After a ‘torrid year’ for general practitioners, Kathy Oxtoby examines how their role is developing, what these changes mean to them, and what being a GP could soon look like
CREDIT: This is an edited version of an article that originally appeared on The BMJ
“Our specialty, which has always evolved and adapted, has changed dramatically in the last eight months, and many of those changes are likely to be sustained into the future.” Martin Marshall, chair of the Royal College of General Practitioners (RCGP), was speaking at its Building the future of general practice conference last October, reflecting on the challenges brought by COVID-19.
There have been many.
Lack of support for stress, mental health, and wellbeing
GPs and their practice teams have been through a “torrid year,” says Richard Vautrey, chair of the BMA’s General Practitioners Committee. He tells The BMJ that the association’s COVID-19 tracker survey from October 2020 “demonstrates quite clearly the pressure the medical profession is under, and GPs are no different.”
Almost half (47%) of GP survey respondents said that their levels of stress, anxiety and emotional distress had got worse since the pandemic began. GPs have been under “continuous pressure this year, without a chance to recharge and rest, and they are suffering from increased anxiety and stress,” says Vautrey. Unlike secondary care clinicians, GPs have very little access to occupational health services; this is a real concern, he says. “Despite our lobbying, the NHS hasn’t put free occupational health in place for GPs.”
Good news: recruitment
Positive news for general practice is that recruitment has hit record levels for the third year running; figures from Health Education England (HEE) show that 3,793 trainees accepted posts in 2020. Building on the success of recent trainee recruitment, GP training places will increase under the new GP contract from 3,500 to 4,000 a year from 2021.
Recruitment is also set to receive a boost from the targeted enhanced recruitment scheme to support GP trainees, which HEE announced in November. This initiative offers a one-off payment of £20,000 (€22 070; $27 100) to GP specialty trainees who are committed to working in a select number of training locations in England—areas that have a history of under-recruitment, or are under-doctored or deprived.
HEE, in partnership with NHS England and NHS Improvement, has agreed to provide 500 places in England for 2021-22, the largest number of places offered so far under the scheme. But there’s no room for complacency; Marshall tells The BMJ that “professional bodies have to continue pushing hard to get the government to deliver on its target of 6,000 extra GPs.”
Bad news: retention
Despite the record recruitment figures retention continues to be a major problem in general practice. “There are still a lot of GPs retiring early because it’s the only way to cope with general practice pressures,” says Marshall. Figures published by The BMJ in 2019 show that the number of GPs taking voluntary early retirement rose from 198 in 2007-08 to 616 in 2018-19.
Pressures resulting from the pandemic could cause even more GPs to leave the profession. The BMA’s COVID-19 tracker survey in October found that GPs’ career plans for 2021 had changed to the extent that 29% were now more likely to take early retirement, 22% to leave the NHS for another career, and 25% to take a career break.
“We need to support our experienced colleagues who have a significant workload, and we need to reduce workload pressures to ensure that they can work safely and that more of them stay for longer rather than potentially seeking early retirement,” says Richard Vautrey.
Preeti Shukla, a GP at the Richmond Hill Practice in Colne, Lancashire, says that GPs are leaving “in droves” because the role, particularly regarding COVID-19, is exhausting. “Less bureaucracy, less ‘media bashing’ of doctors, and having less of a regulatory burden from bodies such as the Care Quality Commission and NHS England” could help, she says. But, if working conditions don’t improve, “people will continue to leave.”
Increased ‘part time’ working
More GPs are reducing their hours. In 2019 an annual workforce report from the General Medical Council found that 46% were contracted to work less than full-time, and 36% have reduced their clinical hours in the past year, with many citing stress.
However, ‘part-time’ is a bit of a misnomer, say some GPs. “Usually, when people say they’re working part-time, it means they’re working fewer days,” says Gaurav Gupta, GP partner at Faversham Medical Practice, and chair of Kent Local Medical Committee. “Most GPs I know [working part-time] will work 37.5 hours in three days, compressing full-time work into part-time hours.”
Nevertheless, the trend for ‘part-time’ working looks set to continue, with 50% of GPs more likely to consider working fewer hours next year according to findings from the BMA’s October tracker survey.
The RCGP’s Marshall says that the decision to reduce hours is “positive for GPs, who are doing this of their own volition – such as wanting a career portfolio, or time with their families.” However, he warns that some GPs are reducing their hours because they’re “finding the job undoable.”
And a greater awareness of the risk of burnout is prompting GPs to reduce their hours, Shukla suggests. She says that GPs would traditionally work nine sessions a week, but that figure is now typically six. Shukla works five sessions a week and says that, because of the work pressures, “this is a good way to keep GPs sane.”
This trend for increased part-time working will, at least partly, negate the gains made in recruitment.
Increase in salaried versus partner GPs
The past five years have seen an ongoing trend towards salaried posts, driven by GPs quitting partnership roles and newly qualified GPs not wanting them. Salaried GP numbers have risen even more sharply since the start of the pandemic; 9,126 full time equivalent (FTE) salaried GPs were recorded in September 2020, up by 455 (5.4%) since the pandemic began in March, according to GP workforce data from NHS Digital.
This could reflect a rise in GPs shifting from locum work into salaried posts during the pandemic because of the drop in locum opportunities. NHS Digital’s workforce data showed 1,391 FTE locum GPs in 2020, down by 116 (8.3%) from December 2019. The option to work as a salaried GP reflects the specialty’s flexibility, says the BMA’s Vautrey. “A GP may start out as salaried, gain confidence to become a partner, then later choose to be salaried again,” he says.
For Marshall, however, the partnership model is “the bedrock of the autonomy of general practice.” Over the years the number of GP partners has fallen from 85% to below 50%, he says. He’d like to see a balance in partnerships and salaried GPs—“maybe 50% each is the right balance”—to maintain that flexibility.
Krishna Kasaraneni, a GP in Sheffield and workforce lead for the BMA’s General Practitioners Committee, says that the BMA is working on increasing the number of GP partners, adding that, “We’ve tried to address this with the new GP contract’s partnership payment [the targeted enhanced recruitment scheme].”
COVID-19 telemedicine: what GPs have learnt
“General practice is going through a paradigm shift around how we’re communicating with patients,” says Clare Gerada—London GP, chair of Doctors in Distress, and medical director of NHS Practitioner Health. Before the pandemic about 90% of GP consultations were face–to-face, and only a small proportion were done remotely. At the height of the pandemic this reversed, as around 70% of consultations were done remotely.
“The pendulum is now swinging back a bit, and practices are doing 55% of consultations face-to-face,” says Gerada. “However, I suspect we’re going to end up with 60% of all consultations starting and ending online.”
Shukla says that this overnight shift to remote consultations brought a need for more training in telephone triage. Some patients, such as those who are deaf or have mental health issues, can find it difficult to communicate their stories remotely, she explains, and trainees, in particular, who have been taught face-to-face consultation skills, need to learn how to deal with patients’ often complex needs over the ‘phone.
Vautrey notes that “doctors didn’t train to work in call centres. They want to have that regular, face-to-face interaction with their patients, which is one of the joys of general practice.”
For Gupta, remote consultations come with “some ‘health warnings’…There is a risk that some populations, such as older people or those for whom English is not their first language, who are digitally disadvantaged, might get poorer outcomes as a result of there being too much focus on remote consultations.”
Rise in self-testing and self-care
During the pandemic more people have turned to self-care, and more conditions are being managed at home. In a survey by the consumer healthcare association PAGB on attitudes to the NHS in relation to COVID-19, some 69% of respondents who might not have considered self-care as their first option before the pandemic said that they were more likely to do so in the future.
Technological advances have boosted the rise in self-test kits – in these self-testing times patients can identify and monitor many conditions, from diabetes to blood pressure. Patients have also been empowered to self-care, even dressing their own wounds, with ‘virtual’ help.
Vautrey believes that GPs could do even more to empower patients to take responsibility for their conditions. “There’s no reason why they couldn’t access, say, talking therapies, drug management and weight management services,” he says. “Making these services more accessible would be a ‘win-win,’ reducing the need to make appointments with a GP and empowering patients to make the right choices.”
However, while this ‘positive’ trend towards self-care and self-testing looks set to continue, Kasaraneni warns that it could, potentially, increase health inequalities among people who can’t afford, for example, blood pressure monitoring equipment. “It falls to the government to make sure self-monitoring doesn’t only become an option for those who can afford it,” he says.
Impact of PCNs
As of the latest primary care network (PCN) sign-up in May 2020, all except a handful of general practices in England have come together in around 1,250 geographical networks covering populations of 30,000-50,000 patients, along with other healthcare staff and organisations, to provide integrated services to the local population. Marshall says that PCNs “are what communities want” and that they will “help take general practice to a new level with a broader, skilled, multidisciplinary team, working to a large scale and sharing staff.”
Vautrey adds that GPs need time to recruit and that NHS England “isn’t giving much freedom as to who is recruited. What NHS England really needs to do is to trust us. We need greater flexibility in terms of the utilisation of the workforce so that we can make the best use of PCN funding.”
Grouping practices together in PCNs is “artificial” and “forced,” says David Turner, GP partner at Chorleywood Health Centre in Hertfordshire, who wants practices to have the freedom to spend money on frontline roles. “What we want are more doctors and nurses.”
PCNs could, potentially, result in the end of the traditional partnership model. “The old idea of being a partner within a practice will disappear,” Gerada believes. “Instead, we will be equivalent to stakeholders within a PCN – whether that’s for profit, as in a shareholder agreement, or whether it’s a partnership, as in a sort of consultant body – but that will be determined by the next generation of doctors.”
During the COVID crisis “many consultations have, by necessity, become more transactional, and this has reinforced the mistaken view of some people that general practice is largely a transactional medical specialty, rather than a relational one,” Marshall told the 2020 RCGP conference.
But GPs, he said, know that “the trusting relationship between a patient and a doctor—often, but not always, based on continuity of care—is the most effective intervention that we have at our disposal. It’s what helps us to use medications, investigations and specialist referrals appropriately and to reduce the risks of medicalising non-medical problems. It’s what encourages patients to engage with our advice, [and] it’s what many patients want from their GPs.” Marshall told conference delegates that the COVID experience “has reinforced our decision to make the promotion of relationship-based care a strategic priority for the [RCGP].”
Gupta hopes that his practice will continue to provide a personal service to patients. “That is the reason why most GPs have chosen to do this job. We are the only people in the healthcare system who have that relationship with patients and their families, and it would be a huge shame if that personal approach was lost.”
While Shukla likes the personal approach to care, she recognises that, even when “some sort of normality” comes into our lives again, remote consulting will continue and a young population will want instant answers about their medicines and test results.
“We might not like the way care is heading, but we need to be aware of the demands of this younger patient population,” she concludes. “They need us to change, and we will, with time. We always adapt; GPs are good at adapting.”