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Increasing lack of GPs

hifinutt

hifinutt
Many many folks have not been able to see their GP`s . This article stresses the problems that seem to increase
GPs in England are finding it "increasingly hard to guarantee safe care" as the number of doctors falls and demand surges, a senior medic said.

Prof Martin Marshall, chair of the Royal College of GPs, told the Guardian GP numbers had fallen by 4.5% despite an ageing population with an increased need for care.

GPs feared making serious mistakes due to excessive workloads, he said.

Prof Marshall also defended the continued use of remote consultations.

In 2015, the government promised to hire 5,000 extra GPs within five years, but instead the Royal College of GPs says between September 2020 and March 2021 numbers fell by 1,307 to 28,096.

At the 2019 election, then Health Secretary Matt Hancock admitted they had failed to meet the recruitment target, as the Conservatives made a fresh promise to recruit 6,000 more GPs by 2025.

https://www.bbc.co.uk/news/uk-58524559


Lack of face to face contact is a real problem

Health Service Journal reported that one coroner had raised remote consultations as a risk during the inquests into five separate deaths

just a few weeks back the Dr diagnosed a friend over the phone with muscle strain and saw the physio , the next day we got him into A&e and it was a severe infection that nearly led to sepsis and death . requiring many weeks of IV antibiotics , i can quite see how many have died

problem is Ambitious medical staff just dont want to go into GP frontline survices ... how do we sort this ?
 
just a few weeks back the Dr diagnosed a friend over the phone with muscle strain and saw the physio , the next day we got him into A&e and it was a severe infection that nearly led to sepsis and death . requiring many weeks of IV antibiotics ,

That's a sobering story. About 18 months ago I had some persistent lower back and leg pain and eventually called the doctor and after a telephone appointment I was referred to a telephone physio who prescribed some exercises which worked wonders. So I was kind of thinking that the doctors could judge whether a patient needed to be seen or not. What you say there suggests I was wrong.

problem is Ambitious medical staff just dont want to go into GP frontline survices ... how do we sort this ?

One way would be to require that they do periods of front line service as part of their NHS contract, as a sort of condition of training and employment.
 
I retired from general practice in 2015. I had spent the previous 5 years or so realising that I was a sitting duck for complaints from all sides, without the resources to provide a decent service. It felt unsafe. I could afford to retire and did so, one month before my 59th birthday.
Things have become progressively worse and the pandemic has just about finished it off.
Believe me when I say that general practice is completely unfit for purpose and is a danger to public health.
I predict that early cancer detection rates will have fallen off a cliff when figures are next released.
The shortage of medical staff is a very serious threat to the whole of primary care and if primary care cannot function, NHS secondary care is at serious risk of failing.
 
The frightening thing and it’s the same with consultants in secondary care, is the amount of experience walking out the door never to return, sucked dry of any good will they possessed toward the service. You can as government state you’ll ‘recruit more’, ‘fast track more’ and other platitudes but it won’t make up for the losses.
 
Our youngest became a fully qualified pharmacist on Thursday. He will be working for Boots locally.

I fully expect pharmacists to be under pressure, given this news.
 
congrats on that , yes pharmacists and many others have taken some of the burden off GP`s but its still far too heavy
 
We have nurse practitioners at our GPs. They have been great for minor complaints. Surely more of this is part of the solution. It can’t need 7 years training to deal with an infected insect bite or an ear infection surely?
 
My mate who has been a G.P. for decades now works locum as a G.P.
She didn’t like having to manage the practice.
I can see her point of view.
 
congrats on that , yes pharmacists and many others have taken some of the burden off GP`s but its still far too heavy
The model in NHS Scotland was to make the GP the conductor of a broader orchestra- he/she wouldn’t have to see every patient but delegate out to nurse/advanced nurse/ pharmacist/ other allied health care professional. I’m told by an old friend that indeed his practice is filling with new staff seeing patients but they are simply passing back decision making and tasks to him on top of his own list. There are more ‘on the payroll’ but the pressure on him hasn’t diminished, it’s increased. As a consequence he’s cut his hours down substantially and gone part time.
 
We have nurse practitioners at our GPs. They have been great for minor complaints. Surely more of this is part of the solution. It can’t need 7 years training to deal with an infected insect bite or an ear infection surely?
You are correct that they are great for minor complaints, but I’m afraid they are no substitute for trained doctors. You give an infected insect bite or ear infection as an example. Well in perhaps 95-99% you may be right, but in a small number of bites there may be ascending infection leading to sepsis and in ear infections there may be cholesteatoma leading to chronic ear infections and deafness.
It reminds me of an incident when our local district matron asked me to visit a patient with a cough. She said she was doing chests in 3 days the following week so would I have a listen.
Well learning to listen to a chest in 3 days is a bit like teaching brain surgery in a week.
Specialist nurses are fantastic at what they know within their specialism, but with the best will in the world, they do not have the breadth of knowledge which is vital to formulate an accurate differential diagnosis. That is not how they are trained.
 
The model in NHS Scotland was to make the GP the conductor of a broader orchestra- he/she wouldn’t have to see every patient but delegate out to nurse/advanced nurse/ pharmacist/ other allied health care professional. I’m told by an old friend that indeed his practice is filling with new staff seeing patients but they are simply passing back decision making and tasks to him on top of his own list. There are more ‘on the payroll’ but the pressure on him hasn’t diminished, it’s increased. As a consequence he’s cut his hours down substantially and gone part time.
See my comment above!
 
You are correct that they are great for minor complaints, but I’m afraid they are no substitute for trained doctors. You give an infected insect bite or ear infection as an example. Well in perhaps 95-99% you may be right, but in a small number of bites there may be ascending infection leading to sepsis and in ear infections there may be cholesteatoma leading to chronic ear infections and deafness.
It reminds me of an incident when our local district matron asked me to visit a patient with a cough. She said she was doing chests in 3 days the following week so would I have a listen.
Well learning to listen to a chest in 3 days is a bit like teaching brain surgery in a week.
Specialist nurses are fantastic at what they know within their specialism, but with the best will in the world, they do not have the breadth of knowledge which is vital to formulate an accurate differential diagnosis. That is not how they are trained.
I fully agree yet at my GP the desk jockeys will not let you see a GP without seeing one of them first.
 
an old article but still pertinent

"General practice has become far less attractive as a career option since the 1990s, an analysis of survey responses from 9000 doctors has found.

Making general practice more appealing to current generations of doctors is of “paramount” importance to efforts to increase GP numbers, the UK Medical Careers Research Group said.

Between 1999 and 2015, the group, based at Oxford University, surveyed 9161 doctors three years after graduation, as they were choosing a future specialty career. A report on the findings was published in the British Journal of General Practice.1

The researchers found that, in 1999, 59% of doctors agreed with the statement, “General practice is more attractive than hospital practice for doctors at present.” By 2005, this had risen to 77%. But in 2015, only 36% of respondents agreed with the statement.

Doctors whose specialty choice was general practice were much more likely to agree with the statement (80%) than doctors who chose a hospital specialty (51%). Both groups experienced a “substantial decline in agreement [with the statement] between 2005 and 2015,” the researchers said. They added that the attractiveness of general practice may not necessarily have declined “in absolute terms,” rather that the appeal of hospital practice may have risen more over time.

The study also analysed how doctors rated the influence of 12 factors on their career choice. These included their enthusiasm, domestic circumstances, working conditions, and financial prospects.

In 2015, 55% of those intending to be GPs rated enthusiasm for, and commitment to, the specialty as very important, up from 49% in 1999. The corresponding figures for intending hospital doctors were 91% in 2015, up from 61% in 1999.

Over the 16 year period, wanting a job with acceptable hours and working conditions “retained a huge level of importance” to those who chose general practice. But this was less important among doctors who chose hospital practice and declined over the same period.

The authors said, “The attractiveness of general practice to current medical graduates is undoubtedly affected by their beliefs about GPs’ work-life balance and their exposure to general practice in their training. GP choosers highly value hours and working conditions. This is clearly a key area in which to motivate doctors to choose general practice.” They said that any policies to reduce GPs’ ability to manage their work, or that adversely affect their work-life balance, “may well have detrimental effects on recruitment.”

https://www.bmj.com/content/357/bmj.j2627
 
Our much valued GP legged it to New Zealand where he was, among other things, looking at a few minutes more with each patient. This was around 2012 and he had already reached the conclusion that the lack of time allowed here, meant he was unable to do the job properly.
 
Here are my comments on this. Please note my declaration of interests - I'm a consultant, my wife used to be a GP (but gave up to become a music teacher) and my sister is the senior GP partner in her practice.

1) Being a GP is actually the hardest job in medicine - the vast majority of patients each day will not have anything serious or life threatening - BUT the GP has to be able to pick out every serious problem out of the large number of minor (not to the patients though) ailments each and every week. It's much easier being a hospital specialist, as the GPs have done the hard work for you. To put this into context, I look after people with breast cancer and see lots of patients with breast problems every week, some of whom will sadly have trouble. The average GP will only see on average 2 new patients with breast cancer every year. I also used to look after people with a rare cancer called sarcoma and would see a new sarcoma regularly. The average GP will only see 1 sarcoma in their entire working lifetime.

2) A GP practice is a self contained business, which is contracted to the NHS. The GP partners have to run the business (finance, recruitment, premises/estates, HR disciplinary etc) as well as treat patients. Sure each practice will hire a practice manager to help with this. The GP partners's monthly drawings will vary according to the costs of running the practice. One of my GP colleagues took home nothing (yup zilch) for his monthly drawings as the senior partner just before the pandemic, as the costs of the practice meant that there was nothing for him to draw.

3) Hardly anyone now wants to become a GP partner, as they don't want the hassle or the financial responsibility of running the practice. Most younger GPs have become salaried GPs i.e. they come to work, see patients, take a fixed salary and don't get involved at all in running the practice. This change has led to an existential threat to many GP practices as hardly any partners are left in some practices, once the older partners retire.

4) All doctors (incl GPs and hospital Drs) were encouraged to triage or do telephone consultations during the pandemic. This was to protect staff and other patients, as COVID was contagious and infected GPs/practice nurse could a) become seriously ill or die and b) clinical staff could pass this onto other patients during the initial asymptomatic phase of the infection.

5) Medicine has become a less attractive career. 20 years ago, we knew that 25% of medical graduates gave up their medical careers within 5 years of graduation. This proportion has increased since then as other careers offer a better work life balance and sometimes better salaries too.

6) GPs usually work very long hours. Most are in before 0800 and rarely leave before 1930-2000. Apart from calling or seeing patients face to face, every GP has to write/check prescriptions, write referral letters to consultants, read the letters back from the hospital about their patients, check any lab tests. The partners also have to take time to run the business side as well.

7) The UK has always had amongst the lowest number of doctor per capita in Europe. This is not improving. As the population ages, the healthcare demands of each patient become ever more complex. Moreover, many of the services previously run by hospitals eg diabetes monitoring, breast cancer follow up etc have been handed back by hospitals to GPs to add further burden to their work.

8) One of the main reasons why the UK has a low number of doctors goes back to the inception of the NHS in 1948. The NHS is a virtual monopoly employer of healthcare staff (in primary and secondary care), unlike virtually every other western country. The private sector in the UK is very small by comparison. University admissions to medical school is regulated by the Govt, which ties this in with workforce planning for the NHS. Medical workforce planning has been derisory for decades. Other countries train far more doctors, as they have co-existing vibrant private and Govt healthcare sectors. That means that if the universities train too many doctors, those graduates have the ability to earn a living in the private sector. This substantial private healthcare provision means that there is less strain on the Govt healthcare system - vis a vis in France.

I'm sure that there are other issues as well, which I have forgotten, but I hope my GP colleagues feel that I have put their case for them.
 
Somebody somewhere needs to work out how to prevent 50% of newly qualified medics leaving the UK within 2 or 3 years of qualification. It may mean forcing medics to stay or else having to repay more of their med school fees, but short of making terms and conditions more acceptable, I cannot see any other answer.
 
an old article but still pertinent

"General practice has become far less attractive as a career option since the 1990s, an analysis of survey responses from 9000 doctors has found.

Making general practice more appealing to current generations of doctors is of “paramount” importance to efforts to increase GP numbers, the UK Medical Careers Research Group said.

Between 1999 and 2015, the group, based at Oxford University, surveyed 9161 doctors three years after graduation, as they were choosing a future specialty career. A report on the findings was published in the British Journal of General Practice.1

The researchers found that, in 1999, 59% of doctors agreed with the statement, “General practice is more attractive than hospital practice for doctors at present.” By 2005, this had risen to 77%. But in 2015, only 36% of respondents agreed with the statement.

Doctors whose specialty choice was general practice were much more likely to agree with the statement (80%) than doctors who chose a hospital specialty (51%). Both groups experienced a “substantial decline in agreement [with the statement] between 2005 and 2015,” the researchers said. They added that the attractiveness of general practice may not necessarily have declined “in absolute terms,” rather that the appeal of hospital practice may have risen more over time.

The study also analysed how doctors rated the influence of 12 factors on their career choice. These included their enthusiasm, domestic circumstances, working conditions, and financial prospects.

In 2015, 55% of those intending to be GPs rated enthusiasm for, and commitment to, the specialty as very important, up from 49% in 1999. The corresponding figures for intending hospital doctors were 91% in 2015, up from 61% in 1999.

Over the 16 year period, wanting a job with acceptable hours and working conditions “retained a huge level of importance” to those who chose general practice. But this was less important among doctors who chose hospital practice and declined over the same period.

The authors said, “The attractiveness of general practice to current medical graduates is undoubtedly affected by their beliefs about GPs’ work-life balance and their exposure to general practice in their training. GP choosers highly value hours and working conditions. This is clearly a key area in which to motivate doctors to choose general practice.” They said that any policies to reduce GPs’ ability to manage their work, or that adversely affect their work-life balance, “may well have detrimental effects on recruitment.”

https://www.bmj.com/content/357/bmj.j2627
I argued on national TV news that the new GP contract in 2004 would mean the end of general practice as we knew it.
Sadly, I am being proven correct.
 
One other major change has occurred in the last 30 years. Please do not take these comments as being misogynstic in any way, but this is a real but unspoken issue in medical manpower. Over the last generation or two, there has been quite rightly an increase in young women going to medical school and becoming doctors. When I qualified the balance was probably about 70:30 men:women. Now the pendulum has swung the other way to 45:55 and female doctors make up the larger proportion of newly qualified doctors.

However, the career structure and demands on doctors in the NHS have not changed to reflect this altered demographic. Although part time working and training exists, the system still disadvantages those who train part time. Female doctors tend to shy away from careers which are very demanding in time commitment, as they wish to have a better work life balance. Add into this the fact that many male doctors also now seek a better work life balance, one can see how there is a massive shortage in some specialties including general practice.

Realistically the UK will have to commit to training FAR more doctors and nurses, but the UK is also hamstrung by limited training capacity in its university sector. Hence there will be no easy quick solution to this.
 


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