Is the end in sight for General Practices? Have the jewels in the crown turned to paste?

In 2013 NHSreality nearly finished because there was no realisation of what an impasse we were approaching in patient access and primary care manpower. The best job in the world, when I began in 1979, had become one of the most stressful. Somehow, even since then, GPs in declining full time equivalents but relatively similar numbers, have kept going. There is no realistic manpower plan and there has not been one since NHSreality began. I am so proud of colleagues who have kept going even though their administrators are impotent. Part of the reason for this is long term denial, and surrender / acceptance, but what lies behind this is a culture of fear, where managerial promotion is so speedy that no appraisal is done, and staff exit interviews are hardly ever done, and if they are there is no confidence that what is said will be acted on, listened to or reported to politicians in an aggregated and dispassionate way. Now in “broken” Wales the waiting lists are dangerous and the longest in the UK, and life expectancy and outcomes are the worst in the UK. No amount of money can make up for the lack of sufficient staff. Waiting lists are not likely to improve by 2025 (Jenny Rees for BBC 25th April 2022) , in Wales or anywhere else in the 4 dispensations. They will have a better chance where there is wealth and more choose private options. Primary medical care (General Practice) is about to go the same way as Dentistry. It will not help to force longer hours on GPs, now predominantly a female less than full time profession. The end of a personalised service as the Times describes it. I remember when (2016) the politicians said they would allow smaller GP surgeries to fail. The result of failing GPs is that A&E gets overrun. The five minute appointment is inappropriate when the demographic is changing. Martin Marshall reminds us of a letter in Pulse in 1960 (its first edition): ‘Surely, of all things, the practice of medicine should be a reasonably leisurely business….. how much faith would one have in a mechanic who claimed he could service your car in 5 minutes?’ The idea that we could look at other countries’ systems for inspiration and better outcomes does not seem to occur. Cancer Colon is a case in point, where our outcomes are pretty awful.

2013: Burnout forces almost 10% of GPs to take time off work as pressure on occupational health services grows

2016: The public will only miss what they had – when its gone. GP indemnity fees spiral out of control with 25% rise last year..

2017: In Wales they really can waste money: £68m unveiled for health and care hubs and The flock of geese that laid golden eggs has been culled. It takes years to rebuild, and the fox is at the door.

2018: Doctors to see groups of patients – is probably madness. The fox is waiting.. and The desperate state of General Practice. Black swans will not be diagnosed as often, or as quickly.

2021: Manpower planning failure – Building a new hospital in a deprived, coastal, rural, and left behind area after rationing training places for decades – reflects the Hobson’s choice in front of us all.. With burnout of many staff at risk whatever..

2021: A prolonged reduction in standards is predicted …. But politicians might finally realise the value of GPs, and proper manpower planning.. If only they had used Exit Interviews…

GPonline 22nd APril 2022: Podcast: The demise of small practices, enhanced access and LMC anger over GP contract

Nick Bostock for GPonline: GPs to demand core hours cut to 9-5 and new contract with workload limits – GPs will debate calls to reduce general practice core hours from 8am-6.30pm to 9am-5pm and to build safe workload limits into a revamped GP contract at next month’s UK LMCs conference.

Pulse: RCGP chair. The threat is that General Practice will end up like dentistry and then you could end up seeing your health service GP as they moonlight in a private clinic. Kat Lay opines 27th April: Pressure will push more GPs into private work, says chief

A regular review of the workforce and manpower planning as recommended by the Lords, is rejected for a third time by Members of Parliament. AND Despite the workforce crisis the access has improved since Covid.

Phil Hammond in the Times: There is a brutal efficiency to NHS waiting lists – because dead patients don’t vote! And there is no plan for posthumous voting …

HEALTH HOLIDAY – The Times letters 27th April
Sir, If another bank holiday is to be introduced (“Bank holidays cost economy less than claimed, say bosses”, Apr 26), may I suggest it be July 5, the anniversary of the founding of the NHS in 1948?
Jennifer Johns
Ret’d doctor, London SW12

“Britain’s bureaucratic model of healthcare needs reform to meet patients’ needs and be financially sustainable”. The Times (gently) advocates co-payments.

The idea of co-payments is anathema to most politicians in public, but in private they agree it is sensible. Healthcare has necessarily been dominated since 2020 by the need to combat Covid-19, to protect the vulnerable, save lives and stop the NHS from being overwhelmed. Yet there has been collateral damage to the treatment of other conditions. NHS England has now issued new guidance to health providers to return to pre-pandemic measures for physical distancing and cleaning. Enoch Powell understood the need to ration overtyl and with public agreement. Matt Morgan in a recent BMJ pointed at thhree alternatives: he summarises “The Danes tax heavily and then provide good healthcare and education. The French ration, restricting lung surgery for smokers or heart surgery for obese patients. The Australians collaborate, providing free public healthcare to the poorest people and the same quality healthcare in a better environment to those who are insured. The British pretend to do none of these, yet we ration without honesty, tax without equality, and collaborate without transparency.” He is moving to Australia… Problem: Flat rate co-payments will be regressive, and a two tier system is what Aneurin Bevan was trying to avoid. The idea that the RCGP and the BMA can fund and lead a “fight back” (Peter Blackburn: Picking up the pieces in Doctor Mag) in 2 years is nonsense. The universal systems only gain acceptance where the medical outcomes are the same for rich and poor. Raising the standard of continuity and of care back to where it was 20 years ago is a much longer game.

The Times Leader and view on primary healthcare in the UK: Doctors’ Dilemma 20th April 2022
Healthcare has necessarily been dominated since 2020 by the need to combat Covid-19, to protect the vulnerable, save lives and stop the NHS from being overwhelmed. Yet there has been collateral damage to the treatment of other conditions. NHS England has now issued new guidance to health providers to return to pre-pandemic measures for physical distancing and cleaning.The guidance is a sensible course to allow the NHS to treat more people who are ill. Yet one course to stem the pressures would be to act on the system of GP appointments. There is no technological fix to the problem. GPs need to be more available, there needs to be more of them, and the system of payment for care needs reform.
There is much evidence that capacity constraints are endangering lives. More than six million people are on the waiting list for planned care, and waiting times in A&E departments are at record highs. And last month some 390,000 people who called 999 with serious conditions had to wait more than an hour for an ambulance to arrive.
Moreover, many sufferers from chronic conditions have missed out on essential health checks. NHS figures suggest that only 36 per cent of patients with diabetes received routine check-ups such as tests to monitor their blood sugar last year, and more than 15 per cent have had no contact at all with healthcare professionals since the pandemic began. The charity Diabetes UK says pressures on GP surgeries have resulted in “routine care for people with diabetes being deprioritised”.
It is no hyperbole to call this a crisis, and a particularly vulnerable point is the system of GP appointments. Before the pandemic, according to the British Medical Association, there were 0.52 GPs per 1,000 people in Britain and that figure has fallen even while demand for appointments has soared. Only part of the answer lies in digital consultations. Older and more vulnerable people may not be comfortable in using the technology, and a doctor can only tell so much about a patient’s condition in the absence of a direct consultation.
A lack of availability of appointments due to staff shortages is feeding through into many other areas of care, especially the number of patients attending A&E and possibly waiting times for ambulances. Doctors’ groups are justified in pointing to a need for additional investment but some of the strains are due to GPs’ own preferences. A survey this month commissioned by the Department of Health suggests there has been a sharp decline in GPs’ working hours since the pandemic began, as more prefer to work part time. This is their right, but it increases pressures on the health service. Doctors’ groups should in turn agree to a better alignment of incentives within the NHS, including a greater flexibility of regions to set their own pay levels. It ought to pay better to be a doctor in a region with a severe shortage of skilled staff.
There is perhaps a case for making patients pay more too. They already pay towards prescriptions and dentistry; many other countries also charge for GP appointments. It may not prove practical but it should at least be looked at as a way of reducing the number of missed appointments and reserving consultations for more serious conditions.
The dedication of NHS staff during a historic crisis has been exemplary. It is no reflection on their efforts to point out that Britain’s bureaucratic model of healthcare needs reform to meet patients’ needs and be financially sustainable.

The NHS needs a midlife crisis – but nobody is bold enough to conduct this. Unofficial exit interviews are all we occasionally have..

Times letter in response 21st April:

Sir, Your leading article “Doctors’ Dilemma” (Apr 20) is excellent but does not make enough of the lack of GP availability, which leads to more people going to A&E. E-consultations are satisfactory for some but for others, particularly the elderly, they are a challenge and face to face would be better. One of the main reasons for the lack of appointments is the prevalence of part-time GPs: it is almost impossible for a general practice to find a full-time “partner” to employ these days. “Burn-out” is quoted as the cause of this but perhaps medical schools are taking too many applicants with perfect grades rather than hardworking, dedicated students who will cope with the pressures of being a GP.

I recently tried to get my wife antivirals for quite severe Covid as she is on steroids but it was a Saturday: no GPs available till Monday, 119 no help and 111 “exceptionally busy”. I gave up after 40 minutes. Sadly general practice is a very poor service at present and needs radical reform.

Dr Chris Westwood

Ret’d full-time GP; Yealmpton, Devon

Times letters 22nd April 2022: Easing the pressures on NHS general practice

Sir, After 20 years of working as a GP I have witnessed many system changes but nothing compares to the paradigm shift caused by Covid (“Doctors’ Dilemma”, leading article, Apr 20; letter, Apr 21). To protect vulnerable patients we set up coronavirus assessment centres, vaccinated the entire population and tried to continue to run our normal services despite a large proportion of our staff being off sick. At one point we had no secretarial team for a practice of 12 partners. We have tried to adapt to phone triage (old dog, new tricks), which many of our patients prefer.

In our practice we offer a mix of face-to-face and phone triage, based on clinical need and patient preference. However, this does lead to some appointment duplication when patients who have been triaged then need appointments. We need to address the workforce and workload issues: we should encourage more students to see general practice as an exciting, rewarding career. We also need more ancillary staff to help us, such as clinical pharmacists, frailty teams and social prescribers. We must sort out the tax burden that causes GPs to retire early to take their pensions. We also need a more positive representation of our successes and achievements and we have to stop being the fall guy for all the failings in the health service.
Nicki Perry
GP partner; clinical lead for electives and outpatients, Kent Clinical Commissioning Group

Sir, Your leading article suggests some helpful ways of improving access to GP appointments. More GPs are certainly needed but will not materialise until general practice again becomes an attractive career; no doctor is obliged to become, or remain, a British GP and not enough are choosing to do so. The government should ask why so many are avoiding general practice or leaving prematurely, often exhausted.
Peter Leigh
Poole, Dorset

Sir, I have to agree with your leading article that asking patients to pay to see a GP would help to provide more funds. But I remember discussing this many times during my working life and all the reasons for not doing so were always raised. People with severe problems, eg cancer, might not attend or attend late or not at all; also this would lead to a two-tier system. The BMA was against it: doctors should not be tax collectors. You rightly say that GPs choosing to work part-time has decreased the number of available hours, particularly as more GPs are now female. We should charge patients as they walk into the surgery. If patients are not seen the doctor will not get paid. This would change the incentive for both.
Ken Doran MB BCh
Ret’d GP, Spalding, Lincs

Sir, You report that British patients find it harder to see a GP than in other leading western countries (“Struggle to see GP tougher for Britons than other westerners”, Apr 21) . It is hardly surprising that patients are turning to private providers for primary care, where they will see . . . a local NHS GP. These well-paid GPs can afford to reduce their practice hours and perform lucrative private practice at the expense of patients on their NHS list. The solution is to end the independent contractor status of GPs and put primary care under direct state control.
Dr John Ainley
Ret’d physician, Dronfield Woodhouse, Derbyshire

“Advice and Guidance” GP contract change is imposed in England.

Perhaps it will help recruitment in Scotland, Wales and N Ireland if they decide not to follow England in their Advice and Guidance – a key part of the National Elective Care Recovery and Transformation Programme’s work! (NHS Digital‘s advice for referring clinician teams is part of this). When “out of hours” responsibility was removed, sometime near the turn of the century, under Labour and Tony Blair, the profession of General Practice changed. No longer did we as self employed people, have to contract for 24 hour care. It meant having a family life was possible for single handed GPs, and some GPs could work part time whilst their children were young. A pilot trust led to the Pulse headline “A&G pilot trust urges consultants to reduce GP workload dumping”. “Professor Alistair Chesser told consultants they should ‘avoid asking GP surgeries to do things if possible if they lie outside the bounds of the GP contract’. However, it comes as GPs recently raised concern that Barts may pass on unnecessary workload to GPs in the form of rejected referrals via a far-reaching ‘advice and guidance’ pilot scheme.…” At the same time, even if you see on proctoscopy, or feel secondaries in the liver, and the patient is wasting away, you have to wait for a FIT (Faecal Immunochemical test) before referral. There was no universal BMA and non BMA doctor debate on this change, and it has not been imposed in the other dispensations – yet. I list below the posts in the media which appertain to this controversial bully boy tactical approach. If practices and doctors feel they have no choice they will resent this approach: it does not bode well for the future. Short termism at it’s worst. It adds to the UK post code lottery, and makes medicine less attractive, particularly General Practice.

Constanza Potter in Pulse 14th April 2022: NHS England elective planning guidance confirms mammoth GP A&G task

NHS England has confirmed plans for this year’s 10% increased elective activity target to be predominantly achieved through increased GP advice and guidance (A&G).

The plans were first revealed in draft guidance seen by Pulse last month, which set out that GP A&G ‘could contribute an estimated six percentage points’ towards the target of ‘over 10% more’ activity.

Final NHS England elective recovery planning guidance published yesterday enshrined the plans, including that the number of pathways ‘completed in primary care with the support of specialist advice’ without onward referral will be monitored through a new dataset – the Elective Recovery Outpatient Collection (EROC).

It said that further guidance on this monitoring approach is available on NHS England’s FutureNHS planning platform.

The guidance added that local commissioners will also be monitored against the target of a ‘minimum’ 25% reduction in the following up of outpatients by March next year.

They should plan how they will redeploy released capacity, including to ‘increase conducting A&G in co-ordination with primary care’, it said.

A&G involves GPs accessing specialist advice by telephone or IT platforms, rather than referring patients for a hospital investigation.

The guidance also added that local commissioners and providers should consider how ‘optimal referral management will happen’.

It said that plans must demonstrate ‘an ongoing commitment to the clinical validation and prioritisation programme, including the conduct of three-monthly reviews for patients waiting over 52 weeks and at least weekly reviews for those waiting longer than 62 days on a cancer pathway’.

However, it remains unclear who will be responsible for managing and validating waiting lists, with GPs previously told they could be asked to review hospital waiting lists for elective care.

And the guidance set out that local commissioners should ‘review of primary and secondary care operating principles’ to ensure patients are offered a choice of providers ‘at the point of referral into elective pathways’ via a ‘shared decision-making conversation’.

It added that primary care networks could be responsible for supporting patients who are waiting for elective care.

It said: ‘Systems should consider what additional support or services for patients on the elective pathway is available through local voluntary and community groups. 

‘This may include work with primary care networks to recruit additional social prescribing link workers, care coordinators, and health and wellbeing coaches.’

ICSs must now develop plans outlining how elective targets will be achieved, including ‘going further for those that are able to’, NHS England said.

Chief executive of Lancashire and Cumbria consortium of LMCs Peter Higgins told Pulse that his ‘main worry’ is that A&G is ‘just another mechanism for pushing more work back to general practice’.

He said: ‘It can be a good thing if it’s planned well and it’s planned jointly between primary and secondary care, but the worry is [that] it’s just another mechanism – if it goes wrong or if it’s abused – for pushing more work back to general practice and that’s our main worry.’

He added that it’s ‘absolutely not’ fair that GPs effectively have been asked to mop up most of the hospital backlog and that there is no capacity to do so.

Mr Higgins said: ‘It assumes that capacity is there to do the work and it just is not. 

‘It seems like the Government is full of good ideas, but not the wherewithal to implement them because there just aren’t the staff there, either in general practice, community services or indeed in hospital services.’

Former BMA GP Committee England chair and Leeds GP Dr Richard Vautrey added that while A&G ‘can often be helpful’, setting ‘arbitrary targets’ to increase its use could be ‘completely counterproductive’ if it becomes a ‘requirement’ and referrals are ‘restricted or prevented’.

Dr Vautrey, who is also Leeds LMC assistant secretary and Central North Leeds PCN clinical director, said: ‘Moreover, these plans make no provision for the necessary increase in the GP workforce or shift of resources required for more work to be done in general practice.

‘It’s not acceptable for GPs to be expected to help solve the massive backlog in NHS care without being given any of the funding required.’

In January, NHS England planning guidance set out ambitious targets for ‘over 10% more’ elective activity in 2022/23 than before the pandemic.

And the Government’s long-awaited elective recovery plan – published in February – stressed that GPs’ role in tackling the NHS hospital backlog will focus on the use of A&G to try to avoid ‘unnecessary’ referrals to secondary care.

But Government auditors have warned against ‘overloading’ GPs in clearing the elective backlog.

It comes as Pulse revealed earlier this month that GPs could be held liable for advice given to them by hospital colleagues about their patients via A&G services.

And NHS England warned last month that the second wave of the Omicron strain of Covid is putting the delivery of the elective care recovery plan at risk.

PCNs are due to be incentivised for using A&G through ‘Investment and Impact Fund’ (IIF) points worth £9.9m in 2022/23, however GP leaders have raised concerns about its workload impact in general practice.

Michael Mullineux14 April, 2022 comments: Another in the litany of genius ideas from NHSE. Because we waiting for some extra work to fill the day with plentiful resources, funding and absolutely no staffing issues. ‘Our cups runneth over …’

The NHS needs a midlife crisis – but nobody is bold enough to conduct this. Unofficial exit interviews are all we occasionally have..

In the BMJ 16th April 2022 Matt Morgan opines “The NHS needs a midlife crisis” BMJ 2022;377:o928, but he is really giving his own exit interview evidence as he leaves the Welsh Health Service in Cardiff for Australia. He wont get an official exit interview. A GP explains in the Times letters how demand for a service which is “free” increases with ease of access, and how delays and access problems become an inevitability. All of this has to be part of the “open debate” asked for by Mr Stevens, but never achieved. Matt knows this, and this is why he is leaving. The 4 health services are unsustainable.

Matt Morgan: The NHS needs a midlife crisis | The BMJ: I assumed that my midlife crisis would involve one of the usual cliches—a motorbike, a bad haircut, a skydive. Instead, I’m uprooting my comfortable life in the UK and moving 9000 miles with my family to Australia. This isn’t because I’m unhappy; I love my work, the NHS, my colleagues, my community, and my home. It’s because I’m content—too content. Some change is needed. And radical change can often be easier than subtle transposition. Likewise, the NHS needs a radical change.
A human midlife crisis usually happens when people feel compelled to face their mortality, confidence, identity, and accomplishments. Although the NHS is nearly 75 years old, it’s an organisation facing the same existential crisis, and survival is never guaranteed.
More often than not the NHS feels broken at the seams, struggling to deliver 21st century healthcare in a boat set adrift on a sea of 1970s asbestos. Even when the physical buildings on the hospital estates aren’t condemned as unfit for purpose, the workforce struggles under ever increasing rota gaps and demands for care. From October 2021 to February 2022 more than 60 000 patients have experienced a 12 hour delay in the emergency department.1 That’s more patients waiting over 12 hours for care than in any equivalent period in the previous decade.
To fix this, the NHS needs a midlife crisis. It needs to look after itself while finding new ways to remain relevant. But, before a fix, it has to realise that it’s broken. The honest truth is that Nye Bevan, standing in the Welsh industrial scars of the 1940s, could not have predicted the scope of his promise. His words “free healthcare for all” meant only a handful of operations and drugs. Now, with designer genetic drugs and bionic limbs, a notional percentage of your income can’t sustain that proclamation, even with the recent hike in national insurance contributions. NHS staff stand strong to deliver what patients need, but they need the resources to do it. Patients are willing to wait, but there’s only so long they can hold on, especially if waiting for treatment leaves them with pain, discomfort, or anxiety.
The options for fixing it are simple yet harsh: more taxation, more rationing, or more collaboration. There are precedents around the world for all three solutions. The Danes tax heavily and then provide good healthcare and education. The French ration, restricting lung surgery for smokers or heart surgery for obese patients. The Australians collaborate, providing free public healthcare to the poorest people and the same quality healthcare in a better environment to those who are insured. The British pretend to do none of these, yet we ration without honesty, tax without equality, and collaborate without transparency.
The alternative is to offer false promises about knees that won’t be replaced and cancers that will continue to grow. This is uncomfortable and prevents us from acknowledging the truly deadly lack of capacity in emergency departments and critical care units. Delays in hospital admissions cost lives, while their downstream effects disrupt pre-planned surgical waiting lists—lists that hold hope for so many people with blood vessels liable to burst or growths waiting to grow. Patients, families, staff, and the NHS deserve better: bring on the midlife crisis.

ONLINE DOCTORS in the Times letters 19th April 2022:
Sir, It is appropriate to point out the stake that Professor Dame Clare Gerada holds in eConsult while promoting online consultations (“GP advocate of online care has stake in tech company”, Apr 18). These organisations often have clinical staff who advocate for their services, despite a clear conflict of interest between their medical work and personal investments. Many “regular” GPs have expressed concern at the potential for online consulting to drive extra demand for more trivial inquiries, which we cannot fulfil with our present workforce. I believe this is now coming to fruition and may partly explain why some patients find it difficult to see a GP face to face.
Dr Katie Musgrave
Loddiswell, Devon

NHSreality posts on Simon Stevens & the honest debate or dialogue needed.

NHSreality posts on “unsustainable” health services

Little we can do short term, but we could alter changeover day or restrict consultant leave. We could also aim to staff every day the same in the longer term.

The state of the health service is really dire. Dead patients dont vote, so we rely on the relatives and the living survivors to recount their stories. Critical incidents are often ignored, exit interviews are unknown, and even if they started the professions would not believe in their content unless done by an outide HR firm. Fay Schopen in the Guardian recounts her own experience on 18th April 2022: No sleep, little care, no medication: my 80-hour A&E ordeal – Over four days and three nights, I saw the catastrophic predicament that the NHS finds itself in. But this anecdote reflects many DGHs across the country, East to West, North to South. NHSreality has warned about reducing standards, mainly due to reduced numbers of staff, “our biggest asset”! NHSreality has warned since 2012 that deaths are more common in the first weeks after changeover in August and February. This is something that could be changed. Newly qualified doctors need cherishing and supporting. Their consultants should not be away in their first months. So either we change the changeover day and alter by a monthmto March and September, or two months to April and October, or we deny the consultants holidays in August and February. As far as weekends are concerned, i suspect that we need a rota and cultural change so that every day is treated the same. This means even more staff, and plant, and therefore more capacity, shorter waiting lists, and lower death rates. The Telegraph’s red herring of increased covid deaths at weekends is old but demoralising news… in that it has not changed for 10 years. NHSreality’s first post was in 2012.

JRSM 2012: Weekend hospitalization and additional risk of death: An analysis of inpatient data. “Admission at the weekend is associated with increased risk of subsequent death within 30 days of admission. The likelihood of death actually occurring is less on a weekend day than on a mid-week day.”

2013: Dont be Ill in August & particularly on the 11/12th …. A reminder that nothing much has changed and how hard it is to make the change

2014: August comes around again – don’t get ill in August and 2015: August comes around again – don’t be ill this month and Patients die because of our “arrangements”. Chaos as hospitals promote all trainee doctors at once

HMG 2015: Research into ‘the weekend effect’ on patient outcomes and mortality and from Full Facts: Weekend deaths at NHS hospitals

BMJ 2017: Rachel Meacock – Elevated mortality among weekend hospital admissions is not associated with adoption of seven day clinical standards We …” cast doubt on whether adoption of seven day clinical standards in the delivery of emergency hospital services will be successful in reducing the weekend effect.”

2018: The National Institute for Health and Care Research: Study raises questions about NHS “weekend effect”

September 2020: Russia Today and the 4 Health Services. Are there similarities? We need to alter changeover day from August to October.

2020: August is the “unnecessary death” month. Staffing levels are low, experience is absent and locums thrive..

The Telegraph reports 18th April 2022: NHS Covid deaths more likely at weekends than on weekdays – Britain has one of world’s worst weekend death rates, with 11 per cent more deaths than on weekdays, study finds

2021: Its hard to accept but August is “murder month”.

There might be enough carers & diagnosticians by 2038..

The shortage of diagnosticians, GPs and in particular experienced docgtors, is upon us. 2028 is said the be the first date the shortage might be reversed, but NHSreality thinks this is optimistic. More like 2038..

Kat Lay in the Times 16th April 2022: Tories fall four years behind in pledge to hire 6,000 more GPs

A government promise of 6,000 more GPs by 2024 is unlikely to be met before 2028, Times analysis suggests.

Experts said that, with more GPs now working part time, at least 7,300 would be needed to provide the same level of improved service as the initial pledge. A national survey published this week found that the majority of GPs worked three days a week or fewer.

Patient groups said they were concerned that this meant people would struggle to see the same GP consistently, making serious issues less likely to be picked up.

Doctors’ leaders have said that GPs are working fewer days to safeguard against burnout and to protect their patients, and that the hours worked would be considered full-time in many industries.

In January there were the equivalent of 36,009 full-time GPs. That was up from 34,519 in December 2019, when the Tory election manifesto promised 6,000 more would be provided. Assuming a consistent rate, it will take another six years to recruit the remaining 4,500.

Sajid Javid, the health secretary, admitted late last year that the government was not on track to meet its initial target. Lucina Rolewicz, a researcher at the Nuffield Trust, a health think tank, said: “Even if the government was to meet this target it would likely not be enough to address widespread shortages. More and more GPs have moved to part-time working in recent years. Given this shift to more part-time work, we expect the government’s original 6,000 target would need to increase to over 7,300 GPs if it wants to achieve the same level of improvement on access to services for patients.”

Rolewicz said there was “no quick fix” for the GP workforce crisis, but that the government could “do more to reduce the number of GPs who do not make it through training and incentivise those who want to work full-time hours to do so”.

The number of fully qualified GPs working in the NHS has dropped in recent years. In December 2019 there were 28,129, compared with 27,757 in January this year. Doctors said that this reflected a loss of valuable experience and could hamper the training of new GPs.

Doctors’ leaders, including the British Medical Association, have urged government action on a variety of issues exacerbating the problem, including pension taxation rules that incentivise early retirement. They have also called for more flexibility on how funding can be used to hire other professionals, such as nurses or physiotherapists, to share the workload.

Dennis Reed, from Silver Voices, a campaign group for older people, said: “There is a glaring discrepancy between the government claiming they want to increase GPs by 6,000 and the reality of GP numbers dropping and doctors reducing their working hours. It is patients who suffer the consequences.” He said patients needed “peace of mind that they can see a doctor whenever they need to”, and that he worried people would turn to A&E instead, adding to pressures there.

“The large number of GPs now working part time also damages continuity of care, which is very important,” he said. “All the chopping and changing means you no longer have someone you can call your doctor.”

The GP Worklife study published on Wednesday found that the average family doctor completed 6.3 half-day sessions each week. The average hours worked were 38.4.

The study found that one in three GPs were planning to quit in the next five years, including the majority of those aged over 50. Intense workloads and growing demands from patients were contributing to the exodus.

Ellen Welch, GP and editorial lead with Doctors’ Association UK, said: “I don’t think the general public have a grasp of what part-time working actually means in general practice. As a part-time GP I have 48 patients booked each day. This is the norm.

“UK GPs are consulting at levels way above the 25 patient contacts per day considered safe by the EU.” She said that pressures from the wider system fell on general practice, with the 6.2 million people waiting for hospital treatment coming to GPs for support.

“No other profession is routinely asked to defend their working patterns in the way GPs are,” she said. “If GPs didn’t work part time, numbers would fall even more rapidly due to burnout.”

A Department of Health and Social Care spokesperson said: “We are working to support and grow the general practice workforce. In December 2021, there were over 1,600 more doctors working in general practice compared to 2019 and a record-breaking number started training as GPs last year.

“We have invested £520 million to expand GP capacity during the pandemic, on top of £1.5 billion until 2024 and we are making 4,000 GP training places available each year, to help create an extra 50 million appointments annually.”

Are we heading for two tiers of health care in the UK. Surely yes, but after a few years, when the penny has dropped.

Mr Michael Anderson in the BMJ editorial 9th April 2022 asks a pertinent question and concludes “not yet”, or “unlikely”…. He admits that the potential is there, and has been since the inception of the original NHS. However he fails to recognise the pressure from the medical professions themselves, who know it is half baked. Many doctors have private insurance themselves,and a group policy is the way to go. Whether the profession will get together enough to organise what they need and would like is debateable, partly because they are all working flat out, partly because the BMA representatives are mostly old and retired, and partly because more and more younger doctors are workign part time to bring up families and retain lifestyle. The next 5 years will reveal whether there is any acceptable solution to the lack of carers, nurses, diagnosticians, hospital beds. NHSreality feels that the lack of a workforce plan will mean more private health care, either by direct payment of through insurance: in the next 5 years it could move from 8 to 20% of the population. The IMF warned us that a two tier healthcare system was coming, well before covid, in 2017. London and the South East, and England with “choose and book” already operate at a level above all post codes in Wales ..

Michael Anderson asks: cBMJ 2022;376:o618
Unlikely, because of limited capacity in the private sector.
Extrapolation from a recent poll suggests that about 16 million adults in the UK found it difficult to access healthcare services during the pandemic, and of these, one in eight opted to access private healthcare.1 This could create the conditions for a two tier system, whereby those with the means to pay have access to healthcare more quickly than those who don’t. This would jeopardise the high levels of support the NHS has enjoyed since its establishment and have serious implications for equity in access to healthcare services.
Compared with other countries, the UK has always had a smaller proportion of privately funded healthcare, accounting for 21.5% of total healthcare expenditure in 2019 compared with an average of 26% for countries in the Organisation for Economic Cooperation and Development.23 This is because the NHS is a universal healthcare system giving citizens access to comprehensive healthcare services based on clinical need and not ability to pay.
About 7% of the population have private medical insurance.4 Policies are mostly sponsored by employers and can be used to access certain specialist services. The number of private insurance policies peaked in 2008 at 4.4 million, but this has since declined to just under four million.5 Even with this decline, claims on insurance policies still generate around half of total revenues for private hospitals.6
A further 20% of revenue comes from people paying for private healthcare out of their own pocket. Before the pandemic, the self-pay private healthcare market grew by about 7% a year between 2010 and 2019.7 The remainder of revenue for the private healthcare sector comes from NHS funded patients, who accounted for about 30% of private hospitals’ income in 2019.6 Total revenue in the private healthcare sector actually decreased in real terms by 0.5% and 2.1% in 2018 and 2017, respectively, followed by a 3% increase in 2019.6
Over the next decade, the biggest challenge for the NHS is tackling the massive increase in the backlog of elective care that has developed during the pandemic. By December 2021, over six million people were waiting for treatment in England alone, two million more than before the pandemic.8 Some fear these challenges could accelerate expansion of the self-pay private healthcare market and risk a two tier healthcare system as wealthier people seek to circumvent NHS waiting lists.
Limited capacity
However, this may be realistic only in London and southeast England, where coverage by private medical insurance is already heavily saturated and unlikely to expand further. These two regions account for just under half of all spending on medical insurance in the UK.9 Forty eight of 190 private hospitals in the UK are in the greater London area.610 They generate just under half of all revenue from privately funded patients nationally.10 This is because most private hospitals outside London offer only high volume, low complexity procedures such as hernia and cataract operations,11 whereas several hospitals in London have the facilities to provide more complex and expensive healthcare services. For most people living in other parts of the UK, the NHS is the only option for most complex types of care.
In reality, the private healthcare sector is facing many similar challenges to the NHS when it comes to increasing capacity, including covid-19 infection control protocols that limit the efficiency of theatres and loss of workforce because of staff sickness and self-isolation. They also share the same workforce as NHS hospitals and are recruiting from the same limited supply of healthcare staff—the UK has fewer doctors and nurses per head of population than most other high income countries.12 Therefore it is not surprising that data from the Private Healthcare Information Network show that in the first half of 2021 the number of private hospital stays—whether funded publicly (233 000) or privately (310 000)—had not yet fully recovered to pre-pandemic levels.13
The potential for a two tier healthcare system has caused tension since the establishment of the NHS. Given the stagnation of the private insurance market and limited scope for more patients to self-fund because of rising living costs, a substantial shift towards a two tier system is unlikely over the next few years.
Instructive parallels can be drawn between what’s happening in the NHS now and what happened two decades ago. In the early 2000s, it was not uncommon for patients to wait over a year for specialist treatment after referral from a general practitioner,14 and the proportion of healthcare expenditure that was privately funded (25%) was even higher than it is now.2 Substantial investment in the NHS slowly reduced waiting times over the subsequent decade. NHS England recently launched a similarly ambitious strategy to cut waiting lists to pre-pandemic levels within three years.15 Now, however, lack of a properly funded long term workforce plan to deliver the healthcare staff required is a glaring omission that could slow or even derail the recovery.

The wait for a dentist is a microcosm of the wait for cancer or heart operations. Two tier systems can work but they need planning….

Two tier system threatened for Cervical Cancer in older women.

Covid is mostly increasing inequalities , but in one way reducing them – but temporarily, by dumbing down. A two tier service will resume shortly..

Private care will thrive: a two tier / “class” society by default. So much for Aneurin Bevan’s dream.

Private care will thrive: a two tier / “class” society by default. So much for Aneurin Bevan’s dream.

A&E is a National Accident waiting to be repeated over and over again… Northern Ireland is worse, but there are two tier waits in parts of Wales as well.

A&E is a National Accident waiting to be repeated over and over again… Northern Ireland is worse, but there are two tier waits in parts of Wales as well.

Surgery waiting lists at ten-year high. The perverse outcome is a two tier society…

2018: Surgery waiting lists at ten-year high. The perverse outcome is a two tier society…

2017: IMF forecast is damning.. A two tier system emerges from denial… A collusion of politicians and leaders…?

Falling job satisfaction leads to GPs under 50 thinking to retire.. Lack of local political interest suggests public apathy..

Not looking after people in complex and important job roles is risky. Sustaining that lack of care over a long period, and ignoring the need for cherishing these people, leads to disillusion and disatisfaction. Ella Pickover in the Independent 13th April 2022: Third of GPs to quit within five years – study – Researchers also said that a ‘worrying’ 16% of GPs under the age of 50 were already making plans to leave the profession. The Telegraph and Argus carries the same story as do several other local papers. Watch out as a patient: private care is coming.. With local elections in my own area being largely uncompetitive despite the parlous state of health, the disengagement is a worry. Politicians, local and national, seem to be able to get away without fundamental beliefs. The demise of the health service seems inevitable amongst such apathy.

ITV news is similar: A third of GPs plan to quit within five years, Manchester University survey finds

Around a third of GPs are likely to quit direct patient care within five years, according to a survey by the University of Manchester. A total 61% of GPs over the age of 50 said they were likely to quit in the next five years. While, among GPs under 50, one in every six (16%) said they were planning to leave. The average level of overall job satisfaction, measured between 1 (extremely dissatisfied) and 7 (extremely satisfied), decreased by 0.2 points from 4.5 in 2019 to 4.3 in 2021.
However, over half of respondents (51%) said they were satisfied with their job overall. Decreased satisfaction was particularly acute around the areas of ‘recognition for good work’ and ‘satisfaction with variety of job’. Overall, hours of work showed a slight decline for the second consecutive survey, falling from 40 hours per week in 2019 to 38.4 hours per week in 2021. The GP Worklife Survey has been assessing job satisfaction and job stressors amongst GPs in England since 1999.
Participating GPs are asked to complete a questionnaire which asks them to rate their job satisfaction and the aspects of their jobs which they find particularly stressful or satisfying, as well as their intentions as regards their future work. The survey has run approximately every two years since 1999, and so provides evidence about changes over time. The evidence it provides is used by the Department of Health and Social Care to inform their evidence to the Doctors’ and Dentists’ Pay Review Body. Professor Kath Checkland, who led the study said: ‘We’re very grateful to the GPs who took time out to respond to our survey during this difficult year. “It is not really surprising that job satisfaction has dropped amongst GPs during the pandemic, but the survey provides some evidence about the areas of work they are finding more stressful, which may help in designing ways to support them. “The fact that 16% of GPs under the age of 50 are thinking about leaving their jobs is worrying, and suggests that work is still needed to ensure that general practice is sustainable for the long term.”

“Last man standing” anxiety will determine our future.. Most GPs have no long term perspective ; the GP college (RCGP) seems out of touch with reality.

The continued threat of early retirement cannot be taken lightly. The shape of the job has changed so much, for both doctors and dentists..

A retired GP experiences rejection by all the safety nets he worked for/in, and depended on. This could happen to you.

The threat to Medical School standards: early retirement, redundancy, burnout: loss of experienced staff.

2019: The undervalued workforce. Option: reduce, resign, retire or emigrate. Its going to get worse still..

The Maternity care illness is systemic. Trying to “make this the last” scandal is like pissing into the wind, or farting in a thunderstorm. We need complete feforming, cultural change, and exit interviews.

To change a culture is very hard, and the downward spiral in staffing and diagnostician numbers has been accellerating. The right of passage to spend a year or two abroad is being exercised by junior doctors, even though the ST training system discourages such career breaks. Many will realise when they are away how much better it could be, how much more they feel valued and cared for, and how little possibility there is that any other country will try to emulate the UK’s 4 devolved and post coded systems. The Maternity care illness is systemic. Many trusts are affected. Trying to “make this the last” (Midwives, Managers, and doctors) scandal is like pissing into the wind, or farting in a thunderstorm.

A relative recently had a traumatic obstetric history . Her doctors failed to examine her rectally after an assisted delivery. She had retained products, septicaemia, but worst of all, a third degree rectal tear, undiagnosed until her post natal when it was too late to repair it . She did not complain as she knew everyone involved…and believe it or not, there was no critical incident. There are so many critical incidents that juniors could spend all day writing them up, instead of seeing patients. This was the case well before Covid: for the last 10 years at least.
The worst mistake over the life of the now 4 health services, is that there are no systematic exit interviews of any staff or board members. The Times editorial (below) comments on English maternity units & excludes the other 3 UK dispensations which may or may not compare favourably. Thus the Times’ readers are not finding out fully about an incomparably worsening, and devolved “National Service”. Exit interviews now need to be done by an independent HR service and reported systematically after amalgamating and condensing themes .. Nobody within the service will trust internal exit interviews..

In the BMJ responding to Ockenden Marian Knight, professor of maternal and child population health &  Susanna Stanford, patient safety advocate: another shocking review of maternity services : https://doi.org/10.1136/bmj.o898 (Published 06 April 2022) Cite this as: BMJ 2022;377:o898

Make this the last
The newly released Ockenden report into maternity services at Shrewsbury and Telford NHS trust1 is at least the fourth similar report in recent years, with two more in progress. Many messages are not new, and these are not isolated findings. Women and families accessing care throughout the UK continue to feel ignored.2 Many families remain concerned that they are not receiving full and frank investigations and explanations after the death or injury of a mother or baby.3 Repeated headlines understandably undermine women’s confidence in services when they should be able to trust that they will receive safe, high quality care.
The Ockenden findings, and those of previous reports, must be framed within the context of enormous improvements in the safety of pregnancy over the 20th century because of advances in maternity care.4 Here perhaps lies part of the problem. The fact that pregnancy is now considered so safe seems to have led those managing services to forget that improved outcomes were achieved only by deploying sufficient skilled staff, multidisciplinary care, and a laser focus on patient safety.
Pregnancy, labour, and birth are never predictable, and events can rapidly escalate into life threatening emergencies requiring a rapid and appropriate response. Add to the mix the changing characteristics of the pregnant population,5 including women entering pregnancy with more complex physical, mental, and social problems,6 and staff at the limits of their capacity and the accepted silo model of maternity and medical care becomes no longer fit for purpose.
It is perhaps unsurprising then that one of the main messages of the report concerns staffing. Listening to women’s concerns and providing care that meets their individual needs while being able to respond rapidly when a major emergency develops requires staff time. Time to listen, time to build rapport, time to ensure women’s complex needs are met, time to provide the prepregnancy and postpregnancy care essential to prevent adverse outcomes, and time to train as a multidisciplinary team to respond to emergencies. ~
This will require many more midwives, obstetricians, anaesthetists, and obstetric physicians. Discussions on workforce tend to focus on recruitment rather than retention, but highly skilled staff are not readily available, and training them takes years. Meanwhile, experienced staff have left and continue to leave in the face of serious challenges, including changes to the NHS pension scheme, pandemic working, and adverse cultures in maternity services.
The Ockenden report focuses on maternity services, but efforts to ensure safe pregnancy and childbirth must take a wider perspective.8 Women have complex care needs before, during, and after pregnancy. The need to improve that care has been emphasised repeatedly by the UK’s National Confidential Enquiries into Maternal and Perinatal Deaths and Morbidity91011 and is the concern of all health professionals caring for women of reproductive age.
System change
This latest report represents the culmination of many years of effort by women and families fighting to make their voices heard. It describes multiple examples of babies’ deaths and other serious incidents that were not investigated or were investigated inadequately. Many investigations were inappropriately limited in scope, poor quality, defensive, or lacked parental involvement.
National programmes have also identified a need to improve the quality of maternity investigations,12 and the Perinatal Mortality Review Tool (PMRT) was introduced in 2018 in response.3 Improvements occurred subsequently in some areas, including greater parent involvement,13 driven partly by changes to a safety incentive scheme for maternity units.14 However, few strong action plans result from PMRT reviews.13 Evidence suggests that external national review processes such as the confidential enquiries result in more effective learning and action plans than local reviews.1516Too often, recommendations place responsibility for change on frontline staff rather than calling for change to systems, informed by expertise in human factors.

The Ockenden report, along with others,1213 calls for adequate resourcing for local incident review teams and more external involvement. To this we would add better training of review teams and a move away from a blame culture. It is concerning that the Ockenden report was rewritten at a late stage to remove testimonies from staff who feared the consequences of being identified. Organisations must be committed to ensuring staff are able to raise concerns without fear of reprisal.
In the Ockenden report and its predecessors the clear common message is that if women’s and families’ concerns had been taken seriously and thoroughly investigated with actions implemented and their effect monitored, many women and babies would have benefited from safer maternity care and lives would have been saved. Investment is long overdue to ensure that this is the case: we need adequate numbers of appropriately skilled staff, trained and well resourced investigation teams, and thorough audit and evaluation of measures to improve safety. Neither of us wants to be writing this editorial again in another five years.

allegorical-maternity-existential-threat-timesDownload

• With no plan, the Commons reject the Lords’ suggestion that they review manpower frequently. Rejecting the advice of the experts..
• “Last man standing” anxiety will determine our future.. Most GPs have no long term perspective ; the GP college (RCGP) seems out of touch with reality.
• Its people we are short of and all are working as hard as they can or wish to. Tax relief on Private Medical Insurance won’t change anything.
• Good News for the long term – computerised records may become the great asset they should be – one day.
• Countries with higher levels of emergency presentations have lower survival. With a shortage of experienced GPs, doctors who know their patients, & increasing criticism no wonder cancer diagnoses are later, and outcomes are worse.
• NHSreality posts on Midwives
• NHSreality posts on cultural change

With no plan, the Commons reject the Lords’ suggestion that they review manpower frequently. Rejecting the advice of the experts..

Amendment 29 30th March 2022 was meant to help a struggleing government. Like many populaist regimes, they have rejected the advice of those in the profession, and those knowledgeable about this situation. Rather like the climate issue where they are saying “dont look up”, in health they are just keeping on the blindfold of denial. Yes, its expensive to train diagnosticians, but without them all 4 services are collapsing. Rationing of med school places needs to stop. “No one seems to have the bravery or the will to compare the numbers we have (and will have shortly as more retire) against the numbers we need” (Claudia Pauloni).

NHS staff survey underlines need for national workforce strategy: Adele Waters BMJ: British Medical Journal 2022 April 1, 377: o871
MPs have rejected a “once in a decade opportunity” to tackle longstanding failures in NHS workforce planning after voting against a proposed amendment to the Health and Social Care Bill1 that would require the health and social care secretary to publish an independently verified workforce assessment and plan at least every two years.
Amendment 29, which passed in the House of Lords last month, was backed by more than 100 healthcare organisations, including the BMA, the Academy of Medical Royal Colleges, and the Royal College of Physicians.
Rejection of the proposal in the House of Commons came on 30 March, the same day as the publication of the latest NHS staff survey.3 Ironically, the survey’s findings had prompted universal calls for an NHS workforce strategy, from healthcare unions, health think tanks, and NHS organisations alike. The 2021 survey ran in October and November last year and was completed by 628 475 staff at NHS trusts, a 48% response rate. It showed that almost three quarters of respondents worked in NHS organisations with too few colleagues to allow them to do their job properly. Only 27% of staff said that staffing was sufficient at their organisation, down 11 percentage points on last year (38%).
The survey found that 68% of staff were happy with the standard of care their organisation provided, down six percentage points since last year. But it detected significant areas of concern around the health and wellbeing of staff, as a third of doctors and dentists reported feeling burnt out from work.
Universal disappointment
Before the amendment vote many organisations had appealed to MPs for support. NHS Providers released results of a survey showing that some 89% of trust leaders did not think that the NHS had robust plans in place to tackle workforce shortages. And almost all (98%) warned that shortages would slow down progress in tackling the growing care backlog. Trust leaders overwhelmingly (88%) supported amendment 29, said NHS Providers, and had a loud and clear message for MPs: failing to back it would only compound staff shortages and workforce burnout. Defeat of the amendment by 82 votes (249 v 167) was met with universal disappointment from unions and healthcare organisations. The BMA said that, given the consistent pleas from the healthcare profession about the precarious state of the NHS workforce, the vote was “truly disappointing.”
The association’s deputy chair of council, David Wrigley, said, “The government’s decision to vote this down is a huge, missed opportunity and means we still won’t know how many healthcare staff the country needs—despite being all too clear that staff and services are dangerously overstretched.”
The Doctors’ Association UK agreed, saying that workforce planning failures were at the very root of all problems highlighted in the latest NHS staff survey, so parliament’s refusal to address this was “even more disappointing.”
Its chair, Jenny Vaughan, said, “‘Failing to plan, planning to fail’ was never more bitterly appropriate. How can doctors even hope to cope when the government remains hopelessly oblivious to the critical need to come up with a workforce plan that stands any chance of actually working for the NHS?”
Missed opportunity
The Hospital Consultant Specialist Association, the hospital doctors’ union, called the defeat a major blow to hopes that the NHS would get a strategic oversight to workforce planning. The union’s president, Claudia Paoloni, said, “No one in leadership appears to have the bravery or will to compare the numbers we have against the number we need, acknowledge that we must pay and treat our people adequately, and then fund our NHS to deliver this.
“If the government doesn’t act on workforce, we will face increasing chaos and declining levels of care. Patients will pay the ultimate price for this neglect.” The Royal College of General Practitioners condemned the vote as a “missed opportunity to redress historic poor workforce planning, which is desperately needed.” Martin Marshall, the college’s chair, said that while the result was a “let-down” for all healthcare professionals working in general practice and the wider NHS, it would not stop the college and others from campaigning for a safe workforce strategy.

At a glance—some findings from the NHS staff survey

Care standards

• 59% would recommend their organisation as a place to work, down from 67% last year
• 68% are happy with the standard of care provided by their organisation, down from 74% in 2020
• 68% would be happy with the standard of care provided by their organisation for a friend or relative, down from 74/% in 2020

Workload

• 27% said that their organisation had enough staff for them to do their job properly, down from 38% last year

Enthusiasm for work

• 67% feel enthusiastic about their job, down from 73% in 2020
• 53% look forward to going to work, down from 59% last year

Feeling valued

• 42% are satisfied with the extent to which their organisation values their work, down from 48% last year—the lowest rate in five years

Burnout

• 38% find their work emotionally exhausting
• 34% feel burnt out because of their work (including 41% of nurses and 33% of doctors)

Pay

• 33% of staff are satisfied with their level of pay, a drop of four percentage points on last year. Pay satisfaction among doctors—the staff group most satisfied with their pay—has dropped from 60% in 2020 to 50% in 2021

There is no workforce plan. There never was a plan based in reality, and any plan now will be 15 years to fruition.

NHSreality post on populism