Can we say ‘we told you so’ now?
Life, to use the Great British art of the understatement, has been pretty tough in general practice recently. Over the last decade, the proportion of NHS money invested in General Practice has dropped from a peak of over 11% to a low point of 7.2%. At the same time:
- With an ever-older population which has far more complex health needs, patients are being discharged much more quickly from hospitals. That means we’re providing infinitely more complicated care in the community for sicker and sicker patients
- We have endless targets to reduce hospital outpatient referrals so that in most areas more than one GP needs to review a case before referral to hospital is allowed
- We also have endless targets for reducing prescribing costs, which involves not just refusing more expensive drugs but also switching patients to more cost effective versions. To do this safely, we have to go through the records of every patient on a medicine to check whether a cheaper alternative would be as good for them
- We spend far more time than ever ticking boxes to prove we’re doing what we know we’re already doing – and then the Care Quality Commission descends to pick holes in our figures, never giving encouragement for all that we have achieved
- Patient consultation rates are going up year on year, not just because of more illness but because patients who have their own pressures demand immediate ‘cure’
- We feel stuck in the middle between our Public Health responsibility to prescribe fewer antibiotics, and patients who press loud and hard to be given them
- Patients believe everything they read in the tabloids about GPs being overpaid and underworked, and morale in general practice has never been lower.
The domino effect is serious. 1 in 10 GP training places went unfilled last year, and 1 in 3 were unfilled this year after the first round of interviews. 1 in 3 GPs in the UK are planning to retire in the next five years, and many of them are starting to go already. If a practice loses a partner and can’t replace them – many of my colleagues put out national adverts and don’t get a single applicant – more pressure is left on the doctors who remain. I am officially ‘part time’ in my practice, working 2/3 of full-time – but my ‘eight hour day’ usually lasts from 6.30am - 8.00pm, without so much as a 10-minute coffee break. For doing so, I earn less than a tube driver. We GPs know it’s hard to get GP appointments – we’re patients too – but we can’t magic more staff out of thin air, and someone has to provide the service.
But while the vast majority of my patients are wonderful, we spend more and more time feeling the brunt of dissatisfaction which should be aimed at the Government. Yesterday a patient told me that the GPs in my practice were ‘being irresponsible by taking on too much. Why don’t you just accept that you need more doctors?’. The same day, another explained seriously that the reason he hadn’t been getting any of his essential monitoring tests was because he didn’t want ‘to see a different doctor every time I come to the practice. If you and your kind would just stop leaving, I would have turned up to my diabetes checks and I wouldn’t have put on two stone’. Many complain when I (inevitably) run late. But if I extend my consultation times to 15 minutes, we’ll have even fewer appointments.
But finally, the government has realised that there’s a real problem, and has stepped in with a series of plans to improve the situation in general practice – and the funding to make it happen. Announcing their plans, NHS England chief executive Simon Stevens was remarkably honest about the mistakes of recent years in terms of priorities. He admitted "GPs are by far the largest branch of British medicine and as a recent British Medical Journal headline put it - if general practice fails, the whole NHS fails. So if anyone 10 years ago had said, 'Here's what the NHS should now do - cut the share of funding for primary care and grow the number of hospital specialists three times faster than GPs,' they'd have been laughed out of court. But looking back over a decade that's exactly what's happened. Now we need to act and this plan sets out exactly how."
These plans include:
- £2.4 billion a year for the next five years, to bring the proportion of the NHS budget spent on general practice up to 10.4% by 2020
- Plans to reduce bureaucracy, so increasing by up to 10% the amount of time GPs have to see patients rather than push paper
- Investment in healthcare assistants and other staff who can do the work GPs don’t really need to do, freeing us up to do the really complicated stuff nobody else can
- Changes to hospital contracts to avoid GPs having to duplicate workload by making endless re-referrals to different departments in the same hospital
- Investment in an extra 3,000 mental health workers to support practices by 2020. Mental health has long been a Cinderella service where NHS funding is concerned, so this is particularly welcome
- Funding for 1,500 pharmacists to work in practices, including seeing some patients for routine reviews. Practice nurses have done an amazing job in taking on routine follow-up of patients with long-term conditions like asthma and type 2 diabetes. Pharmacists could, with the right training, offer great expertise in checking medications and ensuring patients have the right medicines and are using them to best effect
- Moves to reduce the hopeless amounts of inappropriate bureaucracy involved in CQC visits
- 18.5% increase in investment in IT
- A target of 5,000 more GPs in five years.
Of course, much of this depends on encouraging junior doctors to choose to train in general practice – and not to move to Australia the moment they finish their training. And to do that, it needs to stop junior doctors leaving the profession before they even reach the stage of choosing a specialty. Jeremy Hunt’s shocking mishandling of the junior doctor contract has resulted in the first all-out strike action by doctors for 40 years – they don’t want more pay; they want a contract that ensures patient safety. The government will have to work very hard to rebuild the trust of the medical profession. And if the medical profession folds, so does the NHS.