Its more than a thin front line, as half timers take over from deserters…

With apologies to the Economist, NHSreality feels this article is an honest summary of the situation and state of General Practice today. Where possible I have linked to previous postings in support. But even if the manpower planning had been better, and if politicians had avoided the repetitive short termism, we still  need a joined up system, and the unified electronic record is where we should start. Cash is not enough — the NHS must be forced to unify: the only cure is a properly joined-up health service (Camilla Cavendish in the Sunday Times 7th Jan 2018) Its more than a thin front line, as half timers take over from deserters… To add fuel to the fire, GP premises development has not been facilitated, even though moving care out of hospitals is policy.

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The Economist: A thinning front line The NHS’s latest problem: a shortage of GPs – As hospitals struggle with a winter crisis, a longer-term problem is brewing in primary care

IN PLOIESTI, just north of Bucharest, Daniela Margaritescu had a grand house, a big car and her own surgery. But when she set eyes on the Beechfield Medical Centre in Spalding, Lincolnshire, it was “love at first sight”. The 46-year-old Romanian was hired last year as part of a pilot scheme to recruit more foreign doctors to fill chronic vacancies in primary care. For Dr Margaritescu it is a “perfect” deal. She learns new skills, her three children attend good schools and her pay has roughly doubled. For their part, the people of Lincolnshire—who voted heavily to leave the European Union in the referendum of 2016—are happy to have new doctors at last.

As people return spluttering from their Christmas holidays, the National Health Service is entering its busiest time of the year. On January 3rd Jeremy Hunt, the health secretary, apologised to patients after non-essential operations were suspended until the end of the month to ease the pressure on hospitals. Senior doctors took to Twitter to lament the “third-world” conditions on wards. But although the scenes in hospitals, where patients have been left waiting on trolleys in corridors for hours, are dramatic, a less-noticed crisis is under way on the front lines of the NHS. General practitioners (GPs), patients’ first port of call and the gatekeepers of most health services, are a dwindling army.

Take Lincolnshire. Before the arrival of Dr Margaritescu and 24 other doctors from eastern Europe, 104 of the county’s 434 potential spots for GPs were vacant. The Beechfield practice ran three recruitment rounds without finding a suitable candidate. “People drive past [Lincolnshire] on the way to Scotland, and then again on the way back to London,” says Kieran Sharrock, medical director of the local body that represents GPs. There is no medical school in the county, depriving it of a pipeline of talent. Doctors balk at joining remote practices with lots of old patients; in some Lincolnshire surgeries, half the patients have at least four chronic diseases.

Lincolnshire’s woes are particularly severe, but across the board the NHS is struggling to hire and retain GPs. It recently changed how it counts them, so deciphering trends is tricky, but the number of GPs has probably been falling since at least 2009, during which time the number of hospital consultants has risen by a third. In 2016 Simon Stevens, the chief executive of NHS England, pledged to recruit 5,000 more GPs over the next five years. But the count has fallen further, reaching the equivalent of 33,302 full-time GPs in September, 1,290 fewer than two years earlier. The number of surgeries has dropped to 7,674, from 8,451 a decade ago. Some towns face losing most of theirs; last year seven of the eight practices in Folkestone, on the south coast, said they intended to close.

Even before the creation of the NHS in 1948, family doctors played an outsized role in providing health care in England. Their pivotal position was described in the novels of Anthony Trollope and George Eliot. Today Mr Stevens calls the GP arguably the most important job in Britain. They decide when to refer patients for hospital care, and provide a wider range of services than their peers in many countries (Polish doctors in Lincolnshire note that back home they rarely saw children or dealt with gynaecological cases). And their role is set to become even more important: the government wants more patients with chronic conditions to be cared for outside hospital, which will require GPs to co-ordinate treatment.

What seems to be the problem?

The shortage of GPs partly reflects a change in the workforce. In 2006, 43% of GPs were women; a decade later the share was 55%. It is set to rise further, since male GPs are closer to retirement age, on average. Because only one-fifth of female GPs work full-time, compared with half of male GPs, more of them are needed. A recent analysis by Imperial College London suggests that an additional 12,000 GPs will be required by 2020—more than twice the NHS’s target.

Another reason is that the job has become less attractive. GPs complain of having to do more work for less pay—and they have a point. The English population has grown by 4.3m in the past decade, and patients are seeking help more often than they used to. The number of consultations per patient increased by about 10% between 2007 and 2014, according to a study in the Lancet, a medical journal. A survey of GPs in 11 countries by the Commonwealth Fund, a think-tank, found that 92% of British GPs reported typically spending less than 15 minutes with a patient, compared with 27% of GPs in other countries. British GPs were also the most likely to say they were stressed.

One London-based GP describes a “light day”: 25-30 scheduled appointments; five to ten emergency ones; one or two home visits; 30-50 replies to be written to hospital doctors, plus a similar pile of pathology reports to read; and 10-20 repeat prescriptions to process. Some feel like secretaries, writing referrals for ungrateful patients. It is a lonely job, without the camaraderie of a hospital ward.

Over the past decade GPs’ pay has fallen. In 2004 the Labour government agreed on a contract that raised the average pay of a partner in an English surgery to £136,665 ($185,000) in today’s prices. Since then partners’ pay has slipped to £104,900, as successive governments have made the contract less generous. Salaried GPs earn an average of £63,000, less than hospital doctors with similar experience. And, unlike those clinicians, GPs pay thousands of pounds a year in indemnity insurance.

In an ordinary labour market, employers could raise pay to fill vacancies. But the NHS, the world’s fifth-largest employer (behind the American and Chinese armed forces, Walmart and McDonald’s) does not operate in an ordinary labour market. In effect, pay is set at a national level. The number of doctors to be trained in each specialism is determined centrally years in advance. Since it typically takes ten years to train a GP, failures of planning mean shortages that take a decade or more to fix.

The government has said it will increase the number of places at medical schools by 25% from September. (Unlike other degrees, there is a cap on places to study medicine, because the course is heavily subsidised.) But that will take time to translate into more GPs. It will also require universities to improve the reputation of general practice; for a certain type of thrusting medical student, only dentists are viewed with more disdain than would-be GPs.

With no end to the staffing problem in sight, some surgeries are adapting. They are employing more paramedics, nurses and pharmacists to see patients. Several surgeries are becoming mega-practices, spreading the GPs they have across many sites. Others will increasingly rely on doctors from overseas. Britain already employs a higher share of foreign doctors (27%) than the average across the 28 members of the OECD club (17%). Of the 12,771 doctors who registered in Britain in 2016, 44% had qualified overseas.

According to research by Aneez Esmail of the University of Manchester, and colleagues, foreign-trained GPs are more likely than British ones to work in poor areas, earn less money and work longer shifts. But doctors trained abroad also score lower on postgraduate medical exams, and are more often subject to complaints. In Lincolnshire the doctors recognise they have a lot to learn. Accordingly, for their first two years they get twice as much time to spend with patients as other GPs do.

Those running the pilot believe that it will continue after Britain leaves the EU, given the need for GPs. The NHS has said it wants the programme to be scaled up to attract 2,000 foreign GPs. Tomasz Grela, a genial new Polish doctor in Spalding, is not too worried about Brexit. “The medical system needs us,” he says. And although he readily concedes that he needs to get up to speed with the British system, he is showing signs of acclimatisation. Asked what frustrates him most about the NHS, he gives the same response as most British doctors: “Bureaucracy.”

This article appeared in the Britain section of the print edition under the headline “A thinning front line”

Call Dr Stalin: the NHS must be forced to unify – Cash is not enough — the only cure is a properly joined-up health service

General Practice is “Closing Down” … Presentation for a unified IT system rejected 1996 / 2001

Facing an understaffing crisis….. Those rejected during the last 30 years should be asking why?

Gender bias. The one sex change on the NHS that nobody has been talking about

A retired GP says retiring “.. was like leaving an abusive relationship”

The GP recruitment farce – Mr Hunt never said the 5000 would come from the UK!

An exodus because of poor planning and the shape of the job. Deprofessionalisation….

Who wants to be a GP? Rebuiling Trust is not just needed for juniors… The NHS: How bad will it get?

Here is an idea to fix the NHS: let’s get rid of GPs. Lets see how Scotland’s GPs vote…Dementia is going to overwhelm all our services, including our GPs unless we address reality…

Despite “adequate or average” funding, our waiting lists are much higher than average. Even communication is failing at a basic level…

Public must pay for better NHS, says Stevens to spineless politicians at King’s Fund

The history of denial in GP recruitment: over 50 years. The result of a sustained collusion of denial.. It’s going to get worse..

The decline of General Practice.. Bribes may be too late…

Mr Hunt needs 40,000 GPs in the next 10 years. 1,500 extra per annum with a 10 year lead in will make no difference.

Severe shortage of GPs is reaching crisis-point in Derbyshire – only 37% of GP training places filled – due political rationing of Medical School places 10 years ago, and the shape of the job

Exhausted GPs shun out-of-hours work. The long term result of rationing medical school places, of declining skill standards, and governments showing they “couldn’t care less” for years.

would the British public be happy to swap a shorter GP consultation time for a longer one that involved payment of it and additional services?

GP premises development frozen, GPs forced to publish pay from 2015: What about comparing overhead?

Child health care: adequate training for all UK GPs is long overdue

The history of denial in GP recruitment: over 50 years. The result of a sustained collusion of denial.. It’s going to get worse..

Medical Schools: your chances – applications-to-acceptance ratio was 11.2.

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This entry was posted in A Personal View, General Practitioners, Post Code Lottery, Rationing, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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