Written evidence submitted by Dr Cym Ryle (FGP0075)

Background

I have been a GP for 40 years now, thirty-three as a partner in a busy council estate practice, and more recently as a locum in remote and rural Scottish locations, and in two English practices located in relatively affluent areas. I was also for 25 years a GP trainer, and at various times a course organiser on the GP VTS, clinical governance lead for my local Primary Care Group, and for 9 years a director of the very successful GP Cooperative that provided OOH care to the Havant/Portsmouth are between 1995 and 2004. My daughter is an ST3 in general practice.

I remain completely committed to the core principles of the NHS, and passionate about the core elements and aims of general practice: timely diagnosis, and continuing care that recognises the human as well as the technical aspects of the work.

Summary

The Problems

  1. Morale, recruitment, and retention of GPs are in steep and potentially self – perpetuating decline, especially in urban areas.
  2. The professional culture of general practice has been eroded by narrow definitions of quality, and the financial incentives to pursue the associated narrow goals.
  3. There have been profoundly deleterious unintended consequences from these cultural and organisational changes - notably a diminution in the value given to key aspects of the job, and the widespread abandonment of any attempt to provide continuity of care.
  4. There is now a cohort of doctors who have no experience of, and no opportunity to participate in, the benefits of continuity of care.
  5. Research evidence consistently confirms that both patients and doctors benefit from continuity of care.

 

Recommendations

  1. All potential solutions to the profound problems facing general practice will require a sustained expansion in the GP workforce. (The expansion of the numbers and roles of other professional groups do not in my view provide an alternative to this increase in the number of doctors)
  2. Sustained and sincere leadership from politicians and senior figures in the NHS, explicitly supporting and celebrating the role of GPs, will be essential to repairing morale – but actions are more important than words.
  3. The provision of continuity of care must be an explicit and central priority and must be supported by appropriate incentives.
  4. The traditional model of general practice should be actively supported where it has survived.
  5. Where the traditional model is not viable, the principle that a small and stable group of clinicians will provide care for a geographically defined population should be central to the alternative models of provision.
  6. These clinical teams could be employed within organisations run by GPs on the sub-contractor model, or by other NHS bodies. However, the creation and support of these teams should be an explicit requirement of whatever body employs them.
  7. The provision of regular, effective professional and psychological support for all

front- line clinicians should become standard practice and must thus be properly funded.

 

Full Text:

The Problems

The crisis in GP has been developing steadily over two decades, and to be frank I am not certain that it will be possible to rescue the specialty and recreate a system in which I would be happy to work. I will attempt to summarise what I see as the key problems, but they are complex and to some extent interlinked, so the summary will be a simplification:

  1. Cultural issues within the profession: business or vocation?
    1. There have always been GPs whose primary motivation was financial rather than vocational, which is not to say that the two are absolutely mutually exclusive. Running a practice efficiently, seeking value for money for the NHS, (and maintaining or maximising income) are a proper part of a GPs role. But I believe a more crudely business – focussed cultural influence has to some extent undermined the professional and vocational ethic that should be at the heart of the job.
    2. Defining quality in general practice is difficult, because of the diversity of roles and functions a GP performs. In the 80’s and early 90’s there was a discussion about this matter within the profession – often in my view a fairly superficial and ultimately fruitless discussion - which confronted an issue that has never been resolved, a paradox:  Those aspects of the job that are most important and meaningful (speedy accurate diagnosis and humane care for people who are, or who think they are, ill) are almost unmeasurable. Those aspects of the job that are easily measured (aspects of chronic disease management, access, therapeutics, etc.) though important, are a small part of the job. But defining quality in relation to this diminished account of the job has become central to the systems of remuneration, since the mid-1990s.
    3. The ways in which GP income is generated have been shaped by successive reforms of the contract(s), some of which changes were, I acknowledge, intended to reward “quality” - but only in the limited sense defined in the preceding paragraph. QUOF and its bastard offspring are the principal manifestation of this approach. This emphasis is I believe a key factor in the development of the “business first” ethos. This in turn has led indirectly to one of the common current patterns of practice structure, where a small core of entrepreneurial (sometimes greedy, sometimes verging on the corrupt) partners employ assistants to do the bulk of the clinical work. This fragments care, makes continuity almost impossible to achieve, and militates against proper team working as there are two distinct tiers of doctors. (I acknowledge that some young doctors at the start of their careers prefer to be employed in this way, wishing to avoid the commitment and responsibilities of partnership.  See also 2 d below.)

 

  1. The human dimension in general practice; continuity of care

 

  1. Crucially, the net effect of the changes outlined above (and other factors – see below) has been the widespread abandonment of the attempt to provide continuity of care (i.e., A way of delivering the service in which there is a long-term arrangement that a specific doctor will be responsible for the overall care of each patient.)
  2. For me, and anecdotally for all the GPs I know who have enjoyed the job, continuity of care, and the complex evolving relationship between doctor and patient, are of central importance. These relationships give a human meaning to the work. This is particularly important for patients who are chronically or terminally ill, but also enriches the interactions which take place in day-to-day consultations where the medical issues are minor.
  3. The quality and importance of continuity and of this human dimension are not measurable; successive “reforms” of the GP contract, by giving large financial incentives to other elements of the work, mean that the attempt to provide continuity of care has been abandoned in many practices.
  4. The professional and personal benefit to doctors, of working in this traditional way, are not apparent to doctors who work on short term contracts, and in practices without any attempt at providing a “personal list” system. This is the landscape that new entrants to general practice inhabit. It is a case of not knowing what is missing, having never experienced it. Without this, GP work is potentially often trivial and boring.
  5. The issue of professional boundaries is a complex one; appropriate limits are of course essential. There has always been a handful of doctors who have crossed these lines, either deliberately, for their own gratification, or sometimes unwittingly, as they lose the appropriate professional perspective. However, in recent years/decades there is within the profession a generally increased sense of being under threat of complaints and litigation. The GMC Code of Practice is long and comprehensive, and in effect attempts to “outlaw” the human dimension of the professional relationship, or at the least generates a sense of risk for doctors who allow this dimension of the professional relationship to develop. Young doctors entering the profession are schooled in a very risk-averse environment. I suggest there is a paradox here, a substantial gap between the ivory towers inhabited by the GMC, and the front line of clinical work, especially general practice, in that the most effective doctors do indeed allow the human relationship to develop – something that patients value hugely. (See also below in Recommendations)

 

  1. Access and Continuity:

These are of course both desirable, but to some extent mutually exclusive. Access is relatively easily measured (though even here current measures partly miss the point). Continuity is both harder to define and harder to measure; contractual and financial arrangements have rewarded access; continuity has been abandoned in many practices. (See also below in Recommendations). All the published evidence (in a domain which is admittedly difficult to research) suggests that continuity is valued highly by both patients and doctors, leads to better outcomes, and saves money.

  1. The attitudes and comments of politicians and sections of the mass media

I will not elaborate; the effect of these adverse comments as a factor in the decline of the specialty is unfortunately all too obvious.

  1. The particular problems in urban general practice

It will always be the case that most of the things that make work in general practice hard are much more prevalent in poor areas; recruitment for practices in such locations has always been difficult. First and foremost, morbidity and poverty are very strongly correlated, so the workload generated by a list size of 2000 might be manageable in a wealthy area but almost impossible in a poor area. In addition, poor urban areas will typically have a higher turnover of patients, a greater ethnic mix, a concentration of social problems, worse premises…. the list goes on. Thus, there is in urban practice a situation of meltdown, with disastrous recruitment and retention, average list sizes rising and now far bigger than in the leafy suburbs and market towns. This is the predictable and predicted consequence of the years of mismanagement. I am deeply pessimistic about the prospects for urban general practice, as I see this meltdown as more or less irreversible. I do not think my preferred model of +- traditional, partnership-based general practice has any prospect of resuscitation for the tough urban areas. Would you apply for a job in inner city practice? See below Recommendations 5. and 6.

  1. A spiral of decline

 

The unholy alliance of these and other factors has led to disastrous morale, recruitment, and retention. In the eyes of some of the public, and within the profession, general practice is seen as a poor profession, a poor career choice in the UK. As WTE numbers fall, and demand and need rise, there is indeed a vicious circle. This is most pronounced in urban areas.This decline has been partly caused by, and watched over, by successive governments, and is now so deep that I am profoundly pessimistic about the prognosis for general practice.

 

Recommendations:

 

  1. GP numbers – the critical “Catch 22”

I must emphasise that in my view none of the problems outlined above can be solved without a substantial increase in GP numbers…. which will be very difficult to achieve, given the demoralised state of the current workforce and the diminished public and professional view of the specialty.

There needs to be a sustained (for years) and sincere programme to reverse the public and professional perception that general practice is a sink-specialty. This must be led by senior politicians, senior figures within the NHS, and the profession. The media outlets which “bad mouth” GPs (most notably the Daily Mail) must be vigorously challenged by these senior figures whenever such comments are made.

There will, of course, need to be a substantial and sustained increase in the resources devoted to general practice to fund this.

  1. Valuing and incentivising continuity of care

This will also require sustained and sincere leadership. Within the profession we need to be more articulate and outspoken about the many benefits to all of continuity of care by a named GP. This will be an attempt to reverse the cultural shift to which I refer above. The crude and the subtle ways in which the financial arrangements for GPs encourage simplistic measures of “access” to the detriment of continuity must be carefully addressed – and ways of providing financial incentives for continuity should be sought.

  1. Traditional vs current models of primary care provision

There are still practices that function within the traditional model of partnership under versions of the GMS contract. Where this is combined with good organisation and an appropriate skill mix (see below) I believe it still delivers by far the highest standards, including or course continuity of care provided by a named doctor. This is however dependent upon a stable team of GPs with a manageable list size and workload, in turn dependent on morale, recruitment and retention. I believe there should be strong and explicit support for the maintenance of this model where it is still functioning, both in the attitudes and statements of political and NHS leaders, and in the funding models.

This model is not likely to survive in poor urban areas, but I do NOT think the “polyclinic” model can ever approach this gold standard which has continuity at its heart. See below for suggestions.

 

  1. Skill Mix

What I am about to say is not “politically correct” and is thus uncomfortable BUT: The central task of primary diagnosis should in my view be undertaken by doctors, whose long and intensive training should equip them for this high-risk role in a way that no other professional training does. The delegation of the diagnostic role to other professional groups, whatever additional training they may have had, is in my view risky, ill advised, and ultimately inefficient as well.

In most other domains of primary care GPs are of course dependent on and grateful for the input of colleagues from other professional groups with complementary skills. This is particularly the case in chronic disease management and in issues related to prescribing, where the arrival of skilled nurses and of pharmacists has undoubtedly greatly improved patient care.

The GP’s role is at the centre (by which I do not mean the head in an hierarchical sense) of a team, ensuring holistic and long-term care are delivered in a coordinated way.

Whatever the structure of the organisation delivering primary care may be, the quality of that care will of course be critically dependent on good team working, which in term depends upon the morale and the stability of the teams involved – recruitment and retention again.

  1. Creating effective clinical teams

The best chance of saving (urban) general practice will in my view be finding new ways to create clinical teams of an appropriate size, with responsibility for providing care to a geographically defined population. In urban, hard-to-staff, urban areas these teams will usually be part of a larger organisation, either run directly by the NHS, or by large GP practices which retain some form of subcontractor function. The clinical function of these teams should mirror that provided by the traditional partnership model, aiming to achieve continuity of care and close team working between the professional groups in the team. This model could easily be developed, especially in organisations run directly by the NHS, so the social workers, community psychiatric nurses etc would be natural and intrinsic members of these clinical teams.

There are of course significant advantages in providing primary care from organisations substantially larger than traditional partnerships. There are economies of scale, the sharing of specialised clinical and managerial expertise not available to small partnerships etc. But the intense, absorbing, demanding, potentially rewarding, often exhausting, day to day clinical service must be provided by cohesive clinical teams of a size that allows close working relationships to develop – in my view around six doctors + an appropriate number of other professions (see paragraph above) is the correct scale.

  1. Providing more effective professional and psychological support to clinicians

The NHS has an appalling record in this respect, with depression,” burnout” and in the case of GPs, suicide, far too common. Recent years have seen belated recognition of these problems, but support is still remote, patchy, and not built into the way primary care clinicians work. Of course, some partnerships, and some nursing teams, create and maintain effective informal means of mutual support, but I believe these are the exception rather than the rule. In contrast, for example, the British Association of Counselling and Psychotherapy requires its members to obtain regular formal support in a set ratio to the time spent in client contact.

The arrangements for appraisal, at least for GPs, do not begin to address the potential need for active regular support. In addition, there is a built-in tension between the supposedly supportive role of annual appraisal, and its essential role in revalidation.

If general practice is to recover, especially in the more challenging environments of inner-city practice, I believe effective regular support for clinicians must be integral to the new model.

 

Dec 2021