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You may be surprised that an obstetrician is talking about primary care, but the key to this is my being Chair of BMA Welsh Council, for this is one of the few places where doctors from primary and secondary care still meet, debate and exchange ideas and concerns; where medical students, trainees and SAS doctors have an equal voice with consultants and GPs; where we look for collaborative solutions to the problems besetting our NHS in Wales using our unique medical expertise that such varied branches of practice bring. It helps, of course, that I am married to a GP and I that have had a great deal of help from my colleagues both in the office and at GPC Wales!
I was asked recently to talk about the challenges in training, recruitment and retention in primary care. Many of these challenges, and most importantly potential solutions, are outlined in the excellent GPC Wales document: General Practice – a prescription for a healthy future
To look at recruitment one must ask why there are so many vacancies. The crisis from GPs giving up or retiring early is at the heart of why new doctors are not going in to practice. A few stark statistics – 1 in 3 GPs will be over 55 in Wales in the next five years at a time when the average age for men to leave general practice is 54 and women 45. Many have already declared an intention to hand back the keys of their practices – they have simply had enough of the intolerable personal, professional and financial stress that is the reality for many GP practices. GP practices are already closing in Wales.
I want to focus here on 3Ms – money, manpower and the mind-set that prevails in our current NHS.
At its crudest, "it doesn’t pay to be a GP in Wales any more". These are not my words, but those expressed by several GP colleagues. Furthermore, GPs have seen their work escalate as the NHS in Wales has closed too many beds, too quickly, without first re-providing the community capacity that prevents patients revolving back into hospital. The out of hours (OOH) service is still underfunded – although negotiations about indemnity for doctors working in OOH in Wales have helped.
The take home pay for many GPs in Wales is reported to have fallen by 25% over the last 10 years, because costs have rocketed and all of these – such as staff pensions, defence fees, pay rises for non-medics – have come from a dwindling pot. Critically, this pot is more than 10% smaller than their English counterparts, so it is easy to see why GPs on the border often vote with their feet. It leads to the fundamental question – why work in Wales?
Many GPs are working in practices that are woefully outdated; our rural communities have been hit both by the alteration to funding that helped support these services previously (minimum practice income guarantee - MPIG) and removal of their local secondary care facilities. Why are we surprised there is a crisis? It is natural for young bright intelligent doctors – with huge debts from their training - to gravitate to where the action is at, not where it once was, but has been abandoned. They no longer want to pay for the privilege of being appallingly undervalued in the workplace. The challenge is for us to change this.
The incredible intensity of modern general practice is unbelievable (and that's me saying that as a consultant) - GP principals just cannot work at such a frantic pace 5 days a week – starting at 8am and finishing at 7pm, then taking administration and accounts home to do later. We know that such pressure leads to increased risk of medical errors. The resulting burnout has led to a flurry of declared retirements and GP practices closing. Practices managed by health boards are MUCH more costly to run and we end up with a perverse situation in which up to 30% more is spent. However, redressing the fall in primary care funding, from its peak at nearly 11% to now being under 8%, might have helped and might still help to keep practices open – in fairness, Welsh Government and (the BMA General Practice Committee) GPC Wales are working closely on this and there have been several welcome announcements of resource investments, but is it too little, too late?
The budget used to maintain and upgrade practices was devolved to health boards; they’ve not had any spare money, so there has been a natural decline in the primary care estate in Wales. Buying in to decrepit premises is not attractive to anyone, and certainly not to those able to choose and be selective about where, when and how they work.
Working in attractive, but remote locations, with no immediate clinical network, has lost its attraction to many, I’m afraid. The Welsh valleys have a proud tradition of welcoming people to their communities from around the world, yet changes to immigration rules conspire to prevent this now.
In the age of the internet and the instant fix, rural isolation is becoming a niche market with unique challenges that may require unique solutions. But the question for many remains – why be a GP principal, with all the stress and hassle, when you can choose to have the flexibility of being a locum, for greater pay and do what you were trained for – treat patients, without the aggravation of paperwork and the anxiety of not knowing if you can pay the surgery staff, let alone give yourself something that month. Again, I acknowledge the ‘sustainability fund’ recently announced by Welsh Government in trying to help with this.
So what has to change? Well, the fundamental mind set of how we all look at primary care – that includes us working in hospitals, the public, and the politicians. GPs are no longer just gatekeepers to secondary care. They are supreme at that role though – they have been trained to assess risk, to minimise the use of scarce resources and maximise the biggest health gain for the smallest buck. They are, to my mind, unequivocally the best and most effective at this. Now, they have also become specialists in acute and chronic complex disease in the community. And how do we recongnise them? We cut the resources directed to this most efficient part of the NHS. They are not only impressively efficient, but responsive in a way that secondary care just isn’t. If a GP wants something to change to improve practice, it can happen the next day. At the same time, we heap work on them and wonder why it is all ending in tears – but it doesn’t have to be this way.
By listening to and valuing the primary care workforce we have, we can work together, collaboratively, to join up primary and secondary care. There may be a transitional cost to pulling work from hospitals, but this funding just has to be found – the diabolically poor IT and communications have to be fixed. A system that deals effectively with the frustrations that primary and secondary care have with each other will make both stronger and an integrated healthcare system more attainable. The pressure on practices has to be relieved – and this is not by a blanket putting in more staff; the is a clear distinction between improved multi-agency or multi-professional working and expecting gaps in GP provision to come from the same ever-shrinking GMS payment.
It must be is recognised that redressing the under-investment in primary care is cheaper than the wider introduction of health board managed practices. I don’t know of any part of secondary care flagged as being marvelously efficient (I am sure that there must be examples somewhere), but I do know that the administrative leanness and direct support in primary care – because it answers directly to the clinical experts and their needs as they care for patients – is envied by those of us working in the most overly complex matrix organisation ever seen - NHS Wales (to paraphrase Keith Lloyd, ex-CEO of Panasonic UK).
We must get back to a situation in which GPs are valued and ‘looked after’ in Wales – generating time and space to teach students and the next generation of GPs. Then we might fill our training posts not only to today’s numbers, but the numbers we need to replace those GPs already being lost – an intake of 200 per annum, with a shortfall of 400 GPs in Wales currently. The inadequate workforce planning for both the GMS and OOH services cannot continue, without consequence.
You cannot shift work without the associated resources – there must be real investment for quality improvements – and primary care is quite possibly the place to realise these, but we must appreciate how terrible the workload pressure already is on GPs. With the reduced spend on primary care, with GP earnings falling dramatically and with these being worse in Wales than England, Wales must do something and do it soon.
Wales can and should do better for its NHS, because it controls – in theory – many of the elements that allow things to change – for example, there have been announcements on the GP retainer scheme, but equally the inflexibility of the medical performers list in Wales could be reviewed.
Primary care needs government and health board support if it is to survive – and our patients and our nation need it to survive. Wales needs to find ways to better compete in attracting doctors to Wales. Listening to an exhausted and disillusioned workforce, facilitating them to do their work, rather than trying to micromanage them, would be a start. And BMA Cymru Wales will continue to work collaboratively for this change.