General practices nationally are at breaking point. The current crisis in general practice predates covid-19, but has been intensely magnified by the pandemic. Primary care is rightly called the “Bedrock of the NHS” dealing with around 90% of patient contacts for under 10% of the national budget. GPs are seen as the “gatekeepers” to the NHS providing over 300 million patient consultations each year, compared to 23 million emergency department visits. If general practice fails, the entire NHS will collapse. When patients struggle to see their GP, work spills into unscheduled care settings including the emergency department, leading to inappropriate attendance and use of hospital services. Despite all this, more and more work is being transferred to primary care without the associated funding or resources.
Both the British Medical Association (BMA) and the Royal College of General Practitioners (RCGP) recently acknowledged the increasing pressures on general practice. . GP teams nationally are exhausted from the pandemic, struggling with a toxic combination of increasing patient demands, poor retention, and a depleting workforce. GP teams are now more accessible than ever due to digital platforms, dealing with the increased risks and complexities of remote consulting. We have helped deliver over 75% of a mass vaccine rollout alongside routine patient care, while running community covid hot clinics and supporting over 1 million patients in the community with long covid. In addition we are supporting the millions of patients waiting for delayed outpatient treatments (recent BMA data estimates that between April 2020 and February 2021 there have been 20.07 million fewer outpatient appointments and 3.24 million fewer elective procedures).
A year’s worth of GP care per patient costs less than two trips to the emergency department, and for the past decade funding for hospitals has been growing around twice as fast as for our family doctor services. Work in secondary care is tariffed, in stark contrast to primary care where we work to a set fee, per person, per year, so no matter whether patients consult their GP every week or not at all, we are paid the same. Commissioners therefore have a vested interest in shifting work from secondary care to the much cheaper primary care which lacks the appropriate funding or extra resources to cope with it.
Contrary to widespread reports across some sections of the media, GP surgeries have remained open throughout the last year, using remote consultations and digital solutions where possible in keeping with NHS England guidelines. In addition to performing their regular contracted duties, GPs have also provided significant contributions to the UK’s largest vaccination programme, and data shows that we are busier than ever before.
At a time when practices are being shut down at record rates, staff resignations are rising, and over 20% more GPs are presenting with burnout to the NHS Practitioner health service, it cannot be more important to roll out potential solutions to this crisis. Staff wellbeing needs to be at the heart of healthcare delivery. Maslow’s hierarchy of needs is a favourite among GP trainers, but colleagues frequently go without breaks and food. An exhausted GP cannot perform at their optimum capability and ensuring staff have their basic needs met alongside peer support is essential. There is no cap on the number of patients seen in a session, with 25 stated as a safe level, but many GPs now report up to 60 clinical encounters in a “half day.”
There is no doubt that every single frontline GP is likely to have some ideas for improvement, and a recent BMJ rapid response lists some suggestions. Our leaders need to urgently find practical and achievable solutions, and we would like to present some ideas:
- Firstly, address red tape, bureaucracy and long hours, which are all key causes of low morale and burnout. Much of the GP box ticking is demoralising, not evidence based, adds little to patient care, and detracts us from our core work. Look for soft touch high trust performance monitoring, including a deferment of Quality and Outcomes Framework and Investment and Impact Fund this financial year. Reduce the additional pressures on staff by re-examining the need for CQC inspections, appraisals, and revalidation. While regulation of GP teams is essential, it should also aim to be straightforward, supportive, collaborative, scientific, and respectful. Chaand Nagpaul has recently called for review of the CQC process.
- Immediate changes are needed to enable hospital teams to generate their own inter-departmental referrals, medical certificates and additional investigations. Secondary care should have the same digital technology enabled as primary care – including interactive SMS, and electronic prescribing (EPS). These simple changes would help prevent the increasing perception of unresourced extra workload being moved to GP teams, many of whom feel they are being used as “community house officers.”
- Simplify referral processes – for both routine work and acute care. A GP referral should be straightforward, and should serve as a clear message to the relevant provider that our patient’s needs can no longer be entirely met within the community according to our professional judgement.
- GP teams cannot be everything to everyone, and our resources are finite. There is clearly a mismatch between “supply and demand” at present and we need to be clear about our boundaries. There is funding via Primary Care Networks to employ allied health care professionals through a scheme called the Additional Roles Reimbursement Scheme. These extra staff are already making a significant impact on patient care, and the ARRS could be easily and rapidly expanded to recruit, retain, and support more healthcare professionals within GP teams.
- Enable flexible working to become the norm. NHS policy is suggesting a move to a “total triage.” Remote working opens the NHS up to a whole new cohort of workers who can provide certain services such as eConsults and telephone triage from home, simultaneously creating more consulting rooms for face to face appointments. Parents, carers, and even those who have taken early retirement overseas may find this appealing.
- Invest in health promotion through education and support at a community level, tackling the lifestyle elements that contribute to many chronic diseases, and trying to address health inequalities. The recent letter penned by Ivy Grove Surgery in Derbyshire shows palpable frustration with the way patients use their services – but patients can’t be blamed for their navigation of a system that many health professionals struggle with. Put the NHS on the school curriculum and educate people about this from childhood.
- We need a strong media team co-ordinated by GP leaders to ensure that the public, and more importantly, our own colleagues have an accurate understanding of what we realistically can and cannot do, and how to access GP teams safely and appropriately.
- Above all we need to keep patients in the centre of what we do and involve them in planning the services they use. We should look to offer continuity of care which is shown to be more satisfying for care providers, and has proven benefits for improved patient care, experience, safety, efficiency, and possibly even life expectancy.
Throughout the pandemic the focus, extra funding, and media coverage has been very much on secondary care. We would argue that now is the pressing time to address the growing crisis in general practice where small changes can and will make a huge difference.
In the words on the NHS Five Year Forward View: “If general practice fails, the NHS fails”.
We cannot allow this to happen.
Simon Hodes has worked as a GP partner in the same Watford practice since 2001, and is also a GP trainer, appraiser and LMC rep. Twitter: @DrSimonHodes
Shan Hussain has worked as a GP in Nottinghamshire since 2007. He is presently standing for election to the GPC to represent Derbyshire/Nottinghamshire. Twitter: @DrShanHussain
Neena Jha is a salaried GP in Hertfordshire with an interest in emergency care and global child health. Twitter: @DrNeenaJha
Lizzie Toberty is a Salaried GP in Newcastle-upon-Tyne, Doctors’ Association GP Committee, Regional Next Generation GP organiser. Twitter: @lizzie_toberty
Ellen Welch is a GP in Cumbria and Editorial Lead at the Doctors’ Association U.K. Twitter: @wanderingwelch
Competing interests: none declared.