both within practices and the emerging grouping of practices and in dealing with the many other bodies which have a bearing on modern general practice.
We need urgent help for general practice: supporting existing GPs and encouraging new blood to enter the profession. In order to transform the way in which general practice operates, we first have to create stability. I support calls from the RCGP for the creation of a 'stabilisation fund', with hypothecated money ring fenced from the NHS budget, to support practices at risk of closure.
Before developing grand plans and schemes for increased access, we must first be confident that we can maintain a safe service for patients. To improve healthcare, the NHS should refocus attention and support on the service where all patients begin their NHS journey, in general practice.
