We have a GP service which isn’t good enough for patients or doctors

Being a medic is great but also miserable, there is too much medicine but also too little… Harry de Quetteville hears a bewildering message from the evangelical GPs’ leader

Martin Marshall, head of the Royal College of GPs, likes to tell a story. It’s about a patient at the East End practice where he works, a man called Mohammed in his early 40s, married with two young daughters.

Mohammed, says Marshall, is obese and has type 2 diabetes which, for the first year and a half after becoming his doctor, he “failed miserably” to treat. That changed, however, after he visited Mohammed at home. It turned out that Mohammed lived in a twobedroom flat with 17 other people. He had no kitchen and he and his family ate all their meals at the local fried chicken shop. Getting Mohammed rehoused and teaching him to cook revolutionised his health. “That one home visit transformed my approach,” Marshall says.

Indeed, the very subject of getting out into the community, meeting patients and engaging with them, fills his long, lean frame with zeal. “There are some doctors who are wary, saying they don’t have time to do it,” he says. “My view is that if you want to be impactful then go where you make the greatest difference.”

You sound more like a priest than a GP of 31 years, I say. “I do. That was a sermon. I think there is something evangelical about it. It’s exciting and important.”

There doesn’t seem anything affected about this medical missionary act. Marshall talks with pride of working in deprived areas, of starting out in 1991 as a GP in Devon, “assuming that I was going to be a full-time, 10 kids and two labradors GP”, but finding himself leaving and winding up in Moss Side in Manchester before coming to the capital.

Nonetheless, Mohammed’s is an odd tale to celebrate because, according to latest figures, just 0.7 per cent of GP consultations are home visits, and in 2019 the doctors’ union, the British Medical Association (BMA), lobbied NHS England to eliminate them altogether.

“Home visits are still used, but much, much less than they used to be,” Marshall acknowledges at the RCGP headquarters on the Euston Road in London, overlooking the vast HS2 building site around the nearby station. “They still add real value,” he adds, reeling off a second story, about an asthmatic patient whose condition worsened until another trip out of the surgery to her house revealed that she was the owner of 40 cats, to which she was allergic. With more home visits, he says, “I’ve got no doubt at all it would be easier to provide high quality care”.

So why aren’t there more? Time is the real problem. And with that he lurches into a description of the “crisis” that is gripping general practice. “There are some practices that are coping but, increasingly, they’re not. Some are very close to collapse,” he laments. It is, he says, a simple problem of supply and demand. The latter is down to larger, sicker, older, fatter populations and the fact that modern medicine offers an ever longer menu of treatments. The former because “the number of GPs is going down”.

Up to a point. According to the Nuffield Trust, the number of GPs per capita has actually risen inexorably over the past half century, from about 50 per 100,000 in the 1960s to more than 75 now. But it is true that the past decade has seen a very slight decrease from the 2009 peak. Successive health secretaries have promised (and failed) to bolster numbers. But Marshall insists that recruitment is not the problem. “Recruitment is pretty good. But retention is [a problem], and that is a consequence of early retirement and part-time working.”

On the latter he shrugs. “We know that the next generation of doctors will want to work part time. Every full-time recruit that comes in, you might get 60 per cent productivity and that’s something I think we need to accept.” He himself has a “portfolio career” – as an academic, a researcher and a GP. “I’ve got three prongs to my career which is, I guess, the norm for many GPs nowadays.”

But doesn’t the rise of part-timers and locums make continuity of care, – about which he is also evangelical – impossible? “It’s definitely much more difficult to pull off.” He talks of “team-based continuity” instead.

Money certainly isn’t behind the crisis, or at least not for the GPs themselves, who earn an average of around £100,000. “Pay isn’t the issue. We recognise that we have got good pay. We’ve got good benefits. Good pensions.” Such good pensions in fact, that droves of GPs are hitting the £1.1million tax threshold for contributions and retiring early. “If you’re fortunate enough to be able to afford to work part-time or retire early, you do it,” he says. But that’s nothing to do with being pampered, he insists, more a consequence of working conditions in which “your physical health and mental health, and your family life and everything else suffers”. Naturally, though, “you feel guilty about leaving your college in the lurch as a consequence”.

Doctors’ morale is one thing, patients’ another. The latest GP patient survey was published this week, capturing the views of some 700,000 people. The findings revealed a dramatic fall in satisfaction with primary care in the UK, with only half happy with the process of getting an appointment. So bad have things become that a quarter simply gave up trying to make an appointment because it was too difficult, and got no care at all.

The findings confirm results from the British Social Attitudes survey last year, which found that respondents thought fixing access to GPs should be the NHS’s very top priority. Satisfaction with GPs fell to a record low of 38 per cent – astonishing given that until 2018 they were the highest rated NHS service, topping 80 per cent.

“They are very distressing results,” says Marshall of the patient survey. He doesn’t sugar-coat the results – “I don’t think it’s unfair” – though he does deflect some criticism. “Patient expectations have gone up as well. We live in a more consumerist society.”

He comes back to supply and demand and the “workload crisis” it has placed on GPs. “Basically, we’ve got a service which isn’t good enough for patients and isn’t good enough for clinicians either.”

It is a “we feel your pain” stance he is at pains to emphasise. “One of the reasons why GPs [who are independent, not NHS staff] refused to become salaried when Bevan was stuffing doctors’ mouths with gold in 1948 was because they wanted to be on the side of their patients against the state,” he says.

Such fellow-feeling sounds a little disingenuous when he adds that although GPs should not add “to the burden of patients” by going on strike, “that doesn’t mean I would be unsympathetic to the reasons for industrial action”. And the idea that GP and patient are joined at the hip, with the same concerns, fighting the same good fight, crumbles altogether when he mentions that “so many people in my generation, a lot of my peer group, retired two or three years ago, because they felt they were no longer able to do the job that they were trained to do”. Marshall is just 60. Not many of his patients, particularly in today’s cost of living crisis, get to retire at 57 or 58.

He blames the pandemic for some of the mess, with GPs paying the price for the “hospital backlog… holding the ring for those patients waiting for an operation” even as they get sicker and sicker. But he’s pleased with some elements of the change that the pandemic forced through, notably remote consultations. More than

80 per cent of consultations were face-to-face before March 2020, now that’s 64 per cent, which he describes as “about right”. He immediately qualifies himself. “We’ll end up with a service which is certainly more convenient when it’s remote, but not necessarily more productive. I don’t think there’s necessarily massive efficiency gains, but there definitely are convenience gains – for both [patient and doctor].”

Patients at his east London practice, he says, are generally young and tech savvy and happy to log on for care, which he admits is not the case with “older, more conservative, more traditional communities”.

I think of rural areas, far from the drilling and hard hats of the Euston Road and its attendant construction, of the towns and villages that recently had one or more surgeries, but which now have none.

“The idea of branch surgeries in village halls was a really nice one,” Marshall says, as if describing a picturesque scene from a Thomas Hardy novel, not the medicine of just a few years ago. “But there has to be balance with what is practically deliverable. Something’s got to give.”

The trend, he notes, is for “practices to get bigger and bigger. The days of Dr Finlay, where you had one GP in a stable community for 40 years, are long dead.” So village surgeries aren’t coming back then? “I don’t think so,” he says – even though his own experience tells him that proximity is vital. Vaccine uptake among his own patients was low, and when he asked why, “people said it’s too far to go… and it might have been no more than a mile, a mile and a half. Even in a big city, local can be very, very small.”

Trying to convince GPs to work in parts of the country, though, is not easy. That’s partly because payment is based on the headcount a practice serves, not the needs of that community. So GPs head to more affluent, healthier places. “There are certain parts of the country, particularly coastal areas and Wales, that have big problems with recruitment of GPs,” he admits. “The funding model just doesn’t work.”

Yet God forbid that money should be shifted away from practices in richer places to those in poorer. “The business model for general practice is not a good one,” he insists. “There’s not a big margin there. I don’t think it’s possible to remove money from some practices in order to give it to others.” In 2019-20, GP partners, who run practices, earned £122,000 on average.

The other funding scheme that he would essentially chuck out is the “cash for box-ticking” scheme introduce by Tony Blair’s government in 2004 and known as the Quality and Outcomes Framework (QOF), which paid surgeries extra for hitting any of 146 targets – measuring enough of their patients’ blood pressure, say, or treating them for asthma. The results, explains Marshall, were perverse: “Measurable improvements in the quality of the data. Measurable improvements in teamwork. All the kinds of process you might want got better. But almost no improvement whatsoever in disease-based outcomes.”

It seems to sum up modern medicine: the triumph of better bureaucracy. Perhaps inevitably, Marshall would prefer GPs were given cash and “trusted to do the right thing”. “Then you’ll have no bureaucracy, [a] simple mechanism of delivery. What QOF does is the exact opposite.”

And yet it’s not always possible simply to trust GPs to do the right thing. Take cancer. Last year, at a health select committee hearing, John Butler, who leads an international comparison of cancer services, raised the example of a patient with ovarian cancer. Doctors in various countries were given the same “clinical vignette” of this patient and asked what they would do. “We found that in lower-performing countries such as England and Wales only about 35 per cent of GPs referred. In betterperforming nations, with an identical clinical history, it was 60 per cent or 70 per cent,” he said. “The threshold for referral appears to be higher in this country, based on our international studies.”

“There’s no doubt at all that our cancer outcomes are poor in comparison with other countries,” says Marshall. “I suspect that, traditionally, GPs have operated at a higher threshold [for referral] than [National Institute for Clinical Health] guidance. Our job is to differentiate between those cases that are serious and those not and very occasionally we get it wrong.”

Not that he would dream of giving up GPs’ treasured status as gatekeepers to the NHS. His argument is financial. To have direct access to specialists, as in France and Germany, rather than having GPs act as gatekeepers, he says, “would mean spending 14 per cent of our GDP on health, rather than our 9 per cent of GDP”. But it’s hard not to

‘Pay isn’t the issue. We recognise that we have got good pay. We’ve got good benefits’

‘If general practice collapses, the NHS will collapse and we, as a country, are in trouble’

detect him taking some perverse pride in GPs’ role of rationing care.

“GPs feel that we have a responsibility to keep the NHS running. And if I decided that I was going to take a very low-risk attitude and refer every patient, the NHS would collapse overnight.”

It’s not just spending, it’s British bloody-mindedness he blames too: “Patients not knowing when to bring things along. There’s something about the stoicism of the British public that they hold on.”

Still, it’s clear that instinctively he is against what he calls “medicalising everything”. At the beginning of his three-year term leading the RCGP in 2019, he said “the NHS does too much medicine”. Today he goes further. “The strains of life have become a pathology, rather than just normal stress.”

Indeed, curiously enough for the leader of the RCGP, it can sometimes seem that he doesn’t see much point in doctors at all. “Most outcomes are not driven by what we do as doctors. Only about 11 per cent of our health is determined by what the NHS does, 90 per cent by social determinants.” He means education, income, employment, housing, diet – the huge range of levers he pulled to transform Mohammed’s diabetes care. “It’s exciting that GPs are getting into that space. We’re using social interventions more.”

If doctors do nothing, they can do everything. It is just the latest in a series of confusing contradictions that, to hear Marshall tell it, illustrate both the beauty of general practice and also the bind it finds itself in as it seeks to retain the best of the old ways while moving inexorably away from them. The home visits about which he rhapsodises, for example, are also “a historical relic which often didn’t add much value”; remote consultations are convenient yet not productive; GPs are well paid yet miserable; patients are too demanding and also too stoic; there’s too much medicine yet, for cancer, too little; continuity of care is critical yet there’s no point challenging part-time-ism; there aren’t enough GPs, so huge numbers of GPs are retiring early (the RCGP has estimated that, overall, 19,000 are planning to leave in the next five years).

It is a topsy-turvy bundle of incoherence which, no doubt, eloquently sums up the chaos the RGCP’s 50,000 or so members feel is afflicting their profession. Marshall does nothing to dispel the impression as we wrap up the interview. “I desperately hope this crisis doesn’t get worse, but it probably will,” he says. “There has to be a stage at which government recognises that if general practice collapses, the NHS will collapse and we, as a country, are in trouble.”

It all seems so terribly gloomy that I presume he would recommend his nephews and nieces (he and his wife have no children of their own) to do almost anything else than become GPs themselves. On the contrary. “It’s the most professionally satisfying and privileged job in the world. It’s amazing.” I nod, trying to reconcile, as he does, such extremes of good and bad. “Things will get better,” he tells me. “Things will get better.” The doctor in him might be a realist. But the evangelist has to have faith.