Ninety per cent of NHS patient contacts are said to occur in primary care. GPs manage the tasks of being physician/healer, friend/advocate, resource-finder, and gatekeeper.
That is why we value them although we know that different GPs will prefer some roles to others. But in 10 years time the GP and primary care systems may look very different. How will this be decided?
Sheffield’s developing primary care strategy seeks radically to change the way we seek help for our health problems
Many politicians, both national and local, seem unaware of how deeply the NHS crisis affects general practice. Indeed some consider that since Labour’s 2004 GP contract upped GPs’ pay and conditions and exempted them from routine out-of-hours duty, GPs have been sitting pretty, with many able to afford to go part time.
That contract helped to improve GP recruitment, especially among women doctors, but it also contributed to the increasing difficulty of seeing the GP of one’s choice and led to a steady decline in public satisfaction in the NHS GP patient survey (though satisfaction remains high). However Downing Street’s suggestion that the crisis in NHS hospitals is down to GPs not offering a Sunday service smacks of ignorance and desperation. Recent trials (including in Sheffield) suggest lowish demand for Saturday afternoon surgeries and even less for Sundays.
The truth is that we’ve actually been going to see our GPs much more often in the last 15 years and recent research suggests a 15 per cent increase in consultations between 2010/11 and 2014/15. GP numbers grew by only 4.75 per cent (much less than hospital doctors) and practice nurses by 2.85 per cent.
Funding for primary care as a share of the NHS overall budget fell from 10.6 per cent in 2005/6 to 7.2 per cent this year but the costs of maintaining a practice and keeping to regulations have risen. Last year some practices, including those working in the most deprived areas, had their income reduced. The small increase offered by Hunt by 2020 will barely make up for this.
Pressure on GPs and their staff is also fuelled by generally higher expectations, by having to keep up to date with new developments and technologies, by the erosion of other sources of patient support, particularly through cuts to local authority services and the benefit system, plus the administrative failures of Capita’s newly privatised support services. Overall GP job satisfaction is at its lowest since 2001. GPs are leaving the service or retiring. Few current GP trainees contemplate working full time. Practice staff are becoming harder to recruit. In Sheffield 30 per cent of practice nurses and other support staff are over 55 and the ratio per patient is the lowest in South Yorkshire.
Good patient care is further complicated by difficulties in liaising with other services, including hospitals and social care. Last year’s Challenge Fund initiatives in Sheffield found that lack of liaison caused significant problems for both GPs and patients and a promising improvement scheme was abandoned because the private sector social care partner could not adjust its structure to meet the flexibility required.
Most GPs in Sheffield are said to be genuinely enthusiastic for changing working practices to provide a better NHS service – provided they can find the time to think about it! Sheffield’s developing primary care strategy seeks radically to change the way we seek help for health problems, relying on our willingness to see other health care professionals rather than going first to the GP. It casts GPs both as medical generalists and clinical leaders for neighbourhoods. By getting services to work together, it hopes to help tackle demand for health care and significantly to reduce hospital admissions.
We’ve heard such overly hopeful NHS-speak before, going back at least to 1996.
Changes like this will only happen after an open and public renegotiation of the balance of the key elements of NHS care (including some transfer of funding from hospitals). No politician or party has yet felt confident about taking this on, not least because both efficacy and public acceptability have yet to be tested. Moreover, at the moment there just isn’t the right level or mix of staff.
Some important local proposals depend on gaining transformation funding from NHS England. But much will depend on exactly how primary care is organised in the future.
But more radical moves may be under way. The local Sustainability and Transformation Plan (STP) talks of running most local health care under an Accountable Care Organisation. This proposal is problematic in itself, but the ACO, probably hospital-centred, could easily decide to subcontract neighbourhood care not to GPs directly but to organisations which employ GPs – just like the contracts Virgin Care has elsewhere. So most if not all GPs would become salaried employees and indeed nationally 27 per cent already are. This would be a very different type of service.
General practice matters to us all; its future needs discussion. The CCG and Sheffield Healthwatch need to take this on, as well as political parties. We need to join in too, as well as keeping up pressure on the Government to protect the NHS as a whole. Try joining your surgery’s patient participation group – and check it’s linked with the new CCG-sponsored network of similar groups.