A new charter for General Practices
How General Practices can be restored from crisis
Currently there is a crisis in general practice as many, whether patient or professional, know all too well. General Practitioners (GPs) are overworked and have become the target of vilification by the populist press intent on misleading the public as to the true causes of the dire state of primary care. The number of GPs has fallen every year (down almost 1,500) in England since government pledged an increase in 2015. Many routinely work under extreme pressure and well beyond their contracted hours and are frequently subject to abuse from patients and relatives. Increasing numbers are looking to early retirement as a way out and GPs are leaving the profession faster than numbers entering training. The suicide rate for doctors has been estimated at between two and five times that of the general population, and evidence suggests GPs are at greater risk of suicide than most other specialties.
The UK has the lowest numbers of doctors and nurses /1000 people among the Organisation for Economic Cooperation and Development countries and the EU. Recent figures show that annual GP and practice nurse consultations have increased by 16%, now hitting record highs. Evidence also shows that UK GPs see far more patients daily than their counterparts in 10 other high income nations. In a new poll of GPs, only 13% thought their practice was safe for patients all the time with 70% saying threats to patient safety were increasing. The government seems to have no answer except to promise more GPs and then admit its targets will not be met. While being integral to the NHS, ministers are also misleadingly using GP’s independent contractor status to deny concerns about privatisation, claiming that the NHS has never been a fully public service and has always relied on the private sector.
Looking to the future
Those ‘on the left’ are sometimes accused of looking at the past through rose tinted spectacles, and being preoccupied with defence of the NHS rather than thinking innovatively of a broad strategy designed to bring together health, social and economic justice. This charter from Doctors in Unite (DiU, formerly the Medical Practioners’ Union) gives the lie to such assertions and provides a challenging perspective. In fact, rather than calling for a return to the status quo, DiU argues that the starting point must be a radical programme of supported change in primary care if its ultimate demise is to be prevented.
That this is urgently needed can be seen from the facts that current morale, recruitment and retention are at an all time low because of inadequate funding, poor working conditions, erosion of continuity of care, and an inadequate focus on Public Health, health promotion and confronting the social determinants of health. A new national care, support and independent living service is also required, together with funding targeted to where there is greatest need. Hospitals must support primary care in their communities, and closer working with local authorities is also required.
Rooted in communities
General practice must be firmly rooted in its communities, committed to understanding them and the diverse people who live in them, and supporting them in pursuing their own health. Reorganised and reinvigorated services should be based within ‘Neighbourhood Health Committees’ (NHC) serving a population from 25 – 75k, with practices covering 10k patients and having access to a wide primary care team (not for the purpose of substituting less-trained staff for GPs, but acknowledging the truth that good primary health care depends upon a range of skilled workers in addition to GPs). NHC will have their own Public Health leads, who will be combining general practice/practice nursing with Public Health work.
A first step should be the appointment of Community Development workers, initially to the most deprived neighbourhoods but then progressively expanding coverage. These would be funded to develop local community initiatives. Community Development strengthens social networks; weak social networks are one of the major adverse determinants of health. It facilitates local community organisations to strengthen community spirit, provide mutual help and allow communities collectively to address the determinants of their health and articulate their needs.
Both salaried and independent contractor status for GPs should be maintained, while working towards a system where GPs will positively choose a salaried service option. This recognises that in the current commercialised NHS, independent contractor status has a utility (independence from corporate control) that will no longer apply in the future with a reinstated and fully publicly funded service. Improving working conditions for GPs will include career progression, an agreed finite working day, list sizes of no more than 1200 patients/GP, and an expanded primary care team. The current situation of worst access to services for those most in need must be reversed. Public Health will be comprehensively improved.
Give GPs the tools they need
GPs will have access to high quality, fit for purpose, well maintained IT systems to enable most appropriate use of face to face or remote consultations. Digital exclusion will be addressed to prevent a growing area of health inequality. Enhanced IT systems will enable the extensive use of data for clinical care, research and population health analysis whilst requiring specific consent for any commercial use, protecting the confidentiality of individual patient information, and maintaining security of data whilst it is in identifiable form. Patients must be assured of timely, adequate access to the health or care worker most appropriate to their need; triage must facilitate this rather than being a barrier. Continuity of care will be supported and incentivised; the ability to provide continuity of care should be a significant part of how quality is judged.
Creating a fully public NHS
While these plans are both urgent and eminently affordable, this is not a quick fix, as it would require a re-instatement of the NHS as a public service, and a political party in power that shared the vision of transformational change – this cannot be delivered in a system that relies on commercialisation and fragmentation. A decisive movement away from policies of public sector cuts and preferential investment in the private sector must be abandoned. This would stop the expansion of a two tier service and give the population of all four nations of the UK the healthcare that they need.
About the author
Dr Jackie Applebee
Dr Jackie Applebee is the Chair of Doctors in Unite and is a General Practitioner in Tower Hamlets.