Not just another primary care workforce crisis …

Irish and Purvis¹ have written a useful article summarising the imbalance between GPs entering and leaving the GP workforce, and indicate that this imbalance is likely to worsen in the next few years. The problems that the deaneries face now are acute and have serious implications for future recruitment of GPs at surgeries, and hence the viability of clinical services. There are two other dynamics in play that make the situation even more challenging than they describe.

First, many new roles are opening themselves up to GPs, and they currently sit somewhat uncomfortably alongside the traditional service roles of the general medical services and Personal Medical Services contracts. As a speciality we have accommodated training for many years. We have just about got enough appraisers. We have so far been able to recruit senior GPs to lead clinical commissioning groups. We have medical directors who are system leaders but nearly all of them are coping with too much work (a lot of it protracted and complex) for the time they have available. All these additional roles are useful and interesting, and do contribute to patient care and safety. However, they all take GPs away from direct clinical work.

We have always seen some drift of GPs to post overseas, or moves sideways to other specialities such as occupational health.

So as a speciality we have many new roles opening up to all GPs, and we still have the patients to see. There may not be enough of us to go round all these roles.²

Secondly, we have a primary care service that is poorly configured in terms of its structures and processes to achieve the outcomes that both doctors and patients want and need. We have GPs working flat out in their surgeries coping with the daily treadmill of acute reactive demand. We know that there is much unmet need, but we feel so busy that meeting it can seem an impossible challenge. Our supposed 10-minute consultations already average 11.7 minutes, and still fail to fully address all the problems patients have, and the comorbidity that needs addressing. We can see the challenges of age, complexity, and comorbidity are going to increase, and we are not well set up even for current demands. The GP's work is not well integrated with the specialist nurses available in primary care. Too often they are hospital outreach staff directed by consultants, rather than GPs. There are developing tools such as the Bolton Dashboard and the BUPA/Nuffield predictive risk management software that will in future allow us to ask ‘who needs to be seen today?’ as opposed to ‘who's booked in today?’. But at present in our surgeries we are lumbered with the burden of acute reactive medicine and we struggle to see past our list of patients. And our work with our specialised nursing colleagues is not yet fully effective, and their work is not always best targeted.

So we see an ill-configured and specified primary care service with rising clinical and managerial demands on it, trying to meet it with too few staff. This scenario is intrinsically unstable, and a new settlement for primary care will soon become necessary.