Written evidence submitted by Dr Philippa Matthews (FGP0129)

I have been a GP for 30 years. Given my current roles as a GP Federation Medical Director AND GP locum - I have close connections with many, many practices. I have also worked in 2 different cities in the past, and several areas of London. I have also, in the past, been involved in investigations of practices/GPs where there have been causes for concern.

Incidentally, starting on 30th March 2020, with my team I worked tirelessly to help practices adopt infection control procedures and to re-open and see selected patients face to face. I systematically visited practices - starting in my borough - and then was commissioned to do so across 4 more London boroughs. This was long before the govt clarified that practices should re-open! It is so galling when blanket criticisms are applied about practices needing to see patients face to face and being lazy if they don’t - ignorant, insulting, undermining. Some patients respond to this kind of talk by leadership with aggression of course (although I have only encountered verbal).

I feel as though what I write here is the most important thing I have written in my whole career: general practice is dying under our noses. I wish I were joking or exaggerating. I know three formerly thriving practices that in the last 4-6 weeks:

One has TWO doctors gone sick with stress (neither before having ever had sick leave for this) - like dominos.

One has THREE doctor vacancies and has had not a single suitable applicant

One, by the end of March, will have THREE doctor vacancies and has not had a single suitable applicant (either). First of the three leaves in one week, second one in 4 weeks.

Its like torture for my colleagues.

Several talk about fearing they cannot practice safely - for the first time in their careers.

I get 1 to 4 messages a day from practices and other GP services with which I am directly connected, begging for help with cover.

My heart is broken, to be honest. I personally cannot visualise how primary care can survive. And huge private organisations are not going to be able to magic up new doctors across the land. What is the end game here?

 

Increased clinical risk

Fury and stress on the part of the patients

Huge, incessant, stress on the part of practice teams: reception, doctors, everyone.

Patients attending other parts of health system inappropriately - emergency departments and shifting pressure there

 

In normal times I would have said that this is an essential part of high quality care for complex patients; older patients; any patient through an episode of a mental health problem (eg 9 months of depression or anxiety); families with safeguarding issues etc etc. I moved from 10y working in an excellent practice to 6y working in another excellent practice in another city: at the latter practice we had much better continuity (a named doctor system) and I always felt it made me a 20% better doctor.

Now: we are in crisis, its survival mode.  I cannot see how we can even consider continuity with the current shortage of GPs.

Lack of doctors: recruitment: a complete inability to cover leave, to cover sick leave, to cover maternity leave, to recruit to vacancies.

A vicious cycle of stress and misery leading

Unsustainable workloads which lead to almost every GP doing enormously less than full time clinical work.

Wholly unattractive career - in the last 3 months, even champions of general practice have stopped enjoying it and started working out what else they could possibly do.

Not in a position to say. But I often think - if both buzzy central, and leafy outer, areas of London can’t attract ANY applicants - how will many other areas be faring?

They are locally / community-based and so is obvious/excellent to have close links with - or provide - smoking cessation, exercise interventions and facilities, support of weight loss etc etc. The advice of your personal doctor has been shown again and again to help behaviour change - primary care should remain closely interconnected with prevention.

[these next paragraphs up to ***** are a repeat of my introductory paragraphs:]

I have been a GP for 30 years. Given my current roles as a GP Federation Medical Director AND GP locum - I have close connections with many, many practices. I have also worked in 2 different cities in the past, and several areas of London. I have also, in the past, been involved in investigations of practices/GPs where there have been causes for concern.

Incidentally, starting on 30th March 2020, with my team I worked tirelessly to help practices adopt infection control procedures and to re-open and see selected patients face to face. I systematically visited practices - starting in my borough - and then was commissioned to do so across 4 more London boroughs. This was long before the govt clarified that practices should re-open! It is so galling when blanket criticisms are applied about practices needing to see patients face to face and being lazy if they don’t - ignorant, insulting, undermining. Some patients respond to this kind of talk by leadership with aggression of course (although I have only encountered verbal).

I feel as though what I write here is the most important thing I have written in my whole career: general practice is dying under our noses. I wish I were joking or exaggerating. I know three formerly thriving practices that in the last 4-6 weeks:

One has TWO doctors gone sick with stress (neither before having ever had sick leave for this) - like dominos.

One has THREE doctor vacancies and has had not a single suitable applicant

One, by the end of March, will have THREE doctor vacancies and has not had a single suitable applicant (either). First of the three leaves in one week, second one in 4 weeks.

Its like torture for my colleagues.

Several talk about fearing they cannot practice safely - for the first time in their careers.

I get 1 to 4 messages a day from practices and other GP services with which I am directly connected, begging for help with cover.

My heart is broken, to be honest. I personally cannot visualise how primary care can survive. And huge private organisations are not going to be able to magic up new doctors across the land. What is the end game here?

 

****

We have far too few GPs:

Those GPs that we have seem to be - every single one I have spoken to - extremely stressed. They are desperately wondering about what else they can do with their lives.

Priorities now:

Stabilise the primary care workforce and introduce proper, strategic, transparent, workforce planning:

The fastest way to getting more GP time is to make their jobs doable so that they are able, and want to, do a bigger proportion of clinical work (as in the past). In current. It’s still not going to be fast!

Bring in further funding to ensure that all ‘para-GP’ cadres are available to all GPs from ASAP - its not just money but also support with centralised training or recruitment or employment (PCN footprints / teams often too small - so we find our Federation much valued in doing this). I have spoken to practices who would like to bring in a physician associate, however they cannot imagine how they could induct and fully train such a person given their current firefighting and overwhelming commitments.

 

How can the current model of general practice be improved to make it more sustainable in the long term? In particular:

 

Personally, I left one city as an experienced partner a decade ago, and had my nose rubbed in the lack of a career structure in general practices. Partnerships were put off by a GP with quite a few other strings to her bow. It took me 2 years to find a salaried job in a practice I loved.

I don’t think the partnership model is a good one. But current salaried roles are demoralising, highly variable, stressful and under paid. Very difficult to feel valued in a practice as a salaried doctor no matter how massive a contribution you make to ideas, implementation of change, clinical care etc.

It’s not all bad, but:

I think QOF is a very 2 dimensional measure. A much broader view should be taken if QOF targets are not being met

BUT I noticed that with failing practices - when NHSE notice they are simply not delivering on QOF:

-          They are more concerned to start the long process to terminate the contract than they are to implement urgent checks to check the patient care is safe / OK

-          They don’t care if the doctor(s) retains their license to practice, just as long as they lose the contract

Incidentally I think the CQC has an incredibly mixed approach and have seen it virtually bully practices that I have always admired. It becomes part of the sapping of morale.

I think PCNs are usually too small to provide an infrastructure to recruit, train and employ cadres of staff such as a team of practice based pharmacists.

Often the practices don’t appreciate being herded together and the politics are a nightmare, particularly for the leaders, who may feel unsupported/isolated

I have only very recently had anything to do with a Federation, but working at a functional one has made me see the real potential - we employ 30 practice-based pharmacists and can provide real clinical governance oversight, support, leadership, cross-cover when leave is taken etc etc. Similarly for social prescribers, high tech admin support and many others. We support PCNs, they do do things on that footprint - but we are, on the whole, much appreciated. We can run community gynae and ENT; a covid phone (+sats probe) assessment service etc.

In my experience General practice is innovative and adaptive to change - and has truly embraced other professions within primary care.

However GP time is still needed, still in short supply.

 

Dec 2021