Written evidence submitted by Dr Dirk Konig (FGP0010)


Challenges facing General Practice in the NHS over the next five years




What are the main barriers to accessing general practice and how can these be tackled?


For the past 18 years I have been working as a full time GP Partner in a Hampshire practice with 19,000 patients and over 50 employees.


I see the main barrier to accessing General Practice in the lack of trained GPs who are still able and willing to do their exhausting work every day.


Years of steadily worsening working conditions in General Practice, very poor work force planning and punitive tax changes to the NHS pension scheme have all contributed to our current GP recruitment and retention crisis.


To avoid excess pension taxation (which has sometimes resulted in GPs effectively having to pay to come to work), many older GPs have felt forced into early retirement and have now been lost to the profession forever.


The remaining GPs are having to work harder and harder (many GP Partners now regularly work 13-14 hours a day), and as a result tend to burn out more quickly.


This has resulted in increased stress-related GP sickness absence and further resignations, thereby worsening patient access to GPs even further.


Meanwhile the unfunded transfer of work from hospitals to General Practice has further accelerated during the pandemic (GPs now having to manage patients themselves as hospitals are rejecting their referrals, hospitals requesting GPs to follow up patients on their behalf, hospitals asking GPs to do blood tests as well as their sick notes, prescriptions, and re-referrals), which is bringing the remaining GPs to their knees, too.


Improving access to GPs would require cessation of unfunded transfer of work (from all sources) into General Practice, limiting the (currently unlimited) workload GPs are contracted to do, training more GPs and making General Practice an attractive work place again.



To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?


Due to worsening working conditions in General Practice, and despite the promises made by successive governments to recruit an additional 5,000 GPs (later upgraded to an additional 6,000 GPs), the reality is that this country has continued to haemorrhage GPs and has now nearly 1,000 less qualified full time GPs than 5 years ago.


Providing additional funding for staff via Primary Care Networks (shared home visiting paramedics, clinical pharmacists, social prescribers and first contact physiotherapists) has meanwhile helped only to a certain extend. This is because none of these professionals (some of whom frequently spend 30min assessing each patient and then often ask a GP for further management advice or a prescription) can to do the work of a GP, who is trained to complete the same work more cost effectively in only 10-12 min.


Whilst it is obviously very welcome for practices to receive additional funds to be able to pay all their staff for successive pay rises and for overtime or extra shifts, the additional funding does not actually create more GPs available and/or willing to take up a permanent position in General Practice.




What are the impacts when patients are unable to access general practice using their preferred method?


The consequences of patients not being able to access General Practice by their preferred method can range from minor inconvenience to the risk of adverse health outcomes.


However, given that many conditions patients present with to General Practice are self-limiting or do not require any intervention, and since there are many alternatives to seeing a GP, temporary lack of direct or convenient GP access also encourages patients to make better use of existing resources, such as accessing the advice and guidance of their pharmacist, of 111, of online resources such as patient.co.uk, what0-18.nhs.uk and ‘eConsult, and if all fails patients can attend their local Minor Illness Treatment Centre.


Reassuringly, given that the UK has nationwide 24/7 medical cover (via 111, the Out-of Hours Services, 999 and A&E) there is no reason that anyone needs to suffer any serious adverse health outcomes in these circumstances at all.




What role does having a named GP and being able to see that GP play in providing patients with the continuity of care they need?

Having a named GP can improve patient care, as it can be beneficial for the patient if their GP already knows their medical history, and that this history does not need to be re-explored during each subsequent appointment.


GPs also benefit from being more familiar with the patients they see, as it makes their consultations more efficient and allows them to follow up their own patients, making their day-to-day work much more enjoyable and fulfilling.


However, some younger patients with only minor problems often prefer to see any GP (rather than having to wait for their own named GP to become available on a later date), and some patients also prefer the option to see a different GP to their own named GP for a second opinion, if their symptoms have failed to respond to the treatment already offered.


Sadly, given the current recruitment and retention crisis and the resulting severely depleted number of practicing GPs, having always access to the same GP during a prolonged illness is now no longer a realistic prospect. This is because the remaining GPs are now constantly under pressure to manage as many patients (sometimes more than 60-70 patients per day) in the shortest time possible, which makes the prioritisation of continuity of care no longer an achievable goal.




What are the main challenges facing general practice in the next 5 years?

Negative spin from the media and government ministers and the ever-increasing workload has badly affected General Practitioners’ morale and has further contributed to the steadily worsening GP recruitment and retention crisis.


In some parts of the country the required conditions for a perfect storm in General Practice will soon be met, and when the first practices start to collapse neighbouring practises will also fold as they will be unable to cope with the additional patient demand, which will lead to local hospitals being overwhelmed by patients in a matter of days.


All of this could of course be avoided if the issue of steadily escalating (and often both unfunded as well as unlimited) GP workload was being addressed.


Once the daily workload becomes manageable again, many GPs who used to enjoy their work (but who quit their jobs prematurely because of burnout) might once again be enticed to return to work in General Practice.




How does regional variation shape the challenges facing general practice in different parts of England, including rural areas?


Some areas (including rural but also rough inner-city areas) can be particularly difficult to recruit to, as health care professionals may not wish to live and work in those challenging and understaffed areas, and it may take significant investments both in staff and facilities as well as financial incentives for them to do so once again.




What part should general practice play in the prevention agenda?

Prevention has always been at the heart of what we do in General Practice, but particularly during the pandemic prevention has been very difficult to address, mainly due to our clinical time being diverted by having to both provide safe acute care to our large patient population whilst also having to simultaneously send clinicians to staff Red Hubs and Covid vaccination clinics.


When we finally started to get back on our feet during the summer 2021 and invited all our patients for their chronic disease management appointments, the UK suddenly did not have enough blood bottles required for those preventative patient health checks!




What can be done to reduce bureaucracy and burnout, and improve morale, in general practice?

This can only be achieved by improving staffing levels and staff pay, stopping government ministers attacking GPs in the media, encouraging the population to self-care and/or to seek advice from sources other than their own GP, and stop secondary care passing unfunded workload to primary care.


In addition, you could free up a huge amount of GP time by simplifying the annual GP appraisals (or alternatively by changing it to every two years), and you could also encourage GPs at retirement age to continue working by reversing those recently introduced punitive changes to the tax- and NHS pension scheme.




How can the current model of general practice be improved to make it more sustainable in the long term? In particular: Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?


Nigel Watson’s recent review of General Practice has shown that the GP Partner model of primary care remains the most robust, flexible, and most cost-effective model of Primary Care that we have.


Given that our newly qualified GPs usually only work a maximum of three days a week it takes now three of them to replace a single retiring full time GP Partner!


The effectiveness of the GP Partner model has once more been demonstrated during the pandemic, where GP Partners together with their PCN colleagues set up local Red Hubs and Covid-19 vaccination centres, all in addition to their day-to-day work, something which could never have been achieved with an employed GP workforce only.


And whilst it is true that it has been much harder to recruit Partners in recent times, this model remains the preferred model for most practices, supported by salaried GPs and other professionals such as nurse practitioners and paramedics, and which will continue to exist for many years to come.




Do the current contracting and payment systems in general practice encourage proactive, personalised, coordinated and integrated care?


The current contracting and payment system does only to some extent encourage the above care, as it fails to re-imburse GPs for all the currently unfunded work they are required to do every day, including work transferred from hospitals, such as sick notes, prescriptions, blood monitoring of toxic drugs as well as completion of child protection- and DWP reports etc.


If GPs were paid along the same system hospitals are (i.e. via item of service payments), money would truly follow the patient, which in turn would allow GPs to increase capacity by employing more staff to provide much improved and more personalised patient care than they are currently able to do.




Has the development of Primary Care Networks improved the delivery of proactive, personalised, coordinated, and integrated care and reduced the administrative burden on GPs?


Local feedback suggests that so far Primary Care Networks had only limited impact on the delivery of proactive, personalised, coordinated, and integrated care and on the reduction of administrative burden of GPs


However, local PCNs have been instrumental in organising local Red Hubs and Covid-19 vaccination clinics.


Please also see my response to the final question below.




To what extent has general practice been able to work in effective partnerships with other professions within primary care and beyond to free more GP time for patient care?


The funding provided to PCNs has allowed the employment of shared home visiting paramedics, clinical pharmacists, social prescribers and first contact physiotherapists.


Our home visiting paramedics have proved very popular with both patients and GPs, as they helped to free up GP time and therefore allowed GPs to treat many additional patients instead of visiting only a very small number of patients in their homes.


Whilst social prescribers have been very useful in helping patients with their social isolation and in providing carers with practical help and support, local feedback regarding the effectiveness of employing clinical pharmacists and first contact physiotherapists has however so far been less convincing.


Nov 2021