Fit for the future? Does the report go far enough?
Dr Michael Brooks, a practising locum doctor and chief medical officer of PatientSource, gives his take on the “Fit for Future” report published by the Royal College of General Practitioners.
It’s encouraging to see that the Royal College of General Practitioners (RCGP) has recognised the unreasonable demands placed on GPs and outlined a vision as part of an extended report, set out with the intention of redressing the issue. However, what’s immediately clear is that the report doesn’t go far enough – markedly underestimating the pace of change that is required.
I have a lot of sympathy for my GP colleagues. Every day they’re being asked to deliver the impossible – they’re being asked to see 35+ patients in their office, conduct tens of phone appointments, chase blood and pathology test results, send referrals to secondary care, meet clinical targets, complete an ever-mounting volume of reporting paperwork and, all the while, they’re being asked to find the time to demonstrate their competence through Revalidation paperwork.
On top of this, GP Partners have to find time to run their Practice accounts and regulatory affairs, taking inordinate amounts of personal financial risk to do so. As a result, many are finding themselves in the “last man standing” position – facing financial ruin. And they take all this risk on just 9% of the NHS budget.
We’ve ended up in this situation through a progressive trend of more paperwork, more secondary care work getting farmed out into the community as hospital beds are closed, more clinical targets, a proliferation of disconnected data silos and this is on a background of a progressively ageing population with more co-morbidities. It has been the perfect storm.
The buffers are now exhausted. Over the past decade, GPs have been working harder and harder with less remuneration in real terms to try to absorb this extra work. Typical workdays for a GP are 7:30am-8pm. Only a superhuman can deliver thorough care that ticks all the boxes in a 10-minute appointment, and I can imagine how demoralising that must be for our GPs. But now there is no more spare effort to give. Hardly any GPs I know want to work a full 9 sessions per week. Many have taken early retirement.
I see the fallout from this in my Emergency Department: we are picking up more and more Primary Care problems. Patients frequently cite 3-week waiting times for routine appointments and the fact that duty doctor appointments are all booked within 10 minutes of a Surgery’s phone line opening. This is not the fault of our GPs, it is the fault of a system of inertia, fragmentation and underfunding.
The “Fit for the Future” report by the Royal College of General Practitioners explores these causes and recommends the right approaches to fixing the issue. I just don’t think it’s anywhere near radical enough.
First and foremost, if we have our hearts set on delivering more care out of hospitals and in the community, 11% spend primary care funding is nowhere near enough. I estimate it needs to be above 16%.
The report explores prevention as a long-term strategy. This is excellent in principle, but we need both quick wins and a serious investment in prevention now. We can’t keep cutting public health funding, because today’s lack of preventative care (especially around obesity, type 2 diabetes and its complications) will be tomorrow’s problems landing into the GP & A&E safety net. We also need to incentivise people to take more responsibility for their own health.
Integrated Care has been cited in the report as the future, and thus we should design for it. I agree, however once again the recommendations are not radical enough. We have disjointed data systems across Primary and Secondary Care. The baton is getting handed between them in the form of clinical referrals and discharge letters, inefficient and incomplete data exchange. We are wasting resources repeating tests in Primary Care that have recently been conducted in Secondary Care, it’s just that the GP can’t access the results.
We need to hold clinical software vendors to account here. Primary and Secondary Care IT systems should be interoperable via published standards by default and at no extra cost to the healthcare organisations involved. It is not acceptable for an electronic medical records system manufacturer to try to charge an NHS Trust or GP Practice to be able to link their system to a third party system because that is holding patients’ data to financial ransom. We need to evict vendors who rely on lock-in strategies like this from our NHS because it is harming patients and driving up the costs of care. We built PatientSource to be as interoperable as we can for these reasons.
Finally, we need to look at GP as human beings when it comes to attracting people to the area of Medicine. Ask yourself: would you seriously put yourself through 5-6 years of university study, rack up £70k worth of debt, be moved around from hospital to hospital every 4-6 months until your 30s, miss out on weddings/holidays/ family events at the whims of a rota coordinator for six more years, to do a job where you work 12 hour days yet are repeatedly hounded by the media for “not working hard enough”, and take on personal financial liabilities of hundreds of thousands of pounds as a partner in a GP Practice?
And that’s excluding the stress of Revalidation, the uncertainty of the medical pension pot and the Damocles Sword of GMC Fitness to Practice hearings. It is a career that through all these small stressors no longer seems worth it to many young medical students and doctors. RCGP needs to blast away all these points of friction if it ever hopes to recruit the number of new GPs we need.
While we don’t want a swathe of challenging change deadlines to further burden GPs, we do need the Royal College of General Practitioners to make their voice heard to ensure that GP services evolve at pace. The suggestions that the RCGP makes are already being carried out in pockets throughout the NHS, it shouldn’t take 11 years to amplify and propagate these across primary care.”