General practice is in a state of crisis. Despite the promises and the optimism of proposed plans to reform primary care over the next five years, the reality on the ground offers little comfort.
The GP Forward View (GPFV) published 12 months ago promised us 5,000 more GPs by 2020. So one year on, where do things stand? Yes, there was a rise in GP trainee recruitment in 2016 (167 more trainees than in 2015), but overall, GP numbers are falling. According to the latest NHS England figures, 92 practices closed in 2016, up 114% on GP surgery closures in 2014. While 34 merged with other practices, the remainder shut completely. And the number of GPs fell by more than 400 between October and December 2016 alone.
While the lure of jobs abroad, early retirement and locum jobs explain some of these figures, there is a growing crisis in retention. In the south–west, a survey of more than 2,000 GPs, published today, has found that around two in five GPs intend to quit within the next five years. More than half report low morale.
Poor retention is also both a cause and effect of staff shortages and escalating workload (with 12- to 14-hour days). A recent British Medical Association poll showed that 84% of GPs find their workload unmanageable. Reduced take-home pay, particularly for partners as practice costs increase, is also a factor, as is red tape. There is more paperwork than ever before, as work is shifting from secondary to primary care. Resources are stretched and rationing more widespread. I see a greater influx of patients, a faster turnaround from earlier hospital discharges, more limited access to outpatient referrals and longer waits for elective surgery. A significant amount of work also goes into preparing for Care Quality Commission visits, with the bulk of the responsibility on the shoulders of practice managers and partners. And where the government has given primary care more funding on the one hand, it has taken away with the other by cutting investment in other areas or linking it to extending access or seven-day services.
The effect on patients of this shortage of GPs is stark. The scale of practice closures meant that 265,000 patients had to register with a new surgery last year and now often face travelling further to see a doctor. Yet the government is still keen to develop super-practices of 30-50,000 patients, despite GPs and patients not being in favour of these models that reduce continuity of care and autonomy. It feels like we are being pushed towards privatisation and a salaried GP model, stripped of the sense of ownership for our practices and responsibility that we feel for our staff, premises and patients.
As one of the antidotes to the retention crisis, the practitioner health programme (PHP), commissioned by the government for GPs, was rolled out earlier this year and in only four weeks it saw the number of GPs it was commissioned to see for the whole year. The PHP has cited stress, burnout and post-traumatic stress disorder as some of the commonest problems faced by GPs, often from “practice meltdown”.
One year on from the GPFV we have seen little change when it comes to improving the working lives of GPs, who may be independent contractors but nevertheless work for the NHS and provide a crucial and cost-effective service.
Retention schemes to keep over-55s in work by allowing them to work more flexibly, or giving “golden hellos” to trainees to work in under-doctored areas are all a drop in the ocean. The PHP is certainly welcome and well overdue. But it would also make sense to increase core funding of general practice to reflect the explosion in workload. This will improve retention and recruitment. As things stand, it seems a herculean task for the government to rescue something it has little understanding of or empathy with. It may be time to go back to the drawing board.
Time for a rethink on GP numbers | Zara Aziz
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