Unsustainable, unsafe, and unfair: General Practice in crisis
Key Facts (attached)
Number of appointments in March 2021: 28,4 million
Number of appointments in March 2019: 24.6 million
March 2019 – 28697 fully qualified GPs*
March 2021 – 28096 (-2%) fully qualified GPs*
*Full time equivalent (FTE)
Full analysis of the latest GP workforce and activity data can be found on our GP pressures page.
GPs and practices are under unprecedented pressure, delivering a far greater number of consultations with almost 5 million more appointments in March than they did the month before, and nearly 3 million more than they did in the same month two years ago, long before the onset of the pandemic. This is not just due to the serious impact of the COVID-19 pandemic, but also the major scale of the NHS backlog with millions more waiting for treatment, combined with a falling numbers of GPs relative to the growing population, despite government pledges to address this. On top of this GPs and their teams are working incredibly hard to deliver the hugely impressive COVID vaccination programme quickly and effectively.
It is unsustainable, unsafe and unfair for GPs and their teams, whether in practices, urgent care services or other settings, to be working such excessive hours at an intensity that is increasingly at the expense of their own physical, mental, social and families’ health. This is putting patients at risk.
The first duty for GPs, as doctors and professionals, is to do no harm. GPs must, therefore, take all steps possible to deliver care that is safe for patients and protects their staff. With social distancing and infection protection and control measures still necessary, patients should only receive a face-to-face appointment if they need one, not simply because they demand one. Many surgeries have restricted and unventilated reception areas and are not yet safe for patients to walk-in without an assessment.
Practices are already working well beyond their safe limits and the impact of this on patient care has yet to be fully appreciated or recognised. GPs and their practices, as independent practitioners, with the support of GPC England and your LMC, should deliver care to their patients in the way they determine that best protects and cares for their population. They should not be disempowered by national guidance.
Most importantly, it is for practices to determine how best to manage and deliver their services and the best arrangements for appointments, based on their expert knowledge of their local community, and with regard to the need to maintain good infection, protection and control measures in place. Practices have the contractual freedom to do this in a manner determined by each practice, taking in to account their capacity and workload pressures, and using their best clinical judgement to interpret any guidance, and by doing so delivering a safe service to their patients and a sustainable working environment for their workforce.
As we have repeatedly stated throughout the pandemic, GPs must be trusted to lead and given the autonomy to look after their patients as they think best in their expert judgement. GPC England and BMA, as well as your local LMC, are here to support you in doing that.
The simple truth is that within the constraints of limited resources, dwindling workforce numbers and infection control measures it is not possible for practices to continue to deliver all that is expected of them. This is set against the context of rising infection levels and the spread of the B.1.617.2 variant in the UK, cases of which have risen by more than 160% in the past seven days. It is this clinical context that should determine the key priorities for General Practice in the coming days and weeks, not politically-driven or media-fuelled edicts.
GPs have always put the needs of their patients and communities first. It is important that that we continue to prioritise our resources to our sickest and most vulnerable patients, and that we do everything within our power to ensure they are kept safe.
Over the next few weeks, we will be producing a series of support and guidance resources to help you to:
define what unacceptable and dangerous workload looks like
push back against unacceptable workload demands and workload shift
work collaboratively at an ICS level to introduce an ‘OPEL alert’ system for use by practices supported by their LMC
deal with any abuse from patients.
GP online report on our response to the SOP published last week. In response to this Farah Jameel, GPC England Executive team said: “Despite NHS England’s claims otherwise, this SOP fails to clarify how GPs are meant to offer face-to-face appointments to those patients who need them, while at the same time maintaining infection control and social distancing measures. In writing such an SOP, NHS England displays a critical lack of understanding of what the average GP surgery estate physically looks and feels like and how many patients it can safely accommodate at any given time.”
The Daily Telegraph (paywall) also quoted the Dr Jameel saying that GPs are 'incandescent with rage' after being asked to justify patient appointment numbers. She also said: "Practices have continued to see patients face-to-face throughout the pandemic. The proportion of in-person appointments recorded will obviously vary between practices – not least because no two practices are the same and because GPs are the best people to know their patient communities and provide care in the most appropriate way for them. Practices will feel very much like they are once again being reprimanded and asked to “explain themselves” for responding directly to their patients’ needs and providing care in the best way they can, given the immense pressures they are experiencing."
BBC News has published an article about the rising numbers of patients needing care and a shortage of GPs is threatening to overwhelm the system. I was quoted relation to recently updated SOP and the GPC England motion of no confidence in the NHS England leadership, where I said that doctors were left "angry, frustrated and disappointed" by the SOP letter, especially given the incredible contribution GPs have made to the vaccination programme. The article also includes an excellent interview with Dean Eggitt, Medical Secretary of Doncaster LMC and former member of GPC England, about GP practices in England facing 'tsunami of patients'.
I was interviewed on Talk Radio on Tuesday about the pressures facing general practice.
Today the Guardian reported on the crisis in general practice and abuse against practice staff. I said: “There can never be an excuse for this kind of behaviour. Unfortunately, GPs and practice staff are very often at the receiving end of this frustration, when really it has originated as a result of many issues outside the control of the practice, such as lack of resourcing, chronic understaffing and years of underinvestment by the government.” GP online, Practice in Management, and Mail online also reported on the crisis in general practice.
Urgent meeting held with ministers to seek action to address pressures in general practice
Yesterday, I, together with Chaand Nagpaul (BMA council chair) and Ben Molyneux (Sessional GPs committee chair), met with the Secretary of State for Health, Matt Hancock, and Parliamentary Under-Secretary of State for Primary Care, Jo Churchill where highlighted the huge concern of the profession about the current pressures facing general practice. This followed the motion passed by GPC England, calling for an urgent meeting with the Secretary of State.
We stressed the urgent need to support surgeries to reduce workload pressures and to deliver care and appointment arrangements in the way they knew their patients would benefit from. We called for an urgent end to national directives and criticism, and more help and understanding for practices trying to care for those patients who are now part of a huge NHS backlog, caused by the pandemic.
Although it is encouraging that senior members of the Government prioritised this urgent meeting following our request, it is only through swift and meaningful action by them, and from NHSEI, that we will be convinced that they are serious about tackling the crisis currently facing general practice. We will continue to work as hard as we can to ensure this happens. Read the full statement here.
GPC Scotland survey
A GPC Scotland survey found that the COVID-19 pandemic has left GPs in Scotland at breaking point with unmanageable workloads and serious concerns about the level of support they will receive to care for patients as the NHS seeks to recover from the past 15 months. The survey also found that GPs and their practice staff are facing unacceptable abusive behaviour from members of the public – with 87.7% saying they or their staff have been subjected to verbal or physical abuse in the past month, and almost two thirds saying it has deteriorated since the beginning of the pandemic. As a result, around 70% of GPs surveyed said they are now more likely to take early retirement or leave the profession altogether. Read more in this statement by Andrew Buist, Chair of GPC Scotland.
This was extensively picked up by the media in Scotland, including STV, The Scotsman, The Times, The Daily Telegraph, Daily Mail, Daily Express, Metro, The Sun, and many regional papers and local radio stations.
RCGP statement on NHS pressures
We have been working closely with the RCGP on how to both highlight and tackle the workload pressures impacting general practice. As part of this they have published a statement saying that that NHS pressures are not just about hospitals, as GPs deliver record numbers of consultations. Professor Martin Marshall, RCGP Chair, said: “GPs and our teams are working flat out, delivering record numbers of consultations - almost 13 million in the last four weeks. This is in addition to their remarkable contribution to the COVID-19 vaccination programme, with 75% of vaccines currently being delivered in general practice alone.”
COVID-19 vaccination programme
Those aged 30 or over are now eligible for the COVID-19 vaccines and will be receiving texts inviting them to book a vaccination via the national booking service, at an NHS vaccination centre, pharmacy or GP vaccination site.
15-minute observation period (Pfizer)
We continue to question the necessity for the 15-minute observation period following a Pfizer vaccine, particularly for second or subsequent doses. MHRA have informed us that the evidence related to this is regularly reviewed by their Expert Working Group, but as yet no change has been made.
Over 62 million doses of COVID-19 vaccines have now been delivered in the UK, and over 18 million have also received their second dose. The latest data show that over 32 million people in England have received their first dose, and 20 million their second dose.
Locum doctors in the NHS: understanding and improving the quality and safety of care
Manchester University, funded by the Institute for Health Policy and Organisation, is conducting a research project which is examining how temporary or locum doctors work in the NHS, what they do, how their work is organised, and what effects that might have on the quality and safety of healthcare for patients. Their aim is to help find ways to improve the working arrangements for locum doctors and the quality and safety of patient care they provide. For more information, including how to take part, see here.
New PCSE GP Pay and Pensions portal (England)
The new PCSE GP Pay and Pensions portal is due to go live next week, on 1 June. PCSE has advised that via this new portal, practices and GPs working in general practice will be able to access a range of new services to help manage their payments and pensions administration online.
PCSE has written to all practices to ensure they have the correct details on file for the correct contact who will control the access within their practice to the new system. We have been assured that this work is complete but if a practice believes that they have not had this correspondence or they are unsure who their assigned contact is they should email email@example.com Once the service is live, these ‘User Admins’ will then be able to log in to the portal and assign the roles to their practice staff. A suite of guidance for using the new system can be found on the PCSE website here.
The payments element of the new system should allow practices to submit payment claims, such as for premises or Locum cover, online. Monthly practice statements will also move to the portal from 1 June. These will only be available via this route.
Practices should find it easier to submit pension information such as an Estimate of GP and Non GP Provider NHS Pensionable Profits with the new system. Practices should also be able to provide updates on salary changes in real-time to ensure the correct pensions contributions are being deducted. Approving Locum A forms and other pensions administration work should also be easier.
Any GP who is a member of the NHS Pensions Scheme as a GP partner, salaried GP or locum GP will be able to access an improved service from PCSE to administer their pension account and access their pension records from 2014/15 onwards. Members will be able to do the following via PCSE online with the new service: Type 1 Annual Certificate of Pensionable Profit and Type 2 self-assessment forms; Estimates of Pensionable Profit/Pay form; Retirement, 24 hour retirement and death in service; GP Locum contributions; GP Solo contributions; opting members in or out of the NHS pension scheme; amending member’s Additional Voluntary Contribution (AVC). Further information can be found on the PCSE website.
Members of the scheme are encouraged to log onto the new portal from 1 June 2021. To access this functionality you will need to have a verified PCSE Online account. If you don’t have an account, or have yet to verify your existing account, please contact the PCSE User Registration team at firstname.lastname@example.org. If you already have an account but have forgotten your log in details you can set up a new password on the PCSE login page.
£120m COVID expansion fund - fair shares allocation per STP (England)
NHSE/I has now published a fair shares allocation per STP for the £120 COVID expansion fund for 2021/22.
Following significant pressure from GPC England we secured additional £120m for general practices from April 2021 until 30 September 2021. Whilst the funding will be available to all practices it will be weighted towards those practices involved in the vaccination programme.
The funding will be allocated to systems, ringfenced exclusively for general practice, to support the expansion of capacity. Monthly allocations will be £30m in May, £20m in June and July and reach £10m in August and September.
Medical indemnity insurance rates in Northern Ireland
Alan Stout, Chair of Northern Ireland GPC, has written an article about the implications of the Damages (Return on Investment) Bill on general practice in Northern Ireland. NIGPC fully support for the purpose of this bill, and the principle of 100% compensation for claimants, but are concerned about the impact on general practice. GPs in Northern Ireland are the only doctors within the health and social care system who must provide and pay for their own indemnity insurance. The cost of this varies depending on a number of factors but can run to £12,000 per annum for a full-time equivalent GP. The cost of this indemnity insurance is, in part, dictated by the discount rate. When the rate is lower, indemnity costs are higher. It is clear from this bill that the indemnity rate has the potential to impact on indemnity costs for GPs in Northern Ireland. Read the full article here.
GP Data for Planning and Research (England)
NHS Digital has published a Data Provision Notice (DPN) in order to begin extracting data as part of the GP Data for Planning and Research (GPDPR) programme, which is the successor to the GP Extract Service (GPES). Your IT supplier will be in touch separately with instructions on how to comply, as these vary by system. As this is a legal direction, responsibility for communicating these changes to the general public sits with NHS Digital and the Department of Health and Social Care. Should you wish to communicate it to your patients you may do so, but it is not an obligation.
These are the next steps that practices need to take:
If patients register a Type 1 Opt-out, practices must process this. Codes for opt-out can be found here and are copied below for ease:
Opt-out - Dissent code
9Nu0 (827241000000103 |Dissent from secondary use of general practitioner patient identifiable data (finding
Opt-in - Dissent withdrawal code
9Nu1 (827261000000102 |Dissent withdrawn for secondary use of general practitioner patient identifiable data (finding)|)]
Further information, including a transparency notice and next step for GPs, is available here.
A joint statement from BMA and RCGP can be found here.
Final Seniority Factors for 2017/18 (England)
The Final Seniority Factors for 2017/18, for England, have now been published by NHS Digital.
NHSEI review of urgent and emergency care standards
Based on the responses to their consultation, NHS England and NHS Improvement (NHSEI) have announced on 26th May their intention to replace the four-hour A&E target by a bundle of new standards and an overall new approach to measuring performance in Urgent and Emergency Care (UEC) services. Any final proposals will however require government sign-off, which has not yet been given.
They are proposing to introduce 10 new standards which they say would provide system-wide information rather than focusing on one-part of the system. They argue that the current four-hour target focuses on only one part of a now much more complex range of urgent services for patients, including ambulance care, UTCs and NHS 111.
A summary of the proposed new metrics is attached.
Cameron Fund – 10 top tips for financial wellbeing
The Cameron Fund has had a difficult year in common with the rest of the world, but has continued to support our colleagues and families including those who have been affected by Covid. One of the objects of the Cameron Fund is the prevention of hardship and being aware of the financial pitfalls that can cause so much worry and stress to those who ask the Fund for help, they have produced: "10 Top Tips for Financial Wellbeing".
Health inequalities toolkit – call for examples
The BMA is producing a toolkit for frontline clinicians, including those in general practice, who feel frustrated by the health inequalities they see in their work, and who wish to do something about it.
The initiative is part of a project by BMA president Sir Harry Burns, who is making inequalities the focus of his one-year term in office. The BMA also published a paper in March recommending actions UK governments could take to mitigate the effect of the pandemic on health inequalities and the social determinants of health.
We would like to hear from those who have seen or participated in schemes to address health inequalities in their local area, and hope the final published toolkit will support clinicians to tackle health inequalities, either through direct action on behalf of their patients, through joint working with other local organisations, or indirectly through lobbying local, regional or national government.
Please send any examples of projects or initiatives you have seen in your local area to reduce health inequalities, by filling in this webform.
If you have any general feedback on what you would find useful in a toolkit, as a GP, please email Liv Clark at email@example.com.
The BBC reported on the case of Joy Stokes from Wiltshire, who sadly died from secondary breast cancer, after her husband says she struggled to receive a timely face-to-face appointment with her GP. Mark Sanford-Wood, GPC England Deputy Chair, spoke to BBC Radio Wiltshire (around 3hrs19) around the situation in general practice and reassuring the public that where face-to-face appointments are necessary practices are doing their utmost to fulfil them. He said that there needed to be a "proportionate" approach to increasing face-to-face appointments, noting that some people prefer remote consultations while for others in-person will always be more appropriate.
GPC member Russell Brown also spoke to BBC Radio Sussex (around 1hr40) about GP access.
NIGPC deputy chair Frances O’Hagan was interviewed on Talk Back (05:02) Yesterday about the roll-out of the covid vaccination programme to the over-18s cohort.
BBC Wales worked with Cymru Wales’ GPC Chair Phil White to create advice for people accessing GP appointments. The Q&A format is designed to inform patients how practices are operating across the country, the level of demand for services and what to expect when they make contact. This is part of the BMA’s work to demonstrate the significant rise in demand for GP services in Wales and to address media reports and public views about access to practices and face to face appointments.
Read the GP bulletin here.