J. MEIRION THOMAS: Our GP system needs radical overhaul

If family doctors will only work part time, our GP system needs radical overhaul, writes retired consultant surgeon J. MEIRION THOMAS

Britain’s GP system is nothing less than a national emergency. 

As the Mail reported yesterday, the number of patients per family doctor has soared to above 3,000 in some areas — one of the highest figures in Europe.

Separate figures by the British Medical Association (BMA) have also shown that the number of fully qualified GPs has dropped by more than 1,800 since 2015 — as the UK’s population has grown by well over a million.

Many GPs, according to the BMA, have either quit their positions altogether or switched to part-time work, while Covid has completely changed how many doctors see their patients. 

In millions of cases, vital face-to-face contact has been eroded and replaced with consultations on Zoom and other technologies.

Many GPs, according to the BMA, have either quit their positions altogether or switched to part-time work

J. Meirion Thomas is a retired consultant surgeon who worked in the NHS for more than 40 years

Denial

No wonder patient satisfaction has been plummeting — and this paper has rightly led the way with a campaign to encourage GPs to see their patients face to face again.

Yet despite the groundswell of critical public opinion against the state of primary care in this country, the BMA and the Royal College of General Practitioners maintain a wall of institutional denial about the causes of and solutions to this emergency.

They have been disingenuous and economical with the truth, all to further their own goals at the expense and suffering of the general public.

Let me be clear: the model for providing primary care in Britain is irrevocably broken. My own view is that we need a full public inquiry to investigate it and to rethink the best way of providing it.

But in the meantime, we must identify the reasons for this broken model. And to me one is obvious above all: that at least half of our GPs are working part-time, some for only a few hours per week.

Figures published only yesterday show that the average GP was working a three-day week even before the pandemic, according to a ‘worklife survey’ commissioned by the Department of Health.

In 2019, GPs carried out 6.6 half-day sessions per week, which is the equivalent of just over three days. This was the lowest on record. In 2010, they worked 7.5 sessions.

No successful commercial company could possibly run on this model.

This chart shows the 7-day rolling average for the number of Covid infections per day in the UK 

Today, the exact proportion of part-timers is unknown, and I have submitted a Freedom of Information request to the General Medical Council (GMC) to determine it. But the situation can hardly be expected to have improved since the start of the coronavirus pandemic.

Meanwhile, Britain’s serious shortfall in the number of GPs is only worsened by these part-timers. The maths are simple: if your GP is available for only half a normal working week, you need two GPs to fill the gap.

GPs work part-time because they can. This has been the case for years — but it has intensified dramatically since the pandemic.

Like so many civil servants and other public-sector staff who have discovered the pleasures and conveniences of working from home during (and long after) recent lockdowns, they have taken advantage of a professional situation that makes such flexibility possible.

Many patients do not realise that GPs are not employed by the NHS. Instead, family doctors are self-employed (their practices are small businesses) and they are contracted to the health service.

A relic of the NHS’s foundation in 1948, this gives them huge ability to set their own rules and working hours — far more than hospital doctors and other staff employed by the health service.

I totally understand work-life balance and the parental pressures that many GPs are under. But the interest of the patients and continuity of care also matter, and being a GP is often seen as a vocation.

All British-trained doctors have been educated at considerable public expense, even though medical students have recently had to make a contribution to tuition fees.

Why do so many doctors now feel they have so little responsibility to work to repay the debt that taxpayers have invested in them?

In my view, ‘part-time working’ for GPs could be limited to perhaps four days per week to begin tackling the huge backlog of cases. (As the Mail has reported, the country’s waiting list for hospital treatment is now predicted by some to soar to an astonishing 13 million.)

Added to which, many patients now find it hard to see a regular GP — when doing so might even save their life.

A Norwegian study published just last week showed the real benefits in having the same GP for many years: not only were lives saved, but the need for hospital admissions was significantly reduced.

Urgent

The longer the relationship with the same GP, the less that patients needed out-of-hours care. In Norway, patients are allocated to a named GP, and the benefits of such a relationship appear only to grow over time.

Compare this with the care provided by sessional GPs who rarely follow up the same patients, or transient locums who are here today and gone tomorrow.

Nor is it just the difficulty of getting an appointment with an NHS doctor. Also of great concern is out-of-hours urgent care.

In 2004, Tony Blair’s Labour government agreed a new contract with the BMA for GPs’ working hours. As a result of this, GPs effectively have no responsibility for urgent care at night or at weekends.

This is not their fault: it is a serious failure within the system — and it is entirely incompatible with effective health care.

In the middle of the night, an acutely unwell patient all too often only has the options of ringing 111 for advice, calling 999 for an ambulance or to present at an already over-stretched A&E department.

This model for emergency care must end.

An acutely unwell patient all too often only has the options of ringing 111 for advice, calling 999 for an ambulance or to present at an already over-stretched A&E department

Erosion

In response to this litany of problems, the BMA and the Royal College of GPs are demanding 6,000 extra full-time GPs, as well as greater investment in general practice facilities. Well, that would be fine: but Britain already has huge difficulty in recruiting and retaining GPs.

One in seven GP posts are vacant, as are about 20 per cent of GP training posts.

Experienced GPs are leaving in droves, junior doctors are reluctant to fill their places — and the NHS has relied on large numbers of doctors brought in from abroad and from countries that need their own talented medical staff.

The model of providing primary care must change to make general practice a more attractive career option.

Larger practices, allowing GPs to specialise (for example in diabetes or end-of-life care), and closer links to hospital consultants would make a big difference.

One in seven GP posts are vacant, as are about 20 per cent of GP training posts, and the NHS has relied on large numbers of overseas doctors to fill positions

There might even be a case for GPs to be made direct employees of the NHS, like their colleagues in hospitals.

Needless to say, there are still countless dedicated, hard-working GPs up and down the country who are absolutely committed to their work.

But, sadly, they are swimming against the tide.

The Government has allowed this gradual erosion of responsibility to happen unchallenged — and it is time for the health service’s defences to be built up again.

J. Meirion Thomas is a retired consultant surgeon who worked in the NHS for more than 40 years.

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