Written evidence submitted by Dr Alastair Bateman MA ( Oxon) MB BS ( Lond) MRCP(UK) MRCGP (FGP0134)

GMC number 3260623

I offer  this evidence as the personal comments of a recently retired GP Partner of 26 years standing who has also has a number of other roles in the health service.

I retired from General Practice aged 58 which is slightly older than the current average age for GP retirement.

If my working life had been similar to when I started and pension rules had not changed I would still be working as a GP.

I was a GP partner in the same practice for 26 years

I qualified in 1987 having trained at Oxford then St Thomas’ London.

I have worked as a Cardiology GP specialist in Hospital and Community Clinics

I have been a GP trainer for 17 years so have experience of a number of junior doctors arriving and working in GP

I continue to work in a CCG role in Medicines Management for Hampshire Southampton and IOW CCG and in a vaccination clinic for Vine Medical Group Waterlooville

When considering evidence re GP it is important to remember that all GPs have worked in hospitals whilst most Hospital Specialists have little or no experience of working in GP

When I qualified the majority of my peers wanted a career in General Practice(GP) and there were many applicants for each post. Almost all GPs were partners in practices and salaried GPs were a rare species. By the time I applied for a partnership in 1994 there were 10-20 applicants per post. In 2008 when we appointed 2 partners we were lucky to get 4 applicants per post and by 2016 we were having to employ headhunters to persuade people to look at a salaried post in our practice and pay 5 figure fees if they stayed for 6 months – There were no applicants for partner posts. Virtually no one I know in GP wants to continue working for any longer than it takes to get an adequate pension .  The days of GPs having to be persuaded to leave over the age of 70  are long gone.

I originally had no plans to be a GP and trained in Medicine achieving the usual qualifications required for Consultant practice- I mention this to help dispel the myth that GPs are less qualified than consultants . I realised that if I wanted to look after people rather than illnesses then GP gave the best environment for this to be achieved. When I  started as a GP this is what the work was like but gradually over the years the workload increases in GP have made this impossible and thus the job less satisfying and enjoyable as well as probably being less good for patients.

GP has a vital role in the NHS and I submit this evidence in the hope that it can be used to shape a more positive for this part of the health service- without it the rest of the NHS will flounder.

 

Lack of  qualified GPs and  Practice Nurses. GP numbers have not increased whilst the consultant grade has expanded massively. Practice nurse numbers have increased but the public desire to see a Dr rather than an equally or better suited clinician remains and is fuelled by history and expectations in society.

Support from political leaders for the primary care team as a whole rather than Dr face to face appointments being the main focus.

An increased focus on community care and given the lack of staff in community the consideration of consultant and junior doctor roles that work across community and hospital

Difficult to see how it makes much difference at all. The long term reduction in relative funding of general practice compared to the hospital sector and resulted in a gradual reduction in GP levels with increasing list size per WTE GP. The demand for consultation has increased both through an aging population , increased medical technology for both treatment and prevention and increased expectation of service and reduced threshold for consultation.

Political rhetoric overpromising on what the service can provide has been a long term issue.

Improving access needs more than just saying it will happen and throwing money at it. More Drs need to be trained as many want part time work now ( this has been the case for many years but no action to increase doctors in training to sufficient levels has been taken). Practice nurses are also difficult to find and there needs a focus on development of practice nurses to increase numbers. Practice nursing as a profession needs respect ( it is not long since the post was officially recognised in nursing circles) and investment and more nurses trained with a view to practice nursing as a speciality

The care system and the NHS are inextricably linked and supporting the care system to increase capacity and capability can help – however much like primary care it has been much neglected and will take time and investment into training , recruitment and facilities.

Patients need to be able to access practice by any means – however the convenience of modern communication methods have resulted in practices being overwhelmed with requests for assistance .

This itself is putting patients at risk of harm as the service is overwhelmed.

Some patients are deterred from contacting the practice at all and they may be the people who most need advice/care/referral.

Delayed diagnosis ,reduction in personalised care, patient and staff dissatisfaction, violence and abuse to practice staff,

 

In general it is good for patients and for job satisfaction amongst GPs. For me it was one of the main reasons for becoming a GP and the loss of the ability to provide good continuity of care was one of my main reasons for retiring early. Good notes can help but nothing can match the knowledge you get about a patient from spending more time with them rather than them spending more time with numerous team members

To be honest I am amazed GP still exists in its current form – I felt it was inevitable that a move to a salaried service would have happened by now. Being a partner is no longer a popular option with the unlimited workload due to the terms of the GMS contract and the financial needs to invest in a practice in addition to the buck stopping with the partners – this is not seen as a popular option for most younger recently trained GPs. However losing the partnership model would risk major loss of innovation and efficiency in the system. Being a partner needs to be made a role to be desired rather than feared.

If this is not realistic then a move to a totally salaried service with agenda for change terms across the whole NHS workforce, removing the responsibility from individual partners and controlling individual workloads to improve recruitment and enable to rebuild a service capable of providing continuity of care

Estates Capacity- as the practice teams get bigger they need more space – many practices now have insufficient room in old buildings that are no longer fit for purpose. Even if they can recruit it is difficult to fit the staff in- the PCN DES has helped recruit different roles but made the lack of space more of a problem. NHS Estates seem to belive that practices could use their space more effectively over a 24 hour period but this is not what patients want or what the government has contracted GPs for.

-Recruitment- see comments elsewhere

-Clarification of true role of GP- what do you really want GPs to do?- taking on work from hospitals to reduce their workload is not what GPs are trained to do and not the best use of their skills- they need to be focusing on patients- a lot of work has transferred over the years ( especially due to PBR contracts which encouraged this behaviour as hospital budgets were limited and GP not ) however the primary care workforce has not risen to compensate for this.

-Reducing Retirement and clinical staff walking away from GP,

-Setting clear limits to an individual GPs workload

Ideally placed to be involved in prevention but see comments above about workload / role of a GP.

Adequate staffing, the time and space to provide proper continuity for patients.

I think it is a common misconception outside the GP service that bureaucracy is the cause of burnout. It is the unrelenting patient demand and need to make time pressured complicated decisions every few minutes in a system where everyone is overbusy and fraught. The difficulties getting advice about difficult patient care issues in a timely manner from colleagues who are also overbusy and thus not available or reluctant to make themselves available.

NHS E could help but not putting unrealistic timescales for information and service changes

Unless the recruitment issue is solved I do not think the traditional model will be sustainable. You will be left with the option of a salaried service where it may be easier to fill a rota over a 24 hour period but it is unlikely you will be able to achieve continuity for patients. You will need many more doctors to achieve this than you have now and it would probably prove to be much more expensive ( Similar to the experience of the change in out of hours care with the 2003 contract changes).

Many recently trained GPs do not want to take on the risks and responsibility of partnership. Given the numbers of practices struggling at present how can you expect people to want to take this on?

Consultants are salaried with clear negotiated work plans for their Jobs. GP Partners have none of this and the current GMS contract provides no limit to the workload that can result.

It would amaze me to see any independent/private business take on GP on the terms of the current GMS Contract

They could do but the remuneration in the long term has not been sufficient to encourage suitable staffing levels resulting in the spiral downwards to where we are now. All the desired outcomes require time for appropriate discussion with patients and colleagues in other teams. The contracting mechanisms have never enabled Agenda for Change to be implemented in GP so there is a 2 tier system on work benefits.

NO – added another entity to the practice which requires management, supervision training and reporting.

The roles and funding could have been promoted in individual practices . The encouragement to work together has worked well with some PCNs but other are working together reluctantly

GP has been innovative in bringing paramedics and other AHPs into the system but this was mainly done due to a shortage of doctors- if this had been done in a more stable environment then it could have been much more productive for the future workforce.

Effective working does happen but the pressure of work makes it more difficult  eg Child at Risk Case Conferences – in the past one was able to clear time to attend these but in last 5-10 years has become increasingly difficult due to practice workload- I can’t remember the last time I was able to attend one.

 

Dec 2021