Workforce and workload pressures are building in general practice, so why be a GP?

General practice

There is a workforce crisis in general practice, with difficulties in attracting doctors to GP training and a shortage of qualified GPs. This comes at a time when demand for consultations is rising and there is a strategic goal to move more work from secondary to primary care. Yet funding for general practice has not kept pace with these changes.

I am a GP trainee, in my first year of a three-year training programme. Slightly unusually, I made the jump to general practice having spent five years as a hospital doctor, three of which were spent specialising in paediatrics. As part of my GP training I have been working at the Fund on a project that aims to provide an ongoing independent assessment of the key issues facing general practice, building on the Fund’s previous work in this area.

For this project we have used data provided by ResearchOne to allow us to analyse current activity levels in a sample of 202 general practices. Some headlines from this analysis appear in the Fund’s quarterly monitoring report, which already monitors NHS provider and commissioner finance and performance. We have also carried out a small online survey of GPs and practice managers – we received 129 responses, some of which may have been multiple respondents from the same practice – that provides a snapshot of the current financial, workforce, morale and organisational issues they are facing.

Our data analysis shows that demand for GP appointments is increasing, with a 6.1 per cent increase in the number of face-to-face contacts over the past two years within our sample – the vast majority of our survey respondents also reported an increase in demand. In those aged over 85, our data analysis revealed a 26 per cent increase in contacts.

Only a quarter of survey respondents said they were recruiting more clinical staff to manage this increase in demand, but this is hardly surprising given that 58 per cent of respondents said they were struggling to recruit salaried GPs and 50 per cent were having difficulty recruiting partners. In addition, 44 per cent said at least one partner in their practice was planning to retire in the next two years. Several respondents reported that newly qualified GPs seem to be opting for locum work, which is exacerbating the financial pressures on practices, while several practices said they were struggling to recruit even locum doctors.

It is important not to read too much into what is a very small sample. Nevertheless, these findings are concerning in the context of the debate about the sustainability of the current workforce. Certainly, among trainees I know, barely any want to work full time after fully qualifying, and many are planning to take on locum roles.

So why is this? Well, for one thing, being a GP is very different to being a hospital doctor. You work more as an individual, seeing patients by yourself, which is very different to the team-based approach in hospital, and you manage a higher degree of uncertainty. This is nothing new. What is new is that GP trainees are becoming aware of the extent of current pressures on qualified GPs, and the stress they are under: the increasing number of consultations taking place; the need to manage patients with complex conditions while also processing results and letters, all requiring careful attention to ensure you don’t miss an important result or action. Add to that the pressures for partners of having to deal with the practicalities of running a business, and it is easy to understand why working as a locum, or part-time, is more attractive than being a full-time GP or partner.

So, given all the workload pressure and stress, why do I want to be a GP? General practice offers such variety; in one morning you can see individuals – from babies to people in their 90s – with a whole range of acute and chronic conditions. As a GP you are usually a patient’s first port of call; you may decide that one of their symptoms warrants further investigation, and so refer them to a hospital specialist for support in diagnosis and/or management. But then you will also be there after a diagnosis is made, to continue to support them and monitor their whole health, not just one individual aspect. People place a huge amount of trust in their GP, and it is a privilege to be given a window into their lives.

The nature of health care is changing, with increased demand and people wanting better, quicker access to services. General practice must adapt to reflect these changes and to offer a good service to the population it serves. However, general practice should also be a satisfying and fulfilling career. GPs must be supported to manage the increasing level of demand and the subsequent pressures this causes.

General practice has always been at the heart of the NHS; to ensure its future, the onus is on policy-makers, health care leaders, GPs and trainees to develop a model of general practice that will meet the needs of both patients and workforce.

Comments

I find the GP shortage debate puzzling. The reasons for the shortage will invariably be complex. Nonetheless, a few points seem to be overlooked. One area that I cannot get clear data for is the proportion of medical graduates going into general practice vs hospital/non-GP roles. 15 years ago it used to be quoted at 50% but is the trend increasing, decreasing or the same? As a surgical trainee, amongst my peer group, GP was seen as the 'lifestyle career choice' compared to the perceived (and in some cases, real) heavier load of hospital work. GP seemed to attract those who wanted to work part time and avoid weekend and night work. It's no surprise therefore that, if many GP's are part time, the pressure on the full time staff only increases and exacerbates stress and burnout. GP training is the shortest programme. 5 years (2 yrs Foundation Programme and 3 yrs GP training) vs 8yrs for psychiatry and up to 10yrs for some of the medical and surgical specialties. The more competitive specialties often require further degrees (MSc/PhD) The highest pay scales are therefore achievable at a much earlier age and maybe this facilitates the ability to work part time. This again fuels the shortage. Throughout registrar/ST3 training, despite fewer weekends and night shifts, pay is equivalent to hospital trainees. Locum rates in GP can be (not exclusively) exorbitant. Does this disincentivise GP's from taking up full time practice work? Amongst my peer group, it certainly does. To me, GP seems inherently attractive from a lifestyle perspective (I don't enjoy the work which is why I would never do it) - there's flexibility, good pay (better than hospital consultants), shorter training and a work-life balance if this is desired. One can work in a city or in a rural area if one prefers. One's skills are much more easily transferable overseas compared to many hospital specialties.

Additionally, the Royal College of GP's needs to accept some of the responsibility for the crisis in GP - they are, after all, the leaders of the profession.

To begin to understand the issues, we first need clear, accurate, meaningful data on how many people are going into GP, why they chose GP, why other doctors don't want to do it and what kind of work (salaried, partner, locum, full time v part time etc) they end up doing? Surveys of a few hundred won't give an accurate enough picture on what is happening and, as such, will limit the effectiveness of any proposed reforms.

In every profession, we are facing some kind of work pressure, it will definitely refine our skills and strategies. But ultimately improve stress and depression which brings several kinds of negative results for our success rate. Work pressure ultimately improves our personal skills and ability to deal with situations and handle pressure, so we can say that work pressure will definitely play a vital role in our professional success.
http://www.reginafasold.com/blog/stuck-in-the-past-5-steps-to-personal-growth/

Both comments are very thought provoking. But what is happening is nothing new. As an ex NHS Director of Primary Care Morale Recruitment and Retention. We have known for at least 25 years roughly which NHS doctors where gong to retire and when, simply by age! My role was specifically set up to ensure this problem was carefully managed and NOT reacted too. Our local CCG supported a NHS Primary Care locum bank, so those Doctors who wanted too could slow down. Those who were new Doctors to the area could come and embrace it and be supported and meet the older doctors in the same forum. Crossfertilising knowledge and giving one another support. I am not sure why a general locum bank for each area is not set up. Yes doctors and nurses do cross boundaries and areas, but at least they are still IN the NHS SEA and serving the public. If all the local retired doctors wanted to take a break and then come back and do a little OR a lot then at least we have refreshed professionals and not burnt out ones. Forgive me my family have given 104 years service to the NHS and I say more locum banks please (not private ones but NHS) and lets retain doctors and nurses, because starting again with new staff is very costly. Yes we also have T shirts and videos of recruiting doctors from abroad and some history has shown these doctors do not stay beyond a year unless very well supported. Adaption from one health care system to another takes time. As for responsibility, i think anyone who comes to work in the NHS has responsibility from the time they walk through the doors until they go home. Its all part of the job.

That is a very thought-provoking comment, regarding salary and part-time work. It is of concern to me that many nurses and doctors are taking the agency/locum route rather than employment within an organisation. It suggests to me that they do not want to take the responsibility that goes with their professional practice, other than on a transactional basis with their patients. This certainly adds a great deal to the costs of the NHS and is a drain on resources. People are not putting the service first (which means patients) but themselves. Of course it is important to look after yourself. I think it is also important to share responsibility of running the services and not just be about turning up for your shift or clinic.

This is an interesting comment
"Certainly, among trainees I know, barely any want to work full time after fully qualifying, and many are planning to take on locum roles."

How many young people, newly qualified, have the luxury of considering part time work? None that I know of - and that indicates to me that GPs are grossly overpaid for what they do. Of course it is a stressful job - try being a carer or even try the job of someone else in a different profession on matched pay - these jobs will all be 'stressful'. One of the biggest problem in the NHS today is the enormous salary bill and we are still held to ransom over contracts. I have lost all patience