Part-time GPS are a symptom of failure

The job is unpopular and no longer a vocation – only radical change can make surgeries fit for purpose

General practice is in existential crisis. But while the problems are obvious – long waits for an appointment and no continuity of care – the solution is more elusive, and will require radical change.

In 2015, the then health secretary Jeremy Hunt promised 5,000 more GPS by 2020. Since then, the NHS has lost more than 1,000 GPS. Despite the heroic efforts of individual practitioners, most medical students, aware of the chaos, want to avoid a career in general practice and senior GPS are either leaving the profession in droves or settling for locum posts.

For the last decade, the Royal College of General Practitioners has lobbied for more GPS and investment.

That won’t work. The sooner we accept that the current model of general practice is broken, the sooner a replacement can be devised.

A new report this week has revealed that a third of GPS have reduced their hours over the past year, some citing stress and burnout due to workload and increasing bureaucracy.

Yet hospital consultants, who are exposed to the same difficulties, rarely complain in this way. It would be difficult for GPS to argue that their job is more stressful than front-line hospital medicine, for example performing complex surgery. I worked as a cancer surgeon for 30 years with dedicated and enthusiastic colleagues who were happy and fulfilled in their work. What’s going on with GPS?

Well, a staggering 46 per cent of them are on part-time contracts such as job-sharing. I asked a female medical student recently what her career plans were. Unashamedly, she told me that she wanted to be a part-time GP. It’s as if medicine is no longer a vocation but a highly paid job that can be conveniently fitted around other life commitments.

GPS work part-time because they can. Part-time working should mean four days per week in one practice, and nothing less. That’s the only way to provide continuity of care, the one thing patients most value.

But a more radical solution lies in better integrating primary and hospital care. These operate as two distinct structures with little overlap but they need to function as one cohesive unit that would also expand to encompass social care.

Lord Darzi attempted this in 2008 when, as a health minister, he proposed the concept of polyclinics. The intention was to amalgamate general practices to include about 25 GPS providing services to 50,000 patients or so. This would have allowed extended opening hours and greater investigative facilities, such as X-ray and ultrasound, and hospital consultants would be able to hold joint clinics with GPS.

Unfortunately, the plan was opposed by the British Medical Association and by management consultants on the basis of cost, and was abandoned in 2010. However, some aspects of the polyclinic philosophy need to be reconsidered.

My solution to integrating general and hospital practice would involve appointing clinical nurse specialists, meaning highly trained, subjectspecific ones. Imagine the benefits of employing nurses, trained in care of the elderly, who have detailed knowledge of the services available and are based in hospitals but also work in general practice in tandem with GPS. Now apply that model to diabetes and other common chronic diseases. Not only would GP workload be reduced but patients could have easy access to hospital consultants for advice via the specialist nurse.

Stress and burnout in general practice is often blamed on 10-minute appointments and the demand to see 50-70 patients per day. But how many of those patients really need to see a GP? With reforms and larger practices, patients seeking a GP appointment could be triaged initially to see a physician’s assistant, a pharmacist, a counsellor or a physiotherapist, all working in a multi-disciplinary environment under GP supervision.

These sorts of changes would serve to make general practice more rewarding, attract newly qualified doctors, and improve the patient journey. The large Tory majority to override opposition and Boris Johnson’s promise to increase the NHS budget provide a unique opportunity for radical reform.