Written evidence submitted by The Royal College of General Practitioners (WBR0076)

Overview

• The RCGP welcomes the opportunity to share its response to this important inquiry on workforce burnout and resilience in the NHS. Our membership is comprised of 53,000 doctors across the UK and our response will focus on primary care.

• Throughout the pandemic, GPs have continued to deliver the vast majority of patient care in the NHS, transforming the way services are delivered to ensure patients, GPs, and their teams are safe and preventing the spread of Covid-19. General practice ran ‘hot-hubs’ to triage those with symptoms of Covid-19 whilst caring for patients in care home settings and more than 2 million shielded patients.

• As we emerge from the first wave of the pandemic, general practice will play a key role managing Covid patients in the community, helping prevent an outbreak of winter flu through an expanded vaccination programme, and dealing with a backlog of cases caused by the national lockdown.

• The key role that general practice will play in the next stage of managing the population’s health post-Covid means that it is essential that the workforce within primary care is supported to continue to provide high quality patient care.

• The RCGP is now calling for a sustained focus on wellbeing initiatives including the enhanced availability of the NHS Practitioner Health Services and wellbeing initiatives, and the roll out of fully funded occupational health services within general practice.

• It is essential that primary care does not return to an overburdened and cumbersome regulatory environment post Covid-19. Throughout the pandemic there have been a range of positive changes to reduce bureaucracy and ensure that GPs have more time to care for patients. These must be retained.

• If general practice is to be sufficiently resilient as we head into a busy winter period, and face the possibility of a second wave, there must be adequate staff capacity in primary care. This includes enhancing existing GP retention programmes and ensuring that additional resource is made available to support practices with rapid recruitment exercises to meet urgent need.

Workforce resilience and wellbeing

1. The Institute for Employment Studies in partnership with the RCGP recently undertook a study exploring workforce wellbeing during the Covid-19 pandemic. It was commissioned by NHS England NHS Improvement and found that wellbeing is “low” across NHS staff and below that of pre-Covid population norm. Resilience was also found to be at a level which indicated a “low” ability to cope.

2. Over the past few months, NHS England and Improvement have delivered a range of initiatives to support wellbeing. This includes the provision of helplines, wellbeing apps and training resources, which has been welcome. It is essential that investment in sustaining these efforts is provided alongside research to demonstrate their effectiveness and any outstanding gaps which could be filled.

3. For example, the NHS Practitioner Health Service provides specialist support to GPs, as well as other doctors and dentists, who are dealing with mental health issues, and whose needs have progressed beyond the scope of lower level wellbeing support initiatives. We have heard positive anecdotal reports about the effectiveness of the service and would like to see the service made available to all staff to support their retention in the workforce.

4. Across general practice, there is no standardised approach to the commissioning of occupational health services that supports staff to remain in the workforce. Fully funded occupational health services must be rolled out for general practice, including to support Covid-19 risk assessments in practices, as called for by the British Medical Association. This will be particularly needed to support staff struggling with burnout and possible Post Traumatic Stress Disorder for those who have worked in ‘hot-hubs’, urgent settings or other highly stressful situations during the pandemic. 

5. Those working in under doctored areas have been particularly susceptible to workload burnout during the pandemic due to having less workforce to see patients. Evidence from the Health Foundation[i] also suggests that doctors in under doctored areas are more likely to be at a higher risk of Covid-19, and work in an area where spread of the virus has been higher. To protect these doctors, they must be prioritised with regards to occupational health and mental health services. This is particularly important post-Covid when their patients will be returning with worsening health problems. It is crucial to retain doctors in these areas.

6. We now know the tragic extent to which BAME GPs and their practice staff have been disproportionately affected by Covid-19. This has had an impact on burnout levels amongst BAME staff. The College is calling for the urgent development of culturally competent occupational risk assessment tools as it is essential that BAME GPs can practice without concerns for their safety. Primary care staff must also be included in the NHS Staff Survey to provide an accurate depiction of the professional experience of BAME GPs and our teams. If we are to fully understand where further actions are needed, we must have access to more comprehensive and robust data.

Regulatory changes due to Covid-19

7. GPs and their teams have been working hard throughout the pandemic delivering care to patients with both Covid and non-Covid conditions. During the outbreak, general practice has seen a significant shift in ways of working and bureaucratic responsibilities placed on GPs. Over the past few months, we have seen a temporary suspension or relaxation of many of the routine regulatory processes and contractual requirements. This included the suspension of inspections of practices, relaxation of appraisal and revalidation requirements and several contractual obligations.

8. In a survey by the RCGP in July 2020, GPs said that lower workload administration during the height of the pandemic, resulting from the relaxations of CQC and QOF requirements for example, meant that 67% of GPs felt less stressed and 54% felt able to deliver to higher quality patient care[ii]. In the same survey, the vast majority of GPs said they anticipated several Covid-19 related issues impacting their workload in the future, including indirect consequences like longer waiting times for specialist treatments. Figures from the RCGP and Oxford University’s Research and Surveillance Centre show that the number of GP appointments have moved back up to approximately pre-pandemic levels. While appointments over the last four weeks are down slightly on 2019 figures, this is fluctuating, and appointments were 15% higher at the end of August than in the same week in 2019.

9. Anecdotal evidence from RCGP surveys also suggests that the length of appointments has become longer, and feedback from our members suggests this is likely due to remote consultations taking more time. It is likely that workload could be even higher than current data is able to capture, which only measure the frequency of appointments rather than the length. Clinical administration, including workload such as referrals and communications with secondary care, requesting tests, reviewing and issuing prescriptions, has been significantly higher than the previous year for the last two months. [iii]

10. Throughout the pandemic, GPs and their teams have demonstrated that they can be trusted to deliver safer patient care without spending hours on paperwork and bureaucracy. College surveys of members have shown that GPs have found that a reduction in bureaucracy has enabled them to spend more time with patients and supported them to deliver better quality care. If the system is to be sufficiently resilient during a second wave, it is essential that we rethink the regulatory context in which GPs work and make it more proportionate for GPs.  The Royal College of GPs explored this in more depth in the recent report General practice in the post Covid world.[iv]

Workforce numbers & NHS People Plan

11. If general practice is to be sufficiently resilient as we head into a busy winter period, and face the possibility of a second wave, there must be adequate staff capacity in primary care. The RCGP has long called for the accelerate of workforce expansion programmes and an increase in investment in the schemes which incentivise new and experienced GPs to work in areas of greatest need.

12. Recruitment initiatives and funding for the wider practice team within general practice should be expanded and accelerated, including more flexible funding from October 2020 for the recruitment of additional roles that meet local needs, such as mental health therapists. We would also encourage the development of targeted recruitment campaigns to increase the wider practice team workforce, with a particular emphasis on rapid recruitment within areas of high deprivation.

13. There is, however, a risk that these efforts could be undermined by the intention of many GPs to leave the profession altogether. A recent RCGP survey found that 24% of GPs expect to decrease their sessional commitment over the next 12 months, while a further 7% plan to stop completely and retire.  Additional support is therefore needed to retain experienced staff at all levels and in roles across primary care to retain them in the workforce.

14. The NHS People Plan, published in July 2020, acknowledged the need to grow the GP workforce. Many of the aspirations, values and behaviours contained within the Plan would go some way to increasing the resilience of NHS staff. It seeks to build on positive changes implemented within the COVID-19 response, particularly around staff wellbeing, flexible working, redeploying staff and supporting returners, to prepare for short-term pressures this winter and for the longer term.

15. Despite this, it was frustrating to see a lack of specific detail on how many of these ambitions will be delivered. There are significant gaps within the Plan, namely clarity on how commitments to deliver 6,000 more GPs and 26,000 additional staff in primary care will be met, particularly if not underpinned by clear funding for training and development of staff or additional support outside of employment costs.

16. This is significant as workforce recruitment is more important than ever. Nearly a quarter of GP practices have delayed recruiting staff during the pandemic, due to infection concerns and the prioritisation of urgent patient care. As workload increases in general practice, it is essential that additional resource is made available to support practices with rapid recruitment exercises to meet urgent need, both for GPs and the wider team.