David Oliver: We can support primary care without blaming hospital doctors

At the end of 2020, delegates at the local medical committee (LMC) conference of GPs backed a motion demanding “financial sanctions” against hospitals that failed to limit the “unfunded transfer of work to primary care.” They warned that the covid-19 pandemic had led to a major surge in tasks “dumped on GPs by hospitals.”1

As a hospital doctor working in acute care, I have great sympathy for GPs’ concerns. Primary care (GPs and other practice staff—notably nurses) does around 90% of NHS patient contacts for about 10% of the budget and an annual budget of around £155 (€179; $217) per patient on the practice list.2 A 2019 study in The BMJ compared 11 high income countries and found that UK GPs saw patients at twice the speed of those in the other nations.3 Surveys show an average of 41 patient contacts a day, and 10% of GPs see 60 or more.4

The number of GPs barely grew during 2010-15, and the Nuffield Trust has reported nearly 2000 fewer permanent, qualified GPs in 2020 than in 2015 despite a growing population and demand.5 Community nurse numbers have also fallen,6 and social care and local government budgets have been cut.7 The UK has some of the lowest numbers of hospital beds per capita in the world, and ever increasing activity means ever faster patient transfers into the community and more pressure to keep patients at home.8

No wonder the LMCs are unhappy and see hospital colleagues as part of the problem. The difficulty comes with rhetoric that uses the language of blame and hostility towards us. We also have difficult jobs, and many specialties face growing workloads, rota gaps, recruitment and retention problems, and flagging morale compounded by a year of pandemic medicine.910

Hospitals and their doctors are under tremendous daily pressure to organise the flow through acute beds (not least mid-pandemic) and to discharge all medically stable patients to their homes. This is national policy, ramped up further by NHS England’s covid guidance.11 We’re also urged to turn more patients away at the front door and help them stay at home. This pressure has come not least from GP led clinical commissioning groups, which want to take cost and activity out of hospitals through demand management, although the health white paper will disempower the CCGs.12 Commissioners discourage numerous costly referrals between consultants, pushing more referral decisions back to GPs. And hospitals are discouraged from bringing patients back for routine clinic appointments.13

I completely understand GPs’ complaints that some hospital doctors seem not to understand the pressures on GPs or respect their equal value and expertise as specialists in primary care. I also understand the need to see some transfer of resource or staffing to accompany the transfer of workload—not least more hospital specialists working outside hospital walls in community and population health roles. And the national standard contract requires hospital doctors to follow up their own tests and requests.14

I’m not sure, however, that the fighting talk about fines—as well as a hostile stance that makes hospital doctors feel defensive and under-appreciated—is the way to solve the problem.