The COVID-19 pandemic created a stark divide between a public that was shut off from healthcare, whilst GPs and others found themselves severely overworked and under-appreciated - as highlighted by the response to James Kirkup's column in The Times. In this essay, Doug Russell sets out to answer two questions arising from the difference in responses: 1) why is there a rise in GPs working part-time? and 2) why is there 'under-doctoring' in areas of higher deprivation?
James Kirkup’s column in The Times about current perceptions of General Practice (GP) in England provoked a large number of responses. Those responses illustrated the two apparently parallel universes that patients and public inhabit on the one hand, and GPs on the other.
To patients, particularly since the onset of the COVID-19 pandemic, general practice is effectively shut, the surgery door is locked and the only access is by telephone and a “triage” system – assuming that you can get through to speak to anyone in the first place. Indeed “total triage” was endorsed by the Department of Health and Social Care in May 2020. Nevertheless, GPs continued to deliver just over 50% of consultations face to face, down from the previous level of over 80%
GPs on the other hand feel overworked, under-resourced and under-appreciated, with many reporting low morale, anxiety, depression stress and “burnout”. Data from NHS Digital show that general practice provided 300 million patient consultations a year in 2020, with 17 million in May 2020 alone – at the height of the first “lockdown”.
In February 2020, the Government announced a drive to recruit an additional 6,000 GPs by 2024. That’s 1200-1500 extra doctors in general practice per financial year by the end of 2024. In fact, numbers grew very modestly, between June 2020 and July 2021 by 192 Full Time Equivalents (FTE).
The responses to that column prompted two further questions about General Practice:
- The trend towards GPs working “part-time”, its causes and effects and what – if one thinks that’s needed – might be done to change that trend.
To answer this question, we should ask “What is Full Time”? NHS Digital records it as 37.5 hours per week. GPs tend to describe the job as made up of “sessions”. A session is notionally 4 hours and 10 minutes. A Full Time Equivalent working week would be just over 8 sessions.
This is part of the perception gap over general practice. A layperson might think of “full time” as 5 days a week, which in terms of “sessions” would be 10 a week, two per working day.
The work of the average GP has become more complex and demanding, despite the removal of the burden of 24-hour care responsibility in the 2004 GP contract. There is evidence of rising list sizes, rising demand in consultation rates, more co-morbidities being managed by GPs with transfer of care that used to take place in hospital to general practices. There is the introduction of more and more guidelines, targets, disease registers and an explosion of electronic communication between practice team members, the wider community care services and the hospital. This can easily reach 150 individual tasks per working day – before beginning to deal with individual patients.
Prior to the COVID pandemic, a typical GP working day would consist of a morning surgery of up to 18 ten-minute booked appointments, leaving a notional 70 minutes for telephone calls, checking and acting on investigation results, reading and acting on hospital letters and other correspondence – plus meetings, administrative tasks writing reports, signing repeat prescriptions, dealing with urgent extra patients.
In the afternoon there may be some home visits, to the terminally ill, to the housebound, but the number of home visits has declined quite markedly in recent years. In the afternoon there might be a clinic for a certain group of patients, for example diabetes or heart disease, and then another booked surgery, making sure that all letters, results prescriptions and tasks sent by other members of the team have been dealt with before leaving. When working part-time there is an additional workload on ensuring safe handover of cases before leaving and also picking up strands of work when returning from days off.
It is quite usual for a GP to work at least a 12-hour day with only a few minutes for a meal break if one is taken at all, effectively working 3 “sessions” while being paid for 2. In the face of this pressure, many GPs find the balance between work and home life is no longer practical, particularly if they have caring responsibilities such as for children or elderly or infirm relatives
The make-up of the profession is changing. There are fewer partners, more salaried and locum doctors, and more female GPs. More female GPs are salaried than males, and fewer females are partners. A government-commissioned independent review of medical pay published in December 2020 concluded “The larger gender pay gap among GPs is due to high rates of part-time working by women in this sector”. Just over half of GPs are women (a much higher proportion than among the other types of doctor) and more than half work Less Than Full Time (LTFT).
Adjusting for contracted hours the gender pay gap with GPs is 15.3%. Although the trend to part-time working is often thought to be due to the increasing proportion of female GPs, it is increasingly the norm for male GPs to opt for part-time working too. A cynic might conclude that must mean that GPs are overpaid – “it is fine for them, they can afford it”.
There is a misconception in the public about how much GPs earn. It seems to be commonly held that GPs earn in excess of £100,000 per annum. Whilst a small proportion may exceed that figure – usually as partners in what is effectively a private business contracted to the NHS, salaries are more modest. NHS Digital figures show the average pay of a salaried GP is £63,600.
Between 1999 and 2015, a research group at Oxford, surveyed 9,161 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. They 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.
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. 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. The authors concluded: “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.”
2. Under-doctoring in areas of higher deprivation - its causes and effects and what – if one thinks that’s needed – might be done to change that trend.
It is now 50 years since Julian Tudor-Hart proposed the “inverse care law”:
‘The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.’
It is a sad reflection on 50 years of NHS resource allocation that this law holds as true today as it did then.
Higher deprivation in a population is closely associated with shorter life expectancy (of up to 10 years), poorer quality of life, higher disease morbidity and co-morbidity, poorer health outcomes, poorer experience of health care and lower satisfaction scores with health services.
GP practices in these areas tend to be smaller, have an over representation of single-handed practice, lower CQC scores, lower achievement of quality indicators, higher list sizes, less well-developed primary care teams, and a higher proportion of older doctors. It was notable in the COVID-19 pandemic that the burden of severe illness and death was particularly severe in high deprivation areas.
The existing NHS practice payment formula is supposed to take account of deprivation and allocate greater resource to practices in areas of deprivation. In reality, it delivers extremely limited increases. In 2019 it was found that at GP practice level, a 10% increase in deprivation results in only a 0.06% increase in resource allocated under the formula.
Despite 90% of patient contacts taking place in a primary care setting, general practice attracts a relatively small proportion of the NHS budget – £10.2 billion, against a target of 11% of the budget – a deficit of £3.6 billion. In addition, it can be argued that some of the funds currently allocated to general practice are not being targeted at the areas of greatest need but is instead going to the “leafy shires” where medical need is likely to be lower.
Many indices of deprivation have been produced: Townsend, Jarman, Carstairs, Indices of Multiple Deprivation. An old colleague of mine liked to say “dogs in the street” can tell you where the deprivation and poor quality lie.
How can we encourage more GPs to work in areas of higher deprivation? Basically a mixture of incentives, financial, professional, educational, and balancing disincentives to go to other areas.
Until 2001, a government body called the Medical Practices Committee had to approve the appointment of a GP to a vacancy. Areas were considered as “Designated” “Open” “Intermediate” or “Restricted”, depending on the adjusted population average list size.
This mechanism was abolished in 2001 but nothing introduced to take its place.
Current GP contracts – there are three types in use – do little if anything to rebalance the distribution of doctors. A small number of contracts under the Alternative Provider Medical Services scheme covering special services for groups such as the homeless do make appropriate provision, but these are small and isolated.
There is an opportunity for quality to be addressed by performance managing GP contracts but that approach can be viewed as alienating and overly intrusive bureaucracy. I favour an approach that combines carrots and sticks with the latter very much in reserve.
New forms of contracts may be needed that do take into account deprivation and the health needs of the population being served. The emergence of primary care networks and integrated care systems presents an opportunity here.
It is easy to describe the problems, but finding solutions is much more difficult, as evidenced by half a century of the persistence of Tudor-Hart’s Inverse Care Law.
In 2016 the Kings Fund addressed some the pressures in General Practice and made recommendations which are still very relevant, if not even more so. The BMA has issued a review of pressures in General Practice, most recently updated in October 2021. It says: “GP surgeries across the country are experiencing significant and growing strain with rising demand, practices struggling to recruit staff, and patients having to wait longer for appointments.”
What to do?
- Train more, by expanding training places – this is very long term intervention and takes 10 years, but worth doing. Having trained them, retain them, prevent them leaving and require a certain duration of service delivery in the NHS or Public Sector here.
- Keep more of the existing trained workforce in service delivery.
- Address the adverse pensions incentive to early retirement
- Significantly increase the retainer scheme and add a returner scheme for those who have had career breaks, whether for maternity, other study, illness career break academic sabbatical etc.
- Enable access to affordable child care for all NHS staff,
- Make GP training equivalent to five years specialist training post foundation training with at least three of those years in a General Practice setting
- To retain the sense of drive and purpose and the ethos of vocation and prevent burnout, develop active learning networks, mentorships, rotating placements of GPs and their staff from less well-developed practices and high performing ones, ideally linked to an academic GP centre.
- Provide easy access confidential high-trust occupational health services, particularly mental health to GPs and their teams.
- Re-invent mechanisms that direct new doctors to under-doctored areas.
- Revisit the Carr-Hill formula, or replace it, to recognise the greater health needs of deprived populations. (Carr-Hill used data available at the time to inform the formula. There exists now a far richer set of data within the CPRD and NHS Digital that would enable a new funding formula.)
Expand primary care teams
- Nurses, particularly specialist nurse practitioners can deliver a major proportion of chronic disease management.
- Pharmacists are a valuable highly trained professional group underused by the NHS since its inception.
- Primary Care Networks provide a great opportunity to bring together local authority Directors of Public Health and their teams, social care and community healthcare staff to address systematically population health. The immunisation campaign for Covid 19 revealed some of the potential for this form of working.
- Value and understand the importance of Primary Health Care.
- Be very clear about what service is expected to be delivered for the contracts.
The ethos of the negotiators of the 2004 GP contract was to be agnostic about the numbers of inputs – patient contacts, consultations, visit, referrals, provided the quality outcomes were met. I think this went too far and leaves the patient vulnerable to feeling that they have no access.
The great American primary care expert Barbara Starfield noted that there were two major domains of quality from a patient perspective:
Access – “I want it, I want it now, and I don’t really care who does it”
Continuity of care – “I don’t mind waiting (a bit – several days) but I want to see the person I know and trust”.
She suggested that patients would value continuity of access once they have a particular condition that becomes long term – 2 years is suggested.
Applying this thinking to general practice may provide an opportunity for different models of service for different sections of the population. When GPs switched to (almost) exclusively telephone and online consultations, for some sections of the population this was good: rapid access, no need to travel and waste time in a waiting room. These beneficiaries were usually younger, relatively healthy and tech savvy. However, for older people or those with more long-term conditions and co-morbidity or those less technically minded, the change felt like an abandonment.
We need a mixed economy that is able to respond to both extremes and the centre-ground. The same person might have different preferences at different times for different problems.
Data harvesting and data mining, machine learning, artificial intelligence seem like an obvious development in terms of the aggregated health data of primary care network populations to plan and develop services.
How many appointments are needed for a practice population? It depends. There are benchmarks however, that are a useful reference point. (See worked example in appendix below.)
There is a potential problem that once a practice is allocated funds, it is to up to the practice how to distribute them. There is a risk of perverse incentives with partners in the business retaining an increased share of those funds over time and substituting more part-time and salaried doctors, noting the predominance of female doctors in this latter group, with this possibly contributing to the gender pay gap discussed above.
I think we need a new model of a contract for a truly modern General Practice career that meets the needs of patients, both in terms of access and continuity, addresses deprivation and health needs and finally starts to move the dial on the Inverse Care Law.
NHS England maintain that investment in primary care is rising. The Royal College of GPs says GPs are delivering more consultations than ever, and that the expectation of a return to more than 80% consultations face to face is unachievable within current resources. Consultations and demand are rising, seemingly inexorably. Patient satisfaction is falling. GP morale is declining. Numbers of GPs are falling not rising and the public perception is of a service in collapse. Maybe it is time for a new start?
Worked example of consultations and GPs required to deliver
Experience of mapping demand and supply in Tower Hamlets some years ago after the new GP contract showed most practices had no appreciation of the level of demand, rather just supplied what they always had, historically. The data analysis demonstrated that typically, 70 appointments face-to-face per week per thousand registered patients was sufficient, but in some practices in the most deprived parts this could rise to 110 per thousand per week. This was supported by analysis in 2016 published in BJGP Menon 2016 West Essex CCG also practice Index Nov 2017.
So, a practice of 6,000 patients equates to 420 per week or 84 per day, every day, every week for a low deprivation area and 660 per week and 132 per day in a high deprivation area. If we accept that a FTE GP works no more than 8 sessions and that a session provides for a minimum of 18 face to face consultations of 10 minutes, providing 144 consultations in a week. That would then need more than 4.5 FTEs but does not allow for annual leave, postgraduate training and other necessary activity such as described above, so the funding available is clearly below that needed to support the level of activity required.
Doug Russell qualified at Barts 1975. Choosing General Practice, he trained becoming a partner in 1980. He went on to become senior partner, trainer, Fundholder and Honorary lecturer in health informatics. Invited to be independent medical adviser, then Head of GP Development for mid and west Wales before moving back to London in 2003 as Medical Director for Tower Hamlets PCT. He set up a praised GP appraisal programme, a dedicated multi-professional postgraduate education centre and secured £42 million recurring annual additional investment into general practice and primary care. Alongside this he assisted in performance management of failing practices and GPs. In 2011 he became medical director for NHS North Central London, producing a Strategy for Primary Care. He was involved in early Primary Care Networks. He maintained his own frontline clinical GP practice, from which he has now retired after 44 years, to live in North Norfolk age 70.