General practice in meltdown

Des Spence

doi:10.3399/bjgp16X685021

General practice is in crisis. One in three training posts are empty,¹ 10% of GP positions are unfilled, and this is worsening daily.² Practices are closing lists but this is deflecting pressure elsewhere, and with 25% of male GPs (many full time) over 55,³ the pressure is set to worsen. But there is no cavalry over the horizon. This situation has nothing to do with ‘the Tories’, nor the nastiness of the Daily Mail; its roots lie elsewhere.

There has been a big expansion in hospital consultant numbers, 40% in a decade.⁴ With increasing opportunities to work part time, currently 38% of female consultants choose to do so.⁴ The pay is good and there are opportunities to work privately, do research, attend conferences, and move into teaching and management. Out-of-hours work is much less onerous than before and consultants are shielded by junior staff. Hospital medicine is thus an attractive career.

General practice has changed little, with only a 16% expansion in numbers:⁴ 10-minute appointments, an excess of 30 patients a day, uncertainty, accessibility, and a chaotic working environment. Working in small and often dysfunctional groups, sickness absence can make the workload unmanageable. New GPs can either become a partner with all the headaches that this entails or take a salaried position with all the limitations that entails. General practice is an undervalued, dead-end, and unattractive career for many.

But there is a fundamental professional issue limiting GP recruitment. In England in 2012, 29% of students were privately educated and a further 22% came from selective grammar schools. In Scotland in the same year, only 4.3% of medical students came from the poorest 20% of postcodes and 86% have parents from a professional group.⁵ We are a profession choosing those in our own image.⁶ Medical schools’ attempts at social inclusion are mere tokenism and we are wasting talent. The truth is, a medical degree is often about middle-class aspiration and this is killing general practice. Deans shamelessly promote an obsession with status, telling medical students not to ‘fail and become GPs’.⁷ These pernicious negative attitudes against GPs are everywhere. Our hospitals echo to the sound of patronising laughter directed at GPs and doctors are not choosing general practice due to its low status. Are medical schools failing general practice and choosing the wrong people?

Is there a solution? More money might help with general practice receiving a meagre 7%⁸ of the NHS budget. But if we can’t recruit GPs then what difference will more money make? More nursing support would help but there is a limit on how much medical work can be substituted by nurses.

Fundamentally, GPs need a better working environment and more opportunities. A radical restructuring with bigger and better organised practices, and units of 30 000– 50 000 patients, is needed. This will afford economies of scale, diversification in careers, standardisation, and less chaotic working.

We must also challenge the institutional negativity towards GPs in medical schools and hospitals. GP trainees completing foundation years should train exclusively within general practice. Hospital placements are frequently clinically irrelevant to general practice and general practice specialist training should be the same length as other specialists. We need more GP academic departments, more involvement in undergraduate training, and all foundation-year doctors should rotate through general practice. We also need a large expansion of medical student numbers, with affirmative action on social mobility. Medical student places have a limited supply and high demand, thus artificially elevating its status. Yet medicine is not especially academically challenging and there are plenty of suitably qualified applicants. You never value what you have until you’ve lost it. A collapse in primary care wouldn’t just be bad medicine, but a calamity for the NHS.