Thursday, 6 August 2015


No one I know has any confidence that the 10 point plan developed by NHS England, Health Education England (HEE), the General Practitioners Committee (GPC) and the Royal College of General Practitioners (RCGP) in order to address primary care workforce issues in January 2015 has any chance of making a significant impact. I thought it might be worth exploring why.

The current crisis is down to too many GPs saying it's all too much, that although the job in principle is extremely worthwhile, the pressures mean increasing numbers just don't want to do it.

A way of assessing this is to look at willingness to do the job at different workloads as pay varies. If pay is high and workload manageable people will feel better about doing the job; if it is too low people may feel the job is not worth doing whatever other worthwhile elements or job satisfaction it offers.
A Commons Briefing Paper shows that between 2005 and 2013 real terms pay for GPs has dropped 22% from £137,108 to £107,331. 
The number of FTE GPs in the same period has gone from 29,248 to 32,075. However the estimated annual number of consultations has escalated from (my estimate) 267m to 340m over the same period. The workload (in consultations pa per GP) has therefore gone from 9,134 to 10,600, a 16% increase.
You will notice both measures are going in the wrong direction, meaning that the job in 2005 was 48% more worth doing than in 2013 when this is expressed as the change in Pay/Workload ratio. (Some may query my choice of 2005 as the baseline but bear in mind this was where we were after a solution to the last GP crisis was enacted and generally folk felt the crisis was resolved at that point and so this seems to me to be the most appropriate point to choose for a baseline.)

We can get a handle on the crisis by considering how pay and workload affect the proportion willing to do the job. 

Each line represents willingness to do the job for the same workload at different pay levels, with say 10% increases in workload between lines A through D. As the work stress increases there will come a point where the stress levels are such that willingness to do the job drops away rapidly as in C. In the most extreme cases where the job causes illness, work may become impossible and willingness drops out very rapidly as in D. I suspect that over the last 10 years we have moved from X to Y as real terms pay has dropped and workload shifted up a gear.
 My contention is that our current level of workload means pay vs willingness is not a linear relationship but has a steep slope, if not a cliff. I think there is good reason to think we are now at point Y on the curve C. This is very precarious for two reasons. Firstly, further drops in real pay, without a change in workload will continue to push us down the steep part of curve C. (Bear in mind GPs are generally very capable individuals who can and do switch to other parts of the economy or other economies.)
But this is not the worst thing that could happen. I suspect that secondly, like fissile material at critical mass, further increases in workload could trigger a chain reaction where loss of more GPs pushes up the workload for the remainder suddenly flicking us down vertically from Y onto curve D, in which large numbers just walk as the job becomes non-doable at that or any price. This disaster would be difficult and expensive to recover from! I think the level of anxiety in GP land at present reflects an intuition that this could happen.
So the solution to the crisis relies on finding ways to push us back up the curves to higher levels of willingness to do the job. (To be sure pay and workload are not the only reasons for doing the job as others have stressed (www.whyGP) which is why on curve A people with means would do the job voluntarily but these factors only shift the curve to the left, they don't change its shape at higher workloads: however fantastic you think General Practice is there is always a point when the stress of the job will make you unwilling to work. What makes this crisis such an issue is that the curve is likely to be already left-shifted by the intrinsic value of the job and the values of the profession compared with other jobs and yet we are still at Y.) My view is that reducing workload rather than increasing pay is likely to be more effective and you can see that from the shape of the curves - going from Y vertically to curve B is more efficient than a pay increase in getting people to stay, if I am right. The main determinant of workload is list size and so for an effective solution practices must be given the right to unilaterally close lists to contain workload, NHSE should commission to cope with the overflow and pay must not drop any further in real terms.

We are now in a position to understand why folk might be sceptical about the 10 point plan which fails to address the above adequately.
I will cover the points in turn

1 Promoting general practice 
This is a marketing campaign setting out the positive aspects of General Practice.

This will clearly make no difference to the Pay/Workload issue. It is possible that it might shift the curve to the left by convincing some to be more willing to do the job for the same degree of stress (but the curve is probably already as left shifted as it can go for the reasons listed above). This does rely on pulling the wool over many eyes in an age of social media, and them discounting their experience and the experience of the more experienced, which seems rather unlikely.

2 Improving the breadth of training 
HEE will work with partners to resource an additional year of post CCT training to candidates seeking to work in geographies, where it is hard to recruit trainees. 

This does nothing to shift the curve or address Pay/Workload once the doctor gets into General Practice and may increase work stress generally by taking a cohort out of full service delivery for a year.

3 Training Hubs  
NHS England will invest in the development of pilot training hubs, where groups of GP practices can offer inter-professional training to primary care staff, extending the skills base within general practice and developing a workforce which can meet the challenge of new ways of working.

This too will have no effect on the curves. New ways of working are likely to increase work stress at least in the transition (note there is no mention of transition funding), risking pushing us further down the slippery slope.

4 Targeted support
NHS England will work with the BMA GP Committee and the RCGP to explore a time-limited incentive scheme to offer additional financial support to GP trainees committed to working in specific areas for 3 years.

Once in a post after three years the Pay/Workload ratio is unchanged once the real work starts. Significant golden handshakes have not been very successful for post CCT GPs which rather suggests it is unlikely they will work for GPRs.

5 Investment in retainer schemes
NHS England will review the use of current retainer schemes and invest in a new national scheme, making sure it meets the needs of both GPs and practices. 

The Pay/Workload ratio is unchanged.

6 Improving the training capacity in general practice
The Government’s recent announcement that there will be an extra £1 billion for investment in new primary care infrastructure will enable increased training capacity and a more positive experience for medical students and foundation year doctors within general practice.  More broadly, NHS England will work with the BMA's GPs committee and the RCGP on the strategic direction of the primary care estate.

A nicer building does little to change the willingness to do the job. Current experience with GPR recruitment is not picking up despite the publicised investment and my City has several shiny underused buildings.

7 Incentives to remain in practice
NHS England and partners will conduct a detailed review to identify the most effective measures to encourage experienced GPs to remain within practice. Options may include a funded mentorship scheme, opportunities to develop a portfolio career towards the end of your working life, and a clearer range of career pathways.

The options suggested specifically do not address the Pay/Workload ratio. The options might decrease stress for the individual doctor but will increase stress on others as their contribution is reduced. This might help prevent things being worse than they would be otherwise but won't reverse the slide.

8 New ways of working
NHS England, HEE and others will work together to identify key workforce initiatives that are known to support general practice - including e.g. physician associates, medical assistants, clinical pharmacists, advanced practitioners (including nursing staff), healthcare assistants and care navigators.

Now this might work - but can only do so if it reduces the GP workload without decreasing pay, thus increasing the willingness to work. Unfortunately the recently released information on the Pharmacist Scheme where practices pay an increasing proportion of Pharmacist time means this is highly unlikely to happen.

9 Easy return to practice 
HEE and NHS England will publish a new induction and returner scheme.

See 2

10 Targeted investment in returners
NHS England will make available additional investment to attract GPs back into practice, increasing over time.   Targeted at the areas of greatest need, the scheme will offer resources to help with both the costs of returning and the cost of employing these staff.

Now this might work if they turn out to be serious in meeting the cost of employing these staff on a permanent basis but the numbers are not likely to be high. 

What is striking is there is absolutely no mention of pay or workload which are key to the willingness of GPs to do the job. They just don't want to talk about this Elephant.

So what will change the situation?

In order to increase general willingness to do the job workload has to be reduced. This will push us back up a curve.

I suspect too that it is this cooperation with such ineffective proposals that has contributed to a loss of confidence of a growing number of GPs in their representative bodies.

I'm afraid there really is no way out of this without increased investment in the primary care workforce (as well as buildings) which could be achieved within the NHS budget by stopping activity with poor evidence and diverting those resources. NHS Health Checks are a good place to start.

None of the current proposals reliably move us back up from Y to X and the GP contract is not set to change in a way that will address this.

Pay is set to continue it's downward drift and nothing significant is being offered to relieve the workload. Consequently the situation is set to worsen still, driving the profession down either a steeper cliff or to implosion. If JH does not realise this he is incompetent, if he does but does nothing he is either impotent or malicious - whatever #WeNeedToTalkAboutJeremy and the petition for a no confidence vote is entirely appropriate.

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