Written evidence submitted by Dr Dirk Konig (RTR0006)

What are the principal factors driving staff to leave General Practice and what could be done to address them?

For the past 18 years I have been working as a full-time GP Partner in a Hampshire practice with currently 19,000 patients and over 50 employees.

Years of steadily worsening working conditions in General Practice, in particular the escalating (and now truly unlimited) workload and sometimes resulting in unsafe working conditions, punitive tax changes to the NHS Pension scheme and very poor NHS work force planning have all contributed to our current GP recruitment and retention crisis.

To avoid excess NHS Pension taxation (which has resulted in some older GPs effectively having to pay to come to work), increasing numbers of GPs are feeling forced into early retirement, which means they will be prematurely and irreversibly lost to the profession.

However, lifting the current restrictive limits on both the Annual Allowance as well as the Lifetime Allowance could immediately persuade thousands of GP Partners to change their present plans to either reduce their hours or to retire years before their official retirement age.

The loss of experienced GPs means that the remaining GPs are having to work harder and harder (many GP Partners now regularly work 13-14 hours a day), which can lead to anxiety and depression, breakdown in family relationships and GP burn out.

This has already resulted in increased stress-related GP sickness absence and further resignations, thereby worsening patient access to GPs even further.

GPs are constantly under pressure to manage as many patients (sometimes more than 60-70 patients per day plus hours of additional paperwork) in the shortest time possible, which is sadly now affecting the continuity of care of countless patients across the country.

Meanwhile the unfunded transfer of work from hospitals to General Practice has further accelerated during the pandemic (hospitals are now rejecting more and more referrals and GPs having to manage those patients themselves; hospitals are also expecting GPs to follow up their patients, to do their blood tests, prescriptions, sick notes, and re-referrals), which is bringing the remaining GPs to their knees, too.

The final straw for many GP during the current pandemic has been their treatment by sections of the media, the public and even some politicians, when contrary to what has been reported in the press most GPs never worked any harder in their entire career (by both managing their registered patients as well as organising a mass vaccination programme), and yet they have collectively been vilified for following official health protection guidelines to keep their patients and staff safe from Covid-19.

Improving working conditions and morale amongst GPs would require cessation of unfunded transfer of work (from all sources) into General Practice, limiting the current unlimited workload GPs are required to do, reducing administrative burdens such as GP appraisal, training more GPs (as well as other health professionals like Nurse Practitioners and other clinical prescribers), and NHS England and politicians supporting (rather than attacking) staff working in General Practice.

At present General Practice only receives just over 8% of the NHS budget, even though more than 90% of all NHS consultations take place in General Practice. To future-proof General Practice it is now paramount to finally address the historic funding shortfall of General Practice which prevents it from attracting the best talent during times of significant wage increases across all practice employees. One way to do this would be by paying General Practice an item of service fee, which would mean that the money truly follows the patient, and increased activity in General Practice would finally be funded (and therefore encouraged).

What changes could be made to the initial and ongoing training of staff in General Practice to help increase the number of staff working in these sectors?

Many GPs have lost faith in the government and successive Secretaries of State for Health who in 2015 promised 5,000 additional GPS by 2020, and who after the numbers continued to decline promised again in 2019 to recruit an additional 6,000 GPs by 2024, a promise which has already been confirmed to be unachievable only two years later.

When it comes to training doctors, the NHS and politicians also need to realise that a significant proportion of newly qualified doctors choose to emigrate to other countries that offer a far better work-life balance as well as more grateful patients (such as Australia, New Zealand or Canada).

However, due to the complex, risky and exhausting nature of British General Practice, those newly qualified GPs that remain in the UK are now rarely prepared to work for more than 6 sessions per week (i.e., 3 days of approximately 10-11 hours per day) as salaried GPs. Working that long every day is anything but family-friendly, and as a result young GPs are now voting with their feet and either cut their hours further, or adopt a portfolio career doing appraisal work or getting involved in medical teaching.

Since full-time GP Partners often work more than 70 hours per week to complete their clinical work and to run their own business, it means that if a GP Partner leaves it will now take more than two part-time salaried GPs to provide a similar service to the registered patient population of any given GP practice.

It would therefore seem a dangerous fallacy to assume that the work of retiring GP Partners can easily be done by the existing number of recently trained salaried UK GPs.

On the positive side, the recent funding provided to Primary Care Networks has allowed the employment of shared home visiting paramedics, clinical pharmacists, social prescribers and first contact physiotherapists.

Our home visiting paramedics have proved very popular with both patients and GPs, as they have helped to free up GP time and therefore allowed GPs to treat many additional patients, instead of visiting only a very small number of patients in their homes.

Whilst social prescribers have been very useful in helping patients with their social isolation and in providing carers with practical help and support, local feedback regarding the effectiveness of employing clinical pharmacists and first contact physiotherapists has however so far been less convincing.

Could the training period for doctors be reduced?

Should the cap on the number of medical places offered to international and domestic students be removed?

Safely diagnosing and managing patients with undifferentiated illnesses across all medical specialties (and often only very vague symptoms) in General Practice is one of the most difficult tasks in medicine. For this reason, I believe that omitting some parts of the medical curriculum to speed up the training process of doctors would appear very unwise and would likely result in serious diagnoses being missed or delayed by future doctors.

We already have Nurse Practitioners and Physician Assistants with comparatively limited medical training, who are an excellent addition to the work force, but who are restricted to manage only a certain range of common and/or familiar medical scenarios, as they do not have the required expertise to safely treat rarer or more serious presentations.

However, given our declining medical workforce and the points I have raised in the previous paragraphs I can see no alternative to significantly increasing the number of training places at all UK medical schools, which would help stabilise the existing workforce, and which in turn could make working in General Practice safer (for both patients and doctors) and therefore more attractive once again.

January 2022