Written evidence submitted by Anonymous (FGP0161)

 

I qualified as a GP in 1991 and joined my practice as a GP partner in 1999.

In that era, there was a clear advantage to being a GP partner. With a stake in the practice, there was a balance of rights and responsibility. This was rewarded with higher earnings than non-principal GPs, and potentially a share in the equity of GP premises.

At that time, I was one of 5 partners, one of whom worked part-time. We were (and are) a training practice and cared for a practice population of approximately 7500 patients. Another practice shared the premises effectively mirrored us also with 5 partners and approximately 7500 patients.

The two practices continued in this manner, with retirements and recruitment of replacement partners, until around 2015.

At this time I was leading a premises project for the practice. We had approval for new and much larger premises to replace the extremely cramped and outdated 1970s health centre that we occupied. The new premises allowed for some expansion of the teams and provided modern consultation rooms and offices meeting all modern standards. All of the partners across the two practices were offered the opportunity to invest in the project. Ultimately, all of them declined to participate.

Without dwelling on the gory details, the conflict triggered by this change broke my partnership apart. By the time the new premises opened in April 2017 all four of my partners had resigned. Since that time I have been a ‘sole trader’ GP, with sole responsibility for my practice.

Even in 2015 recruiting salaried GPs was both difficult and expensive. It was a highly competitive marketplace for these clinicians, and for salaried GPs it was very much a sellers’ market. At that time the annual salary per session worked per week was approximately £8000. With some luck, we recruited three salaried GPs. I decided that we needed to diversify our clinical team and recruited first one and then two advanced nurse practitioners (ANPs). I then recruited a very experienced mental health ANPs, on the basis that mental health problems represent 25% of the work in general practice. All three appointments were extremely successful, and all 3 practitioners remain with the practice.

During the period 2016-2019 my practice operated at a loss. Therefore despite working 60-70 hour weeks, I was taking home no income. We were reliant on locum cover for a clinical capacity, and this was hugely expensive. Over time, the salaried GPs that we had recruited moved on, and as they were replaced we noted that the cost of employing replacements was rising to first £8500, then £9000, then £9500 per session. We recruited clinical pharmacists to manage our prescribing, at a cost of £8000 per month.

In August 2019 we were inspected by CQC and rated as ‘requires improvement’. Later that year our neighboring practice was inspected and was also rated as ‘requires improvement’. At that point, the two remaining partners next door decided that they could not continue and informed me that they planned to hand their contract back. I agreed to merge practices and to employ them both as salaried GPs.

So, since July 2020 we have operated as one practice of 15,000 patients. I now employ 8 salaried GPs. Of these, 2 have recently resigned and another is shortly to take maternity leave. I am recruiting, but only one had response to our advert – and that GP has since not replied to emails. We hope that we may be able to recruit salaried GPs from agencies, but they typically charge 15% of the first year’s salary (and one of our most recent agency candidates expected £10,500 per session).

I also employ two general ANPs, three mental health ANPs (one works 1 day a week), a women’s health ANP, and a family planning ANP (one session).

Our Primary Care Network (PCN) also employs clinical staff. We have a total of four clinical pharmacists working in practices, although their role is to assist with quality improvement rather than dealing with clinical workload. We have one First Contact Physiotherapist (a clinical physiotherapist, trained to diagnose musculoskeletal problems) and a second one about to start. We have two social prescribers and are about to start referring to health coaches.

Most frustratingly, although there is funding for mental health practitioners within the PCN enhanced service, this funding is tied to ANPs employed by mental health Trusts. We are barred from using this funding for mental health practitioners directly employed by practices or the network. As our Trust has been unable to recruit a practitioner for our network, this funding is unused.

My practice recruited a frailty specialist ANP in early 2020, and this role was so immediately effective that our network recruited her and a second frailty ANP for a network frailty team in August 2020. They now work with two (soon 3) care coordinators, a frailty occupational therapist and a clinical pharmacist. The frailty team have a focus on older people living with frailty in their own homes and in nursing homes and reduce both GP visits and hospital admission/readmissions. This model is now being funded by the CCG and is being copied by our other 3 local PCNs.

In terms of where we are now, I’m personally experiencing what comes before PTSD. I’m still working 60-70 hour weeks, and I’ve worked almost every day this year and last year. On my days in the practice I work without a break. There was a long period when I was not getting away until after 9pm every night, and often much later, but I’m generally now leaving by 8.30pm. I cancelled two weeks’ leave in May 2021 at short notice to cover another single-handed practice where there was a sudden family crisis. I cancelled another week’s leave in September 2021 to allow one of my salaried GPs time off because they felt in ‘crisis’. For the leave that I have taken, I have used the time largely to catch up with clinical work.

I made a small profit last year of £9000. In August 2021 we were assessed as ‘good’ by CQC.

General practice is in crisis, and the former model of GP partners owning and running small practices is sinking fast.

Primarily, there is no pay differential to reward the additional risk and responsibility of GP partnership compared to salaried work. Why would a salaried GP commit to this, when they can earn a guaranteed (and potentially much larger) salary with full employment benefits (such as sick leave and maternity pay)? Locum GPs earn substantially higher daily rates.

Income for practices is effectively fixed and is not responsive to changing clinical workload or other requirements of modern practice (such as the standards required by CQC). As workload rises, existing capacity is stretched further and further. As staff struggle to cope with demand, and as patients vent their frustration on social media, sick leave rises.  In our case, we had 459 days of sick leave across our team in the last 12 months, which has been uncompensated. Overall, our profitability has been hit catastrophically.

I’m 57, and now very much looking for my exit. Having described my situation, it would seem fanciful that any GP would join me in a traditional partnership. I do not expect one to.

Instead, I am looking at joining a national GP super-partnership in April 2022. This will I believe help to support me in my role as a GP partner, and will provide a very different offer to salaried GPs that might tempt them to commit to partnership. I hope that at least two of my ANPs will also become partners.

I feel an immense responsibility for my staff and for my patients. I am personally determined to see my team through safely. In the last 6 years we have transformed from a relatively small, traditional practice to a relatively large and innovative practice. This has come at a great price to my personal wellbeing, but it’s been the right thing to do.

I believe that the challenges we have faced are the same challenges that almost all other practices face. We have perhaps just had to deal with these sooner than most.

My CCG’s Director of Commissioning recently put it succinctly. “All 31 (of our CCG’s) practices are one GP resignation away from catastrophe”.

Dec 2021