Who would want to be a GP?

We know two things about the NHS: albeit not comparing like with like, acute hospitals and other secondary providers are much less good value for money than the primary sector and we have a critical shortage of GPs. The two are linked. Many go to A&E because they cannot see their local doctor in less than two weeks or out of business hours. Far more money has been pumped into the secondary sector than the primary, at a cost, some would say, to the health provision overall. “A year’s worth of GP care per patient costs less than two A&E visits, and we spend less on general practice than on hospital outpatients. For the past decade funding for hospitals has been growing around twice as fast as for family doctor services.”[1]

The shortage of GPs is attributable to three factors: too few being trained, too many working part-time, often very part-time, and early retirement.  The Blair government ensured that GPs are well paid, so that is not the problem.[2]  Too many are reducing their commitment: they do not want to see patients they hardly recognise every ten minutes, or discuss their health choices (diet, alcohol, smoking, exercise, weight etc) as decreed by the  Department of Health and Social Care (DHSC) before asking what the problem is, and, least of all deal, cope with the mountain of paperwork, meetings and bureaucracy also demanded by the DHSC. 

Last week, the DHSC published their response to this crisis with its “Update to the GP contract agreement 2020/21 - 2023/24”.[3] To be fair, the DHSC consulted widely on the draft and amended it in response to the feedback.  The question though is whether it addresses the problem above.

It claims 6,000 staff will be added to the primary sector at a cost, over the next four years, of over £1bn with a big expansion of the funding of ancillary roles (26,000).  Coincidentally, there will also be 6,000 more GPs.  To see how this comes about it is worth quoting the whole section: “GP trainee numbers increase from 3,500 to 4,000 a year from 2021. 24 months of the 36 month training period will be spent in general practice, from 2022. Together with the increase in trainees, this change will contribute over half of the 6,000 extra doctors working in general practice. The Targeted Enhanced Recruitment Scheme (TERs) will be expanded: from 276 places now, to 500 in 2021, and 800 in 2022, encouraging GP trainees to work in under-doctored areas. 

A two-year Fellowship in General Practice will now be offered as a guaranteed right to all GP trainees on completion of their training. It will automatically be offered as part of signing up to GP training. Our shared goal is to achieve as close to 100% participation as possible.” (p.4)[4]

There are various other good bits, bobs and motherhood (like supporting “good employment practices and seeing if they might do something about bureaucracy) and the big increase in ancillary staff will probably add to the pressures on GPs.  They have to be managed by GPs and will refer many of their patients to those GPs.  The quickest way to get to see a GP in my practice is to see a nurse. 

Some of additional measures may be counter-productive: trainees (registrars) in general practice work at a much slower pace and need considerable supervision from GP trainers. Putting one extra trainee into General Practice is not equivalent to putting in a trained GP. Likewise the mentoring scheme: the senior and junior GPs chatting together will keep both of them away from seeing patients.

This contract revision is well intentioned but timid. Even if the NHS could identify future GPs on their first day at university, a decision doctors make after they have qualified, it would take 12 years, i.e. 2034, for the 500 new trainees a year to become 3,000 additional GPs. Importantly the updated contract does not indicate the total GP shortfall in England, nor how that deficit will be bridged.  In short, it is not going to change theavailability of GPs in a hurry if at all.

[1] https://www.england.nhs.uk/five-year-forward-view/next-steps-on-the-nhs-five-year-forward-view/primary-care/

[2] https://www.telegraph.co.uk/news/uknews/1516095/Blair-defends-rise-that-put-GPs-on-250000-a-year.html

[3] https://www.england.nhs.uk/wp-content/uploads/2020/02/update-to-the-gp-contract-agreement-2021-2324.pdf

[4] Ibid.