We’ll never fix the NHS until we fix our broken GP surgeries
A PATIENT of mine recently raised the challenges of getting treatment when the GP surgery is closed – in this case, she required a prescription medication for a simple problem (a UTI) and highlighted the length of time taken (five hours) and the considerable number of people involved to deal with what was a fairly straightforward problem.
The story caused me to reflect on the GP service changes that have happened across the UK since 2004, often not for the benefit of patients – and raised for me the need to sound the alarm on why we are at risk of repeating the same mistakes.
Since the 1980s, there had been a very significant rise in demand for care outwith core hours (8am-6pm), and that demand was starting to negatively affect GP recruitment and retention. There were many reasons for the rise but they included an ageing population with greater needs, a developing 24-hour culture, rising expectations, and new time-critical medical interventions.
I became a GP in 1992 and knew very well what it was like to work a full day, then be on call for 15 hours (or 48 hours at the weekend), and then get up the next day to work another full day.
It might have been manageable back in the distant past (and indeed some GPS in Scotland in very remote areas still do this), but for most GPS around the country it was becoming intolerable. In my thirties, I could just about manage it and get up at 3am to drive 20 miles on a home visit and then do a full day the next. In my fifties now, I think not.
One solution would have been to put the additional resources required to meet this rising patient need into the core contract to allow GPS to manage it. This would have allowed for an expansion of the GP workforce in practices.
However, that was not the option the then-labour UK Government chose (in 2004, unlike now, the GP contract was negotiated in London). Instead, the contract was split into core hours and out of hours.
I, like many older GPS, have mixed feelings about that. On the one hand it gave us back control of our lives at nights and weekends, and gave us back the opportunity to enjoy Christmas with our families (I once horrendously had nine home visit calls after midnight on Boxing Day) – but many also felt that splitting the contract was a mistake for both continuity of patient care and also a mistake for the GP profession.
The change came at considerable additional financial cost with NHS 24 call handling and the cost of funding the 14 health boards to run GP out-of-hour services. It has not all been bad – the health board services manage around one million patient contacts a year in Scotland, they generally do a good job, and improvements have been made to the consistency of governance of the service compared to pre-2004, not least because the management are, in many cases, themselves working GPS employed by the health boards.
But there is no doubt in the minds of many that had this significant investment in both the triage and out-of-hour services gone directly into practices (obviously with some strings), we would be in a better place now. It is almost certainly too late to put this genie back in the bottle but it’s not too late to avoid making the same mistakes over GP core hours, although time is running out.
The last 10 years have seen the GP workforce reduce by 5%, while Scotland’s population is 300,000 larger, resulting in the average GP having 200 more patients. The population is also getting older and therefore have greater health needs.
Practices are very busy and increasingly stretched by over 30 million patient contacts each year – that is 20 times more than attend A&E. If we don’t do something soon to increase general practitioner workforce capacity, then we seriously risk overflow from GPS into A&E that will quickly swamp the service and make current A&E waiting times – which to be clear are totally unacceptable – look fairly minor.
We have just passed the sixth anniversary of the first entirely Scottish GP contract. As part of that contract, the Scottish Government has invested significantly (£200 million) in expanding the multidisciplinary team to support patient care and practices in the community but again, like out of hours in 2004, with services managed by health boards.
What the Scottish Government has not done, and what we agreed was needed in 2018, is to invest the resources required into core GP services to expand the GP workforce, to bring down average list sizes, and make it easier for patients to get the care they need.
If we don’t fix this GP shortage soon we risk repeating the mistakes of 2004. Not investing is a direct threat to the sustainability of the GP services across the country where GPS are increasingly getting burned out by the demand exceeding their capacity and consequently leaving prematurely.
The shortage of GPS has resulted in practices returning their contracts to the health board and some closing for good. We have 10% fewer practices than we had 10 years ago. As practices close their patients are transferred to other practices and a domino effect of destabilisation can occur.
The expansion of the GP workforce is also a major component required in the recovery of the NHS in Scotland.
In order to transform from the current unsustainable position that NHS Scotland is in, we must move away from our dependence on hospital care towards NHS recovery with a more sustainable community-first based care model where patients are able to have good access to quality care near to where they live.
I am concerned that time is running out if we are going to make the changes required and avoid these mistakes again.