WHey would they do that? The sheer perversity is incomprehensible. Just as ministers and the opposition are calling for more community treatment to prevent NHS beds from filling up, funding is being shifted from GPs to acute hospitals. As always, the magnetic pull of powerful hospitals goes hand in hand with the political need to shorten waiting lists. After years of headlines miss important hospital targets for cancer treatments, emergency care and waiting times, the worst response is to suck funding away from the most productive sector Providing 90% of the care.
The share of NHS spending on GPs is fell to the lowest level in eight years, according to the Health Service Journal, at just 8.4% of the budget. That’s despite the NHS’s long-term plan promising that “investment in primary medical and community services will grow faster than the entire NHS budget”. The opposite happens. In 2019, the government promised 6,000 extra general practitioners this year: they are available now there are fewer qualified, full-time GPs working in the NHS than there were then. Hospital productivity has fallen, while more staff provide fewer treatments The workload of general practitioners has increased by 20%.
“Resources must follow the patient,” says Prof. Kamila Hawthorne, president of the Royal College of General Practitioners. Her university’s manifesto demands an increase in funding to offset their extra work – and, still suffering from George Osborne’s brutal cuts to clinical training in 2010, more GPs in training for this growing, aging population. Why, they ask, do surgeries in poorer areas with 14% more patients per doctor receive 7% less funding than in rich districts? Modern buildings – think Labour’s Darzi clinics plan – are needed to house GPs and all community services. The 46% of GPs in training those coming from abroad need permanent residence, otherwise they will leave. England would need 16,700 additional general practitioners correspond to the OECD average per 10,000 inhabitants.
Ask why GP workloads have almost spiraled out of control, and here is the picture. Ben Shankland is a GP in Tower Hamlets, East London. His day last Wednesday started at 8am and ended at 8pm. His morning clinic continues until the afternoon as usual: there are few consultations that only last ten minutes. During a staff meeting, general practitioners, pharmacists and nurses share difficult cases until 1 p.m. A nurse fears that a vulnerable elderly person is deteriorating. The number of cases of autism and ADHD is skyrocketing: the waiting time for referrals is two years. A patient is angry because he is being refused a drug that the NHS does not prescribe: it has been recommended by a private doctor but he wants to avoid private prescriptions. As private care among Britons rises to 13%, GPs are often caught between the two systems.
Shankland’s afternoon clinic is supposed to end at 6.30pm, after which the out-of-hours services take over, but he always has another half hour of appointments to do. Wednesday is late at night, so he stays until 8 p.m. He has one or two hours of administration a day, with test results, consultant referrals and responses, all of which involve checking patient notes. You can see why, with this extreme intensity, so many doctors burn out, quit or quit working fewer days. On Wednesday, Shankland spoke directly to 40 patients, in person, online or by phone; indirectly he considered many more. A junior intern regularly popped his head around his door to ask for advice, as did nurses and pharmacists.
There was a tragedy: a family without an appointment brought in an elderly man who had collapsed in distress and was unable to move. “I’ve known him a long time,” Shankland said. He calmed him down, called an ambulance and acted as an intermediary to collect his notes from the private hospital. “The ambulance took two hours and did not give him priority because he was in a safe place.” It took up an hour of Shankland’s day.
Shankland says the escalating overload is often due to hospitals handing over work they used to do. He had referred a patient who was still in pain two years after breast cancer surgery to oncology. But the hospital backed her up and said she should be seen by neurology instead. The patient waited a year for an appointment while Shankland cared for her, as GPs often do for the many people on waiting lists. A week before her long-awaited appointment, the neurology consultant decided to review his overly long list and remove her from it, sending her back to “primary care management”, meaning she cannot yet be referred again. “I wrote to say this was unacceptable,” Shankland said. It provides insight into the slippery massage of waiting lists.
Some patients are now sent home immediately after their surgery for care by their GP. This is a heavy burden, made even heavier by the lack of community nurses. The increase in the number of scans creates more work: new lung cancer screening procedures for smokers and high-risk patients find relatively few cases where the lungs are the problem, but frequent calcification of the coronary arteries. “They are sent to us for additional checks, but we have almost always had them treated with statins,” says Shankland. No additional resources are provided to assist with these arrangements.
Shankland estimates that about 40% of patients have mental health problems. His practice usually deals with them: the bed occupancy in mental health care is more than 100% in some parts of England, according to the FT (yes, it’s mind-boggling). But a GP cannot treat the primary causes of poor health or reduced life expectancy, nor the depression caused by the hopelessness of poverty, loneliness, inequality, poor jobs, poor food and housing.
GP bashing is a strange trope of the right-wing press, which dismisses them as idle and greedy. Because Aneurin Bevan were forced to maintain their status as private business partnerships rather than fully integrated employees of the NHS, they never quite fit the local provision template (in fact, partnerships are now declining as new doctors choose to work instead taking salaries). Despite all the bizarre attacks from the Mail and Telegraph demanding in-person appointments, many people prefer telephone and online consultations. A doctor triages everyone who calls the GP practice to pick up urgent cases for consultation.
Some patients, Shankland protests, go straight to the emergency room. “Because the Mail said it was impossible to see a GP, (they think there’s) no point in trying.” In England, 67% of GP appointments are face-to-face, and around 40% are same-day appointments. But only about 53% of people are satisfied with the available times. “Some who want a same-day appointment don’t get it: wanting isn’t always necessary,” Shankland told me pointedly.
Public satisfaction with the NHS fell to the lowest ever a record level of 29% last year. But in England, 71% of people still rate their own GP service as good to very good. This is not the time to shift funding. However, arguments over the distribution of the inadequate NHS cake are no longer relevant as funding per patient has fallen woefully for years and is still well below the lifetime average.