Figures released last week showed a shortfall of one thousand General Practitioners (GPs) in England. In the same week NHS England announced that it would spend £10 million on a range of new schemes to encourage older GPs to put off retirement and encourage those who have left the profession, or the country, to return to GP practice in the UK. The British Medical Association has raised fears that the high average age of GPs, the poor work/life balance and the increasing workload could result in as many as 500-600 GP surgeries closing as GPs take early retirement or choose to leave the profession altogether. Schemes announced by Heath Secretary Jeremy Hunt include the use of promotional videos to demonstrate to medical students that GP practice is just as glamorous as other specialisms, showing GPs working on cruise ships, options to work part time and more flexibly, and the reduction of bureaucratic hurdles for those returning to General Practice from overseas. There is a looming crisis in GP care, the cornerstone of the new look NHS.
The BMA compile a quarterly tracker survey of GP morale and workload. For July/August 2014 by the BMA showed that almost three quarters of GPs stated that their workload was always unmanageable, and over half rated their morale as very low (poorer than all other specialties surveyed). As many as 60% of GPs surveyed reported they were considering early retirement and 28% had considered leaving the profession altogether. GPs were also least satisfied with their work/life balance. When asked why they were so unhappy the GPC, General Practice Council chairman Dr Chaand Nagpaul highlighted three key factors: first, rising patient demand – precipitated by an ageing population, second, declining resources and third, increased pressure to provide services as part of the government led transfer from hospital to community based care. Increasingly GPs are being forced to work in large practises and to provide additional services such as diagnostic services and minor surgery. It is estimated that approximately 340 million patients are seen in primary care each year, up 13% over a four year period.
And yet over the past decade we have been told that GPs have never had it so good. The change in GP contracts under the previous Labour government meant that GPs no longer had to provide cover for their patients at night or over the weekends and their pay went up dramatically. We were bombarded with stories from the media about average earnings topping £100000, thousands of GPs earning more than the Prime Minister, GPs being paid £200 an hour to cover weekends and evenings that they used to do as a routine part of their job and UK GPs being the best paid in the industrialised world. On top of this, the recently introduced Health and Social Care Act (2012) places GPs at the heart of the NHS, with considerable influence over decision making and control of 2 thirds of the NHS budget.
So what has gone wrong?
Possible explanations for the GP crisis include the reluctance of medical students to enter a specialism that is seen as low status within medicine and is used as a political football, either lauded or pilloried by the government. In 2014 just 23% of medical trainees were planning to go into GP training, a fall of 6.2% in a single year. Another suggestion is that, at the other end of the profession, the tail end of the baby boomer generation on final salary pensions simply do not need to deal with increasing workloads and reducing morale. Whilst a cohort of GPs plan to retire each year, however, the feeling within the GPC this year is that many additional GPs are planning to retire with regret because they can no longer cope with the working conditions.
Other possible explanations, from outside the professions, have also been put forward. For example, the Migration Advisory Committee suggests a two-fold explanation. On the one hand they propose the feminisation of the workforce accounts for the GP shortage because women are more likely to work part-time or reduced hours once they have had children. Interestingly, however, the government does not seem to feel that this is a problem as the possibility of part-time work is one of the incentives being offered to draw people back to the UK to work as GPs. The second explanation offered is that we are not recruiting enough foreign doctors as language requirements and strict NHS standards are too stringent. The report states that only approximately 20 GPs are recruited from the EU each year and this number should be raised. These explanations very clearly locate the problem as being external to negative implications of workload and low morale within the profession.
Others suggest that the problem lies, in large part, with the funding crisis brought about by the current governments ideological austerity programme. Writing in GPonline, BMA deputy chairman Dr Kailash Chand stated that “While the government claims the NHS budget is protected, in reality it has suffered £20bn of cuts – billions of which have come from a sustained attack on staff pay”. On top of this, PFI facilities charges are twice the rate paid for non PFI facilities and the money to pay the difference comes through diverting money out of patient care. Dr Chand goes on to argue that as primary care accounts for 90% of patient contact in the NHS, in a time of rising demand and increasing health inequality, additional investment in primary care is the only way of ensuring patient care and, ultimately, the future of the NHS.
The GP crisis could also be seen as yet another result of the government’s piece by piece dismantling of the NHS. Whilst some GPs have signed up to the new regime and both support and profit from the insidious privatisation, many more are demoralised and feel that their ability to uphold their hypocratic oath is being eroded on a weekly basis by workload and resource pressures. Whichever explanation is favoured, the inevitable end result of draconian funding cuts alongside increases in demand from patients and government is likely to be a fall in standards of patient care and ultimately increasing death rates from preventable causes.
Chloe Carter on Mar 6, 2015
Really interesting article, thank you. So many of the NHS New Models of Care vanguard bids (their buzzwords, not mine) identify GPs as the single-point-of-access for all local health and social care services. Tricky to see how sustainable those models can be unless these issues are addressed.
Mary Hawking on Mar 7, 2015
Could I make a factual correction?
GPs are not and never have been on a final salary pension.
However, the the problems with recruitment and retention of GPs have been greatly increased by the actions of the Coalition Government and NHS England in imposing changes which greatly decrease the attraction of general practice as a career choice.
In addition to the ever-increasing workload and decreasing income noted in the article,there have been recent changes in the NHS Pension scheme (fully negotiated in 2008 to provide future affordability – then revised by the Coalition government without costings or consultation) which mean that GPs may be obliged to pay over a quarter of their income into a scheme with greatly reduced benefits; the removal of Seniority (the only recognition GP principals get for increasing experience) and the destabilisation of practice – as opposed to GP – income by removal of the Minimum Practice Income Guarantee which allowed the continuation of GP services in situations such as rural environments and abnormal populations (most practices serving student or large numbers of non-English speaking patients are now financially unviable) certainly contribute to the lack both of a GP workforce *and* to the willingness of such GPs as remain to take up GP partnerships – and take the responsibility – and financial liability – of trying to manage increasing workloads with rapidly decreasing resources and no limitation on hours worked (the down-side of being “Independent Contractors”!).
The Health & Social Care Act 2012 was promoted as giving GPs control: in fact any control was immediately severely restricted by requirements to prevent conflicts of interest (such as paying GP practices for needed additional services) and top-slicing their budgets to provide funds for NHS England: the management funding was reduced to less than a third of that for the preceeding PCTs: is anyone surprised that there was little enthusiasm from front-line GPs expected to take time from patient care to “engage” with their CCGs?
I was fortunate to be in a position to retire before it was fully implemented.
Whether the effective destruction of general practice was planned or not, I would love to see the Risk Analysis for the HSCA even now: what is this Coalition Government – which lacks any electoral mandate – so determined to conceal?