England's unfolding GP crisis

Mike Hardman was the only GP seeing patients on the day that Prospect met him at his surgery in the small Yorkshire town of Bridlington. The “locum,” as medics call freelance stand-ins, had called in sick. Hardman’s fellow doctors were on holiday or not on duty.

Based in an unremarkable 1970s brick building, not far from the train station, the practice has just three part-time GPs, where once there were at least four full-time doctors. Yet despite being over-stretched, Hardman no longer advertises positions: he has learned the hard way that GPs don’t want to come and work in Bridlington. The town of 35,000 people is one of the areas identified as “really struggling” in an interim review on general practice partnership. That review was published in October, after former health secretary Jeremy Hunt commissioned Nigel Watson, a GP and chief executive of Wessex Local Medical Committees, in effective acknowledgement of a mounting crisis in surgeries. The full report is due by the end of the year, but Watson’s interim findings do not disguise the problems: declining numbers as well as “low morale, increased levels of stress, mental health problems and burnout, working days getting longer and the complexity and intensity of work increasing.”

Bridlington is a coastal town, and the British seaside has more than its share of social problems. The bucket-and-spade economy is deep in decline, and there is no draw for younger people. Schools are often poor, and mental illness common; in a much-admired article on Blackpool last year, the FT’s Sarah O’Connor highlighted how GPs would discuss the ailments of their patients in terms of “SLS”—or shit life syndrome.

Bridlington is a quieter place than Blackpool, and the population is especially elderly: almost a third of residents are over 65. In that sense, it is ahead of an aging country. Many are drawn to retire here by memories of family holidays in the 1970s. It was thriving then, but today it includes some of the most deprived neighbourhoods in England, with commensurately increased rates of physical diseases such as lung cancer.

At 51, Hardman remains passionate about the locality despite the pressures: “It’s a cracking town.” He enthuses about the beach, the countryside, the people and practising medicine around here: “The older you get, the iller you tend to get,” he says. “It’s amazingly good work to do.” But there can be no disguising how deprivation, both material and otherwise, is at the heart of a Bridlington GP’s work. Loneliness is a particular concern: Hardman has helped to set up social schemes, including a singing group, for his patients. His practice has even socially prescribed a central heating system for one patient, thanks to a grant from the council: “Their chest will be better because their house is warm now,” he says. The line between such social support and medical care is not always sharp in a place like this.

As well as having a varied role in the community, GPs have perhaps the crucial role in the NHS. They are the only part of the service that virtually everyone deals with from time to time, and they also serve as gatekeepers. Visitors from overseas, used to getting direct access to a consultant, are frequently puzzled and frustrated by the way all access has to be routed through the family doctor. That, however, is the NHS way.

In some ways, the centrality of GPs is peculiar. Historically, many were unhappy about the creation of a national health service in which they remain anomalies—independent contractors. In the 1940s, they feared becoming civil servants and fought a fierce battle to retain their independence. Aneurin Bevan knew he had to give ground, because if family doctors refused to play their full part, the NHS would never have got going.

And so, from the beginning, family doctoring in the NHS has been conducted by GP partnerships, in which some doctors, the more experienced ones, become partners—doubling up as managers and administrators. The system is open to objections: the best doctors are not necessarily the best managers. But the fact that the inevitable “business” side of medicine has been done by medics—rather than faceless suits—seems to encourage public faith that things are being run in their interest. Over the last generation, a whole series of reforms—from Ken Clarke to Andrew Lansley by way of Alan Milburn and John Reid—has made much of putting the trusted GPs in charge of the NHS purse strings.

But some other reforms, under first New Labour and then Lansley, have challenged the traditional model. These allowed, for example, companies like Virgin to open up primary care facilities, ostensibly to boost provision in “under-doctored areas” and offer patients more choice. This, though, left many doctors and patients alarmed by the prospect of creeping corporate take-over. Austerity in the health service has reached a point where there is much less room for any sort of expansion, even of the privatised kind, although some doctors say the thing to watch now is not so much all-purpose corporates opening clinics, but rather groups of ambitious business-minded GPs forming companies to snap up other established surgeries. This is not to mention the launch of the app “GP at Hand,” which uses AI as well as telephone and video consultations with doctors, and has been accused of threatening the survival of traditional practices.

For the moment, however, the vast majority of GPs still work in partnerships. Research by Imperial College has suggested that partnerships outperform care delivered in other ways. The partnership model has proven it can work over time and there is no immediately available appealing alternative to it. But as things stand, circumstances are conspiring to make it unviable.

Lifestyle issues

To be a partner was once the career-crowning goal of every ambitious GP. Today, however, that is no longer the case—many younger doctors shun the option, while older partners are taking early retirement. A recent survey by health think tank the King’s Fund established that only 37 per cent of trainees were interested in becoming partners. Younger doctors look at the deluge of paperwork and baulk—they’d rather reduce their sessions and mix them with projects outside the surgery—training other doctors, perhaps, or taking on an advisory role at a Clinical Commissioning Group—to create a “portfolio career.”

The flip side of fewer partners is more salaried GPs. The number has been rocketing: rising by several fold according to the BMA’s tallying. Some will be working out of walk-in based services connected to hospitals, corporately-run clinics or groups of surgeries led by GP entrepreneurs; many others are staffing traditional practices without becoming partners. But how sustainable is that? Should this rapid trend continue the traditional partnership will, in places, be consigned to history. Some doctors fear that would undermine continuity of care; it would certainly change the nature of the NHS’s “front door.”

The roots of the pressure on family doctors, however, go deeper than the way they are employed. Clinically, much treatment that was once done in hospitals can now be performed at GPs’ surgeries. “Care in the community” has enabled the great reduction in hospital beds, and it is about the only hope that many who work in health policy have of bringing costs under control. This trend is not about to go into reverse. In November, the new health secretary, Matt Hancock, indicated he wanted to further it, coupling a familiar refrain about the importance of preventative health with a grumble about the NHS wrongly imagining itself a “National Hospital Service.” And yet the same trend imposes ever-more work on the shoulders of those who deliver care outside hospital—most notably GPs.

Beccy Baird at the King’s Fund explains that working full-time as a GP is not merely stressful, but increasingly “not safe.” “If you talk to young GPs,” she says, “they will say: ‘I cannot make those kind of complex, clinical decisions for 60 hours a week if I’m working five full days.’ You can’t possibly do that… where you’re looking at a child and deciding whether or not it has meningitis or a cold.”

“Part-time” is often a misleading term in general practice, especially for partners. A GP on standard full-time hours works nine sessions a week. Each session lasts four hours and ten minutes, so that tots up a notional 37.5 hours a week. Notional is the operative word. The volume of paperwork and follow up means that a full-time partner is in fact working at least a 60-hour week. In Bridlington, Hardman works three days a week at his practice—but it’s from 8am till 7pm, and without a lunch break. He comes in on his days off to catch up and works in a hospice one day a week. “We’re no different from anyone else,” he says. That will sound stoical to anyone who is not a GP, but a blunt statement of reality to other partners.

Overall, the rise in the employed doctors is not adequately compensating for the decline in partners. Before becoming foreign secretary in July, Hunt was health secretary for nearly six years, longer than any predecessor. Back in 2014, he set a target for 5,000 additional GPs. But the total number of full-time equivalent doctors has actually droppedby more than 1,000 since, around 2 per cent. Worse, the total number of full-time equivalent trainee GPs—the next generation—has also dropped by 8 per cent. True, more GPs are going into training this year, and NHS England is also actively recruiting doctors overseas, but even so it is unlikely that Hunt’s target will be reached. Even if it were, who is going to manage the practices where they work?

When you ask Hardman why has doctoring got so difficult in Bridlington, demographics and poverty rear their head: “we’re old, deprived and ill.” On an average day, most of his patients will be elderly. He may be dealing with arthritis, following up with consultants, reviewing medications, prescribing an anti-coagulant drug for a patient, assessing a mental health case and possibly attending to a life-threatening condition which requires hospital admission. Some of his patients are on at least 20 different medications. In an aging society, more people will be living with several conditions—in the jargon, “multiple morbidities.” You might have, say, chronic heart disease, hypertension, kidney disease, dementia and diabetes, and the pathology of, and the treatment for, each of these things may complicate the management of any of the others.

After years of austerity, the inevitable demographic pressures are being aggravated. The squeeze on NHS spending is the longest since its inception, and has had brutal effects on GP surgeries, which have fared worse than hospitals. The BMA, in effect the doctors’ trade union, found that the proportion of the NHS budget going into general practice, excluding the reimbursement of drugs, has fallen from 9.6 per cent in 2005-6 to 8.1 per cent in 2017-8. That, of course, is going in the opposite direction to the avowed aim of delivering more care in the community.

The direct squeeze is only the start; more damaging are cuts to social services that leave GPs picking up the pieces. While the proportion of the population who is very elderly has continued to rocket, the Institute for Fiscal Studies reports that local authority spending on adult social care in England has fallen by 8 per cent over the last eight years. Patients denied care present to their doctors with all sorts of needs which, while not strictly “medical,” are fundamental to survival.

GPs report patients are asking for help with housing benefit, food vouchers or a supply of sanitary towels. And they say that the funding formula, which is based on things like age, sex and mortality of patients, does not adequately capture the deprivation effect. Tom Milligan is another Bridlington GP in a practice that serves 6,000 patients with just two doctors, twice the national patient to doctor ratio—and that is only the beginning of his problems. “We’ve got twice the national prevalence of every major disease,” he says. “If you’ve got twice as much disease, it’s your tough luck. [The formula] will account for age, but my problem is with deprivation. My old people who are 75 act like York’s 85-year-olds.” So it is not aging alone, but aging in combination with the local prevalence of disease associated with hardship which leaves Milligan strapped for cash and “in a real pickle.”

A former NHS manager, Stephen Thornton, reflects: “More and more GPs are saying there is an increasing proportion of the patients who come before them who really they can’t help in any meaningful way and don’t just want to send them away with another prescription for anti-depressants that’s not going to help.” To be a GP today is to take on an awful lot. And, it would seem in places like Bridlington, too much for anyone.

Grim diagnosis

So how bad have things already got? Thornton has seen more than his fair share of NHS crises, having worked in the service since the 1970s and as one-time-head of the NHS Confederation. He has never been shy to call out alarmism on the part of the medics whom he has often had to haggle with. Today he is not accusing anyone of crying wolf: he cannot recall a time in his career when recruitment was so challenging. And at the other end of the doctoring age range? “Probably for the first time ever we’re in a situation where there are practices saying we can’t carry on, we’re going to pack up and take retirement.”

How has the crisis got to this point without bubbling over politically? Beccy Baird at the King’s Fund explains that the same sort of comprehensive, nationwide data collated in relation to—for example—hospital waiting times, is not always there when it comes to GPs. They do collect information, but it is not collated partly due to a lack of agreed “coding standards” that would enable the data to be compiled and used nationally. And so, Baird suggests, when GPs began to grumble about being “busy and overwhelmed, there wasn’t any evidence to back that up,” which meant it could be dismissed as a self-interested plea for money.

Baird concedes there is still a lot of “bitterness” about what GPs “got away with” in 2004 when they were handed a supposedly performance-related contract which paid them considerably more money for doing things they already did routinely, such as checking blood pressure and cholesterol. In 2015, Hunt said explicitly that general practice had been starved “in penance” for this overly-sweet deal. Practices’ profits have since been gobbled up by things like fees for locums—one reported partners taking a 20 per cent pay cut over a decade to maintain its more-than-the-minimum 15 minute appointments. Baird concedes it’s still “really hard to say that people earning £80,000 or £90,000 a year aren’t well paid,” but also points out that this is a lot less than some of their counterparts in hospitals.

Grimmer prognosis

During the 1990s, in huge parts of the country, NHS dentistry simply stopped—dentists opted out, “closed their books” to new NHS patients. Patients had to choose between travelling long distances to find another dentist or paying private fees. GPs are not, mercifully, likely to go quite the same way. Unlike dentists, who always had fees and often private patients too, most are not set up to charge, save on the odd certificate for insurance. There are also strict procedures if practices wish to close their lists—they have to demonstrate, for example, that their workload is threatening the safety of their patients.

But even if family doctoring is unlikely to go quite the way of NHS dentistry, many partnerships could nonetheless struggle to survive. Two years ago, all the surgeries in Bridlington restricted their lists after one of the six practices in the town lost almost all its doctors. They have only just reopened them, but with agreed thresholds. That means Hardman’s list is currently at a standstill: he is only taking on as many new patients as leave the practice. Elsewhere, Pulse, the GP’s magazine, has reported extensively on towns where surgeries are handing back their contracts, including Brighton, Wrexham and Plymouth. Some may be taken over by health service trusts or private companies, others will merge with nearby surgeries, and yet more might just shut up shop. In 2017-8, 179 practices have closed or merged and 148 have applied to close their lists.

Back in Bridlington, more than half the doctors in town are in their 50s, which raises questions about the future. If the crisis in recruiting GP partners is not addressed, then all the town’s surgeries could end up being run by trusts or private companies. Beyond the once-unthinkable loss of independence, some will feel a chill at the possibility of mass corporate take-over.

For determined opponents of all “privatisation” this has long been seen as the hidden agenda behind reforms such as those of Lansley. But in the context of cuts and rationing, where increasing recourse is being made to out-of-pocket payments for all sorts of medical procedures, the scope for cosy tie-ins between commercial clinics with private hospitals and insurers becomes greater. At this point, some of those who were relaxed about private involvement will start to worry about whether it is becoming incompatible with the cherished British ideal of a health service that provides the same care for all, without regards to means.

Plans for treatment

The hope must be that the Watson review at least jolts this crisis out of the denial phase. What hopes, however, for the treatment? NHS England already committed £2.4bn additional investment in 2016. That money was welcome, but Hardman is so frustrated with the soul-destroying paperchase involved in securing it that he funds additional staff from his practice’s own resources: “It’s almost a begging bowl, it just feels wrong.” He isn’t alone: the interim Watson report conceded that a “long, bureaucratic process means that money is not getting to the practices quickly enough.”

The NHS cannot afford to alienate GPs at the same time as it is supposedly bailing them out. Despite the crisis affecting family doctors, and the 5 to 8 per cent quitting annually, a former senior NHS manager sees no evidence of “serious thought in Department of Health policy or NHS England on how to restructure primary care.”

Fortunately, some GPs are thinking innovatively. In one London surgery, where two partners are retiring, the remaining doctors were considering handing back the contract but instead reached a novel agreement with the local “GP federation” (a creation of the Lansley reforms, designed to bid for primary health services beyond the general practice contract, such as smoking cessation or sexual health) who will take on the partnership, carry the financial risks and provide much-needed administrative support. Only one of the doctors will remain a partner; the rest will become salaried, but retain day-to-day responsibility for running things without the most onerous management or the financial exposure. It could be a future model for other practices who are losing doctors and finding it impossible to recruit new partners.

Jackie Applebee is a salaried doctor in a deprived pocket of Bow, East London. The young population she serves is, in age terms, the mirror image of Bridlington’s. Mental health is one of the biggest challenges here, but so too is deprivation. Applebee is a member of the BMA council and an advocate for GPs, who used to be a partner, but then returned to work as a salaried doctor after having children. She never liked the management responsibilities of partnership, and thinks the whole model is—and always was—flawed: “from my point of view I think it would be better if we were a salaried service” from the off in 1948; “but who,” she goes on to ask in the context of today’s world, “would we be employed by?” And she finds the potential answers troubling: “Hospital trusts? Somebody like Richard Branson and Virgin Health? I wouldn’t want to be employed by them.” With these options, she’d still “rather be employed by my colleagues,” through partnerships, which at least “have an understanding of general practice and how it runs.”

Inter-disciplinary working can be another palliative for containing the workload. In some such schemes, a family doctor works with a team that might include a nurse case manager, a paramedic, a pharmacist and an administrator; in others they might collaborate with doctors, community health and social care. NHS England does try and encourage collaboration, but it isn’t easy. In the jungle of the new NHS marketplace, co-operation cannot always be assumed: in southeast England, one group of GP surgeries bidding for a tender under the banner of this sort of teamwork neglected to ask the practice serving the poorest local neighbourhood to take part. Back in Bridlington, a plan to build a new medical centre to house multiple practices under a single roof collapsed earlier this year.

Lord Prior, a former health minister who is the new chair of NHS England, has suggested that truly integrated care will require overhauling the financial architecture to iron out perverse mismatches in the current arrangements. For hospitals, funding “follows the patient,” which rewards them for carrying out ever-more activity, whereas in the community-based services of general practice, the money still comes through a traditional block contract, which does nothing to spur on those practices that manage to do more. And when the rewards work so differently for different aspects of care, there is no chance of money flowing smoothly between them, as it will have to if the experience is ever to be joined up for the individual patient.

Watson is due to give his final word on the partnership model by the end of the year, which will have to find something to say on the formidable problems—workload, workforce and daunting financial risks—identified in his interim report. A parallel review into general practice premises might—with luck—do something about those financial risks too. As it is, if a partner is unlucky enough to be left the last man or woman standing in a practice, they are not only liable for their premises, but potentially for redundancy costs too.

Most GPs are today too worn down to fight a 1940s-style battle for independence. Hardman, in Bridlington, is not ideologically wedded to the partnership model. “It’s a way of creating teams which is fine, but there’s other ways of creating teams,” he says, and suggests some alternatives might work better when there are too few GPs and all sorts of more specialist practitioners have to be involved. “We need to relax our egos a little,” he says, “we can’t see everything and do everything.” Sadly for England’s thinning army of GPs, that is precisely what they are expected to do.