Written evidence submitted by Anonymous (FGP0139)

 

As a recently retired GP partner I hope some personal comments/thoughts might be of value in any decision making on the future of Primary Care in the UK. I retired this summer after over 28 years as a GP partner.

 

My retirement was 2 years ahead of schedule. Broadly speaking this was because of the excess workload, reduction in income and increased risk. I (and fellow GPs that I know) started to notice changes from about 2012/13 onwards which gathered momentum in the latter half of the decade.

 

In my view “austerity” was the key catalyst to the decline. Whereas we could cope with periods of reduced/underfunding this became harder as each year went by with no end in sight. This stagnation of income was coupled with an increase in workload – when the system started to fail the expectation was that GPs would get involved in trying to sort out a mess that wasn’t of their creation. This inevitably took GPs away from the front line to any number of CCG initiated “service improvement” meetings which added to the workload and took us away from seeing patients. A lot of these “improvements” seemed to focus on protecting secondary care at the expense of primary care – the expectation was that we’d do more work often with no extra resources. The detrimental effect on morale, income and work-life balance inevitably lead to GPs leaving the system, especially as partners. A domino effect with the fear of “being the last man standing” became commonplace in my experience. This accelerated the whole process with the remaining GPs having to take on the workload of absent ones, and many leaving partnership for the easier life of locums.

 

All of this should have been abundantly clear to the CCGs, NHSE and those in responsibility in the government. It didn’t seem to register and the relentless pressure kept coming. It really felt as if it was a determined, purposeful drive to destroy UK general practice that had, until about 10 years ago, been the envy of the world.

 

It was hard to live through this agenda, an agenda relentlessly pursued by our managers/commissioners, which you felt was going to be bad for patients and the practices, and you also suspected was going to be very costly. Eventually after about 7-8 years of trying to protect ourselves and our patients from the damage I felt defeated - I couldn’t think of anything else to do to maintain a quality level of service. Resignation seemed the only option left to me. I know of many GPs who have done the same (and I know many would do so if they could afford it).

 

I’m sure there will be many managers in the CCGs/NHSE/government who have the belief that primary care has an easy time or are overpaid. The government certainly seem to propagate this belief at times. I suggest this view will come from those people whose driving force is governed by personal gain of some sort and who don’t understand that some people will try to provide a good quality, cost effective service because they want to. I spent 5 years at medical school then several more years of GP training when the emphasis on the provision of such a service was repeatedly emphasised. But, even if those making decisions still consider that GPs are overpaid/underworked and are tempted by pushing them even harder I would suggest you take a serious look at what that has done over the last 10 years. It hasn’t worked.

 

So, what is now needed, in my view, is a reversal of the damaging changes over the last 10 years and in particular:

 

GPs and the other clinical staff need to be seeing patients. This is surely logical when there is a manpower shortage. They shouldn’t be using their time “talking about seeing patients” at “service improvement/ save the NHS money” meetings.

 

Along these lines I would suggest networks are disbanded. This helps the commissioners but, in my view, does not help practices. Practices can work together but it should be on their terms, not the commissioners. Networks just add another managerial level between practices and the CCGs (or whatever is replacing CCGs).

 

Take this a stage further and get rid of CCGs. Why can’t NHSE do the commissioning direct to practices. Two levels rather than the current four (NHSE to practices rather than NHSE to CCG to networks to practices)

 

Even better would be to get rid of commissioning in any shape or form. Service provision should follow best clinical practice and the money follows.

 

Get rid of local variations. Different people in different localities giving their take on national standards and guidelines is more time spent on the whole process overall. Lots of different people re-inventing the wheel. This would also get rid of local variations in service provision.

 

By streamlining these management/administrative areas it might then be possible for the front-line staff to actually see some of the promised extra funding. In recent years the funding seems to have largely spread out sideways at one of the managerial levels with the scraps being left for those on the front-line. In other words, you need to give the front-line workers a decent payrise. I would suggest you look at what they would be getting if they had been given reasonable payrises over the last 10 years and give them a catch up increase to match this – likely to be of the order of 20-30%.

 

Many GPs are “part time” now – I suggest the majority have become part time as the only real option to reduce their workload. The workload on a working day has been increasingly hard to control so the only option has been to take more days off as recovery time. By pushing the pay up considerably, you may then encourage part time GPs and other staff to work more on these days off.

 

Particular financial incentives are likely to be needed for encouraging GPs to be GP partners. GP partners are generally paid more than locums or salaried doctors. This is, in my view, correct bearing in mind the extra work involved. Many GP partners have seen their income dwindle to the extent that their earnings are approaching those of the locums/salaried doctors they employ. In some cases they earn less and at this point it becomes increasingly unlikely that they will recruit new partners in the current doctor starved environment.

 

More GPs would be an option if you can find them but, bearing in mind the training needed, it’s likely this will not be an option for several more years, and I am told that the word around medical schools is to avoid primary care as a career option.

 

If more GP hours can’t be created (by reducing admin, by encouraging more sessions from the existing workforce or by recruitment in the UK/from abroad) then the only real option is to reduce the workload. This will involve some sort of rationing of GP services. This could be a cap on the number of appointments a GP has to provide (but then where would the excess go?). A simpler alternative might be to look at extra services that are funded as extra (eg enhanced services) that are of dubious value, and put this money into GMS. A sort of “back to basics” approach where GPs are primarily seeing the unwell. But with their income protected.

 

There has been a push in recent years to get other health care professionals to do work that is traditionally that of a GP. My own view is that this is rarely cost effective either because they need more time to do the same job (half the wage but more than twice the time is not cost effective) or because they can’t fully do the job (and therefore ultimately doesn’t save time overall). More recently direct access to primary care services by patients, without the need for a GP appointment, has been initiated. A good example is physiotherapy. This is a useful change and could be expanded?

 

The interface with secondary care remains a difficult area. Lines of responsibility need to be clear and followed. Many GP appointments are lost because secondary care haven’t done their job properly (eg passing on results of hospital investigations to patients, giving adequate information at outpatient appointments, resisting prescribing “hospital only” medication  etc). I appreciate secondary care have their own problems but pushing their work onto primary care is inappropriate (as is the converse).

 

Similarly with private patients the boundaries should be clear. Specialists who see patients privately frequently try and get some of that private care on the NHS, by asking the GP to do it (with investigations or prescribing for example).

 

I suggest patient behaviour also needs addressing. The complaints system is weighted heavily in favour of patients, to the extent that GPs and their teams have to put up with pretty much anything short of criminal behaviour. It can be very time consuming to respond to even a small complaint. As the system fails, rude and aggressive patients are becoming commoner. Practices should be able to say no more easily to such patients.

 

Up until now I haven’t mentioned Covid, as, to me, it hasn’t been as much of a problem compared with what came before. If anything, I found the reduction in bureaucracy coming out from the CCGs a welcome relief. Looking after ill patients, be they Covid ones or other illnesses is, to me, part of the job. It has, of course, created many practical changes, some of them difficult. In my opinion Covid would have been less of an issue if the NHS – both primary and secondary care – hadn’t been run into the ground beforehand. I am quite sure the need for lockdowns to “save the NHS” would have been less of an issue if the NHS had been in a healthier state when Covid hit.

 

My final point. I still believe that primary care has been purposefully attacked by those in power over the last 10 years, in the mistaken belief that they can do better. If you still believe this then it’s simple – for the government/NHSE to buy all the premises, take over all the staff in primary care and employ all the GPs. It can then be shaped by those in power to their liking. I’d be very surprised if you get a better, more cost effective system (which is perhaps why it hasn’t happened!). Of course, this may become the system by default if those in power don’t start supporting primary care more.

 

As already mentioned these are my personal views and, as I am almost fully retired, my desire to see primary care improve will no longer impact on me as a worker in the system. My desire to see it succeed is because it is so important to the health of the nation, including me as a user. It has been so frustrating to see it seriously damaged, in my view unnecessarily. Hopefully that can be reversed.

 

Dec 2021