The problem of lack of access to GPs lies not in some deficiencies in the GP service and the individual practitioners, but in the public’s entitlement to access with no conditions. In this essay, John Allingham makes the case for a reorientation of our expectations of GPs.
The total number of GPs has fallen and there is no sign of the 6,000 extra promised in the 2019 Conservative Manifesto. The number of GPs per head of population has decreased steadily for the last 6 years. Compared with countries with similar primary care systems we are consistently at or near the bottom of Doctor/Patient ratio league tables.
The population is ageing, chronic disease rising and long post-pandemic waiting lists are putting pressure on GPs supporting patients who are a long way from getting the treatment they need. The pandemic brought stresses that increased mental health problems. Lack of resources in specialist mental health has raised the bar to referral, leaving GPs managing more and sicker patients.
The media are blaming GPs for lack of access. This emboldens patients. GPs who are working themselves into the ground with 11-hour typical days are criticised and threatened by those they are trying to help.
Some commentators suggest the solution is to cut GP pay to encourage them to work harder. This is in the apparent belief that GPs are financially motivated and that they have the capacity to do more. If this strategy is employed, GPs may walk away and the supply will fall.
The number of GPs and appointments is finite and there is no realistic expectation of more in the near future. The current crisis can only be ameliorated by reducing demand and making the best use of GPs we have.
The NHS needs all health professionals to work at the “top of their licence” as far as is possible. For GPs this means stripping out many of the simpler clinical issues, administrative and bureaucratic tasks. This can only be achieved if a triage system is operated to filter out the tasks that do not need a GP. Unfortunately, patients cannot expect to book a face-to-face appointment without offering an explanation of why their problem can only be solved by a GP.
‘Talk before you walk’ must be the normal way of accessing care.
There are many patients with problems that can be helped by a pharmacist, so “Pharmacy First” schemes need to be universal. Pharmacists with appropriate training can provide medication for many minor conditions that take up GP appointments. Such services are currently patchy but pharmacy is well staffed and could reduce some of the demand on GPs and A&E. It is important that the medication costs are the same to patients as with a GP prescription. Some patients attend GPs out of the financial need to get a free prescription rather than the medical need for help and advice.
A simple example is paracetamol syrup for sick children. This could be provided free by pharmacists and the immediate cost offset against the savings made in reduced GP appointments that result.
Many patients attend GPs simply to get a form or certificate signed. Much of this work could be removed to provide more capacity. The Statement of Fitness for Work (“Med3”) note used to validate inability to work could be completely withdrawn from GPs. The Department of Work and Pensions could police fitness to work and rely on self-declaration and the assessment of its own medical specialists. Employers could use self-declaration and specialist occupational health teams to certify fitness to work.
A national campaign informing patients that signing forms to run marathons, get passports, make parachute jumps, be exempt from mask wearing or join a talking book club is not the responsibility of the NHS or of GPs.
There should be a minimum national fee of £50 for a GP signature on all such forms, with the cost being met by the organisation requiring the information or opinion rather than the patient. That would reduce this demand on doctors’ time. In signing a form, the GP is taking responsibility and the risk that the information and opinion given are accurate and can face sanction in the event of an error. Many patients baulk at any fee for this service and there are examples of patients lying to get an appointment and presenting a heartfelt plea for a signature in an appointment that could have been used by a patient with clinical need.
The shift of administrative tasks such as chasing appointments, results and writing prescriptions has grown exponentially as other NHS providers try to increase throughout, do remote consultations or lack the systems to complete care. It is cheaper for a hospital to transfer such work to GPs than to employ another secretary. A list of tasks that should not be transferred to GPs – with a £50 fee levied for every breach – would stop this practice and force hospital trusts to establish better systems for their own administration.
There should also be a rapid roll-out of electronic prescribing (EPS) to enable hospitals to send a prescription to the patient’s local pharmacy rather than write to the GP who then checks the details, contacts the patient and EPSs the script.
Some readers might look at the tasks I have outlined here and think “that only takes five minutes”. That might be true. But there can be 20 or 30 of these tasks facing a GP every day.
If all the proposals outlined here were adopted it would increase GPs’ available time for patients considerably and so raise the number of patient appointments available, perhaps by 20-30%.
In addition to freeing GPs from bureaucratic and low-level tasks, there needs to be a campaign to preserve what we have. Older GPs need incentives not to take early retirement such as contracts with more time per patient, fixed hours and time to mentor younger GPs. The government need to rethink the pensions tax rules which force GPs to reduce hours and encourage early retirement.
Incentives to work in under-doctored areas such as 5-year enhanced contracts with signing on bonuses working in modern state-of-the-art premises might help balance out the lure of the leafy suburbs and thus help address health inequality.
We need a grown-up conversation about what the NHS will not provide. Many GPs hate the idea of rationing care, but should things such as warts, veruccas, headlice, threadworms and holiday advice be priorities?
GPs are not an emergency dental service. Everyone should have access to an NHS dentist stopping the dental abscesses and toothaches taking GP appointments in desperation.
Public Health budgets have been cut in the last 10 years. The excellent preventative work in weight management, smoking cessation, drug and alcohol addiction and many other areas that help keep the population well are missing. This increases pressure for GP appointments.
Together, these changes could provide a better general practice with a sustainable long-term future. They would require money, effort and political will. None of these things are easy to come by. But do we want to strengthen and preserve what has been described as the jewel in the crown of the NHS or criticise, condemn and destroy it?
Dr John Allingham FRCGP DRCOG Dip SportsMed (RCS Ed) PGCME DLM trained as a GP in the Army. Worked as partner in Beds and Kent and is currently a part-time salaried GP in York. Experienced as an educator of GPs and allied professionals. 11 years as Medical Director of Kent Local Medical Committee representing GPs. Specialist interest in Sports Medicine having worked in motor sport and as team doctor to a rugby club for 14 years. Passionate about the NHS and frustrated by the stream of misinformation fed to patients in the media.