Britain is broken in many respects. From filth in our waterways to chaos on our transport networks, the potentially apocalyptic climate emergency, the negative impact of Brexit, economic meltdown, rampant inflation, unaffordable energy costs and entrenched poverty and inequality, and now a standstill in our court system. We are facing multiple crises.
This litany of disasters has been brought about by long-term political failure. Nothing works properly. The precarious state of the NHS is one that should concern us all. In this article we examine ‘the jewel in the crown’ of our National Health Service: general practice. Primary care is the foundation of the health system. GPs play a vital role in diagnosis, in managing and monitoring patients, and in promoting good health.
Unsustainable pressures
The latest GP statistics reveal that there are fewer qualified full-time equivalent GPs than five years ago. Professor Martin Marshall has called the situation “unsustainable and unsafe” for patients and staff. He said, “the result is a chronically overstretched and under-resourced general practice service”. He points out that the situation is likely to get worse, as almost 19,000 GPs, out of a total of 45,000, may leave the profession over the next five years with many citing intolerable stress and excessive working hours. Many in the profession share his concerns that general practice is in a critical condition, the Cinderella of the NHS: undervalued, underfunded and understaffed.
It is important to acknowledge that problems with access to GP appointments are not new. Pressure on appointments in general practice was already a major issue before the pandemic, with significant pressures on general practice. A retrospective study published in The Lancet in 2016 assessed the direct clinical workload of GPs between April 2007, and March 2014, and revealed an increasing number of patient-doctor/practice nurse consultations alongside a decrease in the number of full-time equivalent GPs. Sadly the situation has further deteriorated. Perceptions of rapidly rising workloads in English general practice are well founded and the overall system seems to have reached saturation point.
Among the complex factors exacerbating these problems are the changing health needs of the population, as it grows and ages. Increasing numbers of people suffer multiple chronic conditions and on average, more people of all ages are consulting their doctor more frequently.
In 2015, the NHS Five Year Forward View promised a better health service following a history of long term under-investment. The government proposed an increase of 5,000 more GPs by 2020. In reality, by March 2021, there were 1,307 fewer full-time equivalent posts than in 2015. Also, the proportion of spending on general practice had fallen – from 9.6% of the overall NHS budget in 2005/6, down to 8.1% in 2017.
Barriers to accessing primary care
The pandemic undoubtedly exacerbated these pressures as primary care had to address pent-up demand created during the lockdowns, provide the clinical care for Covid patients, deliver the vaccine, and support patients caught up in the backlog of cases. GPs were instructed to move rapidly from face-to-face consultations to triage, telephone or digital advice to patients first, in order to keep patients and staff safe. Greater use of digital technology had been on the agenda pre-Covid, but without doubt the pandemic accelerated its introduction. In fact digital access may increase demand by patients, by lowering the threshold for seeking help.
As the push for digital services as the default in GP practices continues, there is mixed evidence as to whether it improves access. It seems that patients with the least need for care are, overall, more likely to benefit most from online and digital access to primary care – i.e. those who are younger, white, highly educated and living in affluent areas. By contrast, moving care online has the potential to exchange one set of barriers to care (transportation issues, time constraints) for another (internet access, device capability, digital literacy).
Thus those patients of high social vulnerability are significantly more likely to experience barriers to online primary care. A study by the University of Cambridge found that in areas of high deprivation, general practice is often underfunded and under-doctored – further evidence of the inverse care law propounded by Dr Julian Hart in 1971.
Rise in demand for GP services
Another factor contributing to the rise in demand is the growing issue of workload pressure due to follow-up care transferred to GPs from hospital consultants, with more than than six million patients on elective surgery waiting lists, many of whom will be living with worsening symptoms and needing help from their GP.
A worrying aspect of the current situation is the level of aggression towards GPs in the mainstream and social media. The Daily Mail ran a hostile campaign about face-to-face consultations which inflamed opinion, without any attempt to understand or explain the complexities properly. Stories repeatedly mention GPs working ‘part time’, as if they were slackers, or comment that women of childbearing age shouldn’t be in the job. This vitriolic scapegoating is demoralising and very damaging and only serves to increase the number of GPs wanting to leave.
Mismatch in supply and demand
The root cause of the crisis in general practice is a persistent mismatch between supply and demand. Issues of recruitment and retention of GPs are of critical concern. The shortage of trained and experienced GPs has placed great strain on the profession with knock-on effects on patients. The populist narrative of some media outlets perpetuates the myth that doctors are lazy, greedy and ‘closed for business’ while ignoring the long-standing underfunding of primary and social care and the chronic shortage of GPs. The avalanche of demand must be addressed and perhaps new models of care considered which meet the needs of patients in terms of access and continuity of care.
The staffing shortfall has been further exacerbated by Brexit, as is obvious to all but the most entrenched Eurosceptics. The NHS has never been self-sufficient in doctors; about 25% are born abroad, with 10% born in other EU countries. Many of the latter group have come to doubt whether they have a long-term future in the UK, many are moving elsewhere even though they may be entitled to settled status.
Settled status and the points based immigration system are no substitute for freedom of movement. Furthermore the points based system is linked to earning potential. Other than doctors, many other healthcare professionals and carers are excluded from it. One consequence has been a need for greater recruitment from outside Europe, for example from South Asian and African countries. This runs the risk of depleting those countries of their much-needed and expensively trained health workers, which is in conflict with the World Health Organization’s Global Code of Practice on the International Recruitment of Health Personnel.
When confronted with these painful realities, right-wing politicians and commentators invariably fall back on the call to increase recruitment from within the UK. They know that in the real world this is no solution, but they persist inanely. To turn a school leaver into a GP takes at least ten years, usually more. New medical school places created today would not bear fruit until 2032. Furthermore there is only finite capacity for medical education and training: medical teachers have many more new demands upon their time, and education is not something which has been prioritised in recent NHS reforms, it is one of the things which suffers when marketplace economics prevails. So simply increasing numbers is more easily said than done.
It gets worse…
The low morale of GPS is not new. General practice has worked for years on a partnership model, in which the partners in effect run a small business. Like many other small business owners they have to make the books balance and this involves input of time and effort above and beyond what is contracted. Paradoxically, GP incomes can suffer when an NHS pay rise is announced. A practice has to pay its staff the increments that have been granted, even if, as now, there is not a corresponding increase in what it is being paid. What could be worse than that? One thing worse is hearing candidates for the prime minister’s job declare that GP incomes should be cut by 10%.
And then there are the incessant NHS reforms. These happen with monotonous regularity and each creates uncertainty and extra work for those on the ground. The most recent, the Health and Care Act, comes on top of the Health and Social Care Act from the Cameron era. Both facilitate a model of marketplace economics in the health service which is to a great extent modelled on what Tory politicians see happening in America, despite the glaring inequity and inefficiency of the American system.
And many of the safeguards that would prevent abuse have been stripped away. To bodies such as the BMA, who plead that at this time of great difficulty the last thing we need is the introduction of vulture capitalism to the NHS, the government simply turns a deaf ear. Such radical reforms can be seen by the main stakeholders, i.e. care providers and patients, as malign or ill-informed, or both.
For GP partners in the past it was always reassuring that somebody could step into their shoes on retirement. With an understandable diminution of interest among doctors in becoming partners, there is increasingly a fear that one person will be left holding the baby when all the others have gone. This prospect itself leads many to shy away from starting down the partnership route, preferring to do salaried or locum work.
Frustration for patients
It was recently revealed that 474 practices have had to close in the past nine years, leaving 1.5 million patients needing to find a new doctor. So the vicious circle continues.
From the patient’s perspective, it is entirely understandable that when demand for services is outstripping the available supply, there is frustration. The patient body Healthwatch reports that more than 50% of complaints are now about a lack of access to care, while polls suggest that seven in ten Britons lack confidence that they can get an appointment with a GP.
Many patients value continuity of care in particular. They want a known and trusted doctor as well as timely interaction with their GP. This kind of working is associated with better health outcomes, fewer hospital admissions and higher patient satisfaction.
Conclusion
There seems little appetite within the government to grasp the nettle of crisis in the NHS. Liz Truss has announced that she will stop doctors leaving and entice retirees to return. Quite how this will be achieved is not made clear.
Also she mooted the idea that GPs could be asked to write prescriptions for money off energy bills for the most vulnerable. Doctor and patient groups alike have condemned this plan. It trivialises the issue and shows contempt for those who cannot pay their bills and for GPs. Furthermore it demonstrates how little regard the government has for our National Health Service,
GPs and their teams are already working under an intense workload delivering more patient consultations every month than before the pandemic, but with falling numbers of fully-qualified, full-time equivalent GPs. The way in which we access primary care has undergone significant change in recent years, with initial contact often by phone and a wider range of health professionals involved in treatment and care. However the service is in crisis. Urgent measures and a long term strategy by government is required as a matter of urgency, if the service is to survive, working safely and effectively.
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