The minister needs to do his maths
It was the day GPs had been waiting for, with trepidation (most), eager anticipation (a few) or something in between. On Friday, Jeremy Hunt, Health Secretary for England, set out his plans for general practice. We all knew things were going to change - the Conservative party had made 7 day a week 8am-8pm GP availability a major plank of their election manifesto. We all know things have to change - the current GP recruitment crisis means most of us can't cope with the impossible workload we already have. The question was how Mr Hunt was going to make the two sides match up.
From the GP's perspective, there was good news. After years of feeling undervalued by politicians, Mr Hunt admitted GPs were right, stating that successive governments had 'undervalued, underinvested and undermined the vital role general practice has to play'. He promised investment in terms of both money and workforce. In brief, the promise is:
- An extra 5,000 GPs within the next five years
- More money for general practice, which now receives only 8.3% of the NHS budget rather than the 11+% allotted to it a few years ago
- 'Golden hellos' to attract GPs to more deprived areas
- 1,000 'physician associates' to help with simple GP cases by 2020
- A total of 5,000 extra non-GP clinical staff to help cope specifically with older, sicker patients.
So far so good - but in return for this he expects practices to see patients for 12 hours a day, 7 days a week - and that's where the maths doesn't add up.
In the last four years, the number of GPs per head of population has fallen while consultations have increased by 13%, up from just over 300 million to 340 million a year. Within five years, Hunt points out that there will be a million more over-70s than there are today.
The most recent workload survey from the British Medical Association shows that 74% of GPs have an unsustainable workload, compared to 52% of consultants and 18% of junior doctors. Over 60% always work outside their working hours and two thirds are planning to leave before they get to retirement. In fact, one in three are thinking of leaving the NHS within the next five years (one in 10 are planning to work abroad - despite what you read in the media, they most definitely don't earn enough to retire for life at 50 or even 60). Looking after patients in general practice is incredibly rewarding but mentally extremely taxing - as a journalist colleague of mine put it, if he makes a mistake nobody dies. But it's the bureaucracy on top that's killing us, and Jeremy Hunt has said nothing about cutting that. He claims to have cut targets since the coalition came into power - but as a GP I can promise that the layers of other paperwork he's added more than outweigh that.
We don't have enough doctors as it is in general practice - GP vacancy rates rose from 4.2% to 7.9% between 2011 and 2013 and the number of GPs as a proportion of all doctors in England has fallen from 34% to 26% in two decades. Add to that the 15,000 who could leave by 2020 and Jeremy Hunt would have to find an extra 20,000, not 5,000 new GPs in the next 5 years to meet his target. For the last few years there have been about 2,700 trainees a year, with about 15% of the existing training places going unfilled last year because of lack of applicants. To get an extra 20,000 GPs by 2020, the number of trainees would have to double.
But hospitals still need doctors, and that would leave a great gap in the number of hospital trainees unless we start training more doctors. Even if universities could start tomorrow, it takes at least five years to train a doctor and 10 to train a GP. What's more, we would need about 2,500 more GP trainers - and they take at least a year to qualify as trainers, even if they're prepared to put themselves forward. GP training is a fantastic opportunity - I wouldn't have been doing it for 20 years if it wasn't - but it's very hard work.
We won't stop GPs leaving unless we do something about the pressure they're under. An extra 10% added to the workforce would certainly help that - but not if at the same time we had to provide 12 hour a day, 7 day a week access. The vast majority of GP consultations come from children and older people, who are much better served by being seen in the weekday, when other hospital services and investigations are available. Most practices offer some evening and Saturday opening, but colleagues of mine who have opened on Sundays say demand is low. I fear the Health Secretary has spent too much time listening to focus groups of healthy adults, who rarely need a doctor. There must be a middle ground which would satisfy them but not make the current flood of GP resignations worse. Jeremy Hunt would be better served spending some of his time brushing up on his maths.