Why would they do that? The sheer perversity is incomprehensible. Just when ministers and the opposition call for more community treatment to prevent NHS beds filling up, funding is shifted away from GPs into acute hospitals. As ever, the magnetic pull of high-powered hospitals conspires with the political imperative to cut waiting lists. After headline-grabbing years of missing key hospital targets for treatment, A&E and cancer waiting times, the worst response is to suck funding out of the most productive sector providing up to 90% of care.
The share of NHS spending on GPs is falling to its lowest in eight years, at only 8.4% of the budget, according to the Health Service Journal. That’s despite the NHS long-term plan promising that “investment in primary medical and community services will grow faster than the overall NHS budget”. The opposite is happening. In 2019, the government promised 6,000 more GPs by this year: there are now fewer qualified, full-time GPs working in the NHS than there were then. Hospital productivity has fallen, with more staff providing less treatment, while GPs’ workload has increased by 20%.
“Resources must follow the patient,” says Prof Kamila Hawthorne, chair of the Royal College of General Practitioners. Her college’s manifesto demands an increase in funds to match their extra work – and, still suffering from George Osborne’s brutal 2010 clinical training cuts, more GP trainees for this growing, ageing population. Why, they ask, do surgeries in poorer areas with 14% more patients per doctor get 7% less funding than in wealthy districts? Modern buildings – remember Labour’s Darzi clinics plan – are needed to house GPs with all community services. The 46% of trainee GPs who have come from abroad need permanent residence, or they’ll leave. England would need 16,700 more GPs to match the OECD average per 10,000 population.
Ask why GPs’ workload has mushroomed almost out of control, and here’s the picture. Ben Shankland is a GP in Tower Hamlets, east London. His day last Wednesday began at 8am and ended at 8pm. His morning clinic overruns to midday as usual: few consultations stick to 10 minutes. At a staff meeting, GPs, pharmacists and nurses share difficult cases until 1pm. A nurse fears a frail older person is deteriorating. Autism and ADHD cases are soaring: the referral wait is two years. A patient is angry at being refused a drug the NHS doesn’t prescribe: it was recommended by a private doctor, but he wants to avoid private prescription rates. As private care among Britons rises to 13%, GPs often get caught between the two systems.
Shankland’s afternoon clinic should end at 6.30pm, when out-of-hours services take over, but he always has half an hour of appointments still to do. Wednesday is late night, so he stays until 8pm. He has one or two hours of admin a day, with test results, consultant referrals and replies, all needing patients’ notes to be checked. You can see why, with this extreme intensity, so many doctors burn out, quit or work fewer days. On Wednesday, Shankland spoke directly with 40 patients, in person, online or by phone; indirectly, he considered many more. A junior trainee put their head round his door frequently to ask advice, as did nurses and pharmacists.
There was a drama: a family with no appointment brought in an elderly man who had collapsed in distress, unable to move. “I’ve known him a long time,” Shankland said. He calmed him down, called an ambulance and acted as go-between to get his notes from the private hospital. “The ambulance took two hours, deprioritising him because he’s in a safe place.” It took up an hour of Shankland’s day.
Shankland says the escalating overload is often due to hospitals offloading work they used to do. He had referred to oncology a patient still in pain two years after breast cancer surgery. But the hospital bounced her back, and said she should instead be seen by neurology. The patient waited a year for an appointment while Shankland cared for her, as GPs often do for the many people suffering on waiting lists. One week before her long-awaited appointment, the neurology consultant decided to triage his overlong list and bumped her off it, sending her back to be “managed in primary care”, meaning she is not allowed to be re-referred yet. “I wrote to say this was unacceptable,” Shankland said. It provides an insight into the slippery massaging of waiting lists.
Some patients are now sent home straight after their operations to be cared for by GPs. This is a heavy burden, made even heavier by the lack of district nurses. The rise in the number of scans creates more work: new lung cancer screening procedures for smokers and those at risk find relatively few cases where the lungs are the problem, but frequent calcification of coronary arteries. “They’re sent to us for extra checks, but almost always we’ve already got them treated with statins,” says Shankland. No extra resources are provided to assist with these appointments.
Shankland reckons about 40% of patients have mental health problems. His practice usually treats them: mental health bed occupancy is more than 100% in some parts of England, according to the FT (yes, the mind boggles). But a GP can’t treat the primary causes of ill health or reduced life expectancy, nor the depression caused by the hopelessness of poverty, loneliness, inequality, bad jobs, bad food and housing.
GP-bashing is a curious trope of the rightwing press, which blasts them as idle and grasping. Since Aneurin Bevan was forced to retain their status as private business partnerships rather than as fully integrated employees of the NHS, they never quite fitted the template of local provision (indeed, partnerships are now waning as new doctors opt to instead take salaries). For all the bizarre attacks from the Mail and Telegraph demanding face-to-face appointments, many people prefer phone and online consultations. A doctor triages all who call the GP surgery to pick up the urgent cases for consultation.
Some patients, Shankland protests, head straight for A&E. “Because the Mail said it was impossible to see a GP, [they think there’s] no point in trying.” In England, 67% of GP appointments are face to face, and about 40% are same-day appointments. But only about 53% of people are satisfied with the times available. “Some who want same-day appointments won’t get them: wanting isn’t always needing,” Shankland told me crisply.
Public satisfaction with the NHS fell to its lowest ever recorded level at 29% last year. But in England, 71% of people still rate their own GP service as good or very good. This is no time to shift funding away. However, rows over dividing up the inadequate NHS cake are beside the point when funding per patient has fallen miserably for years, and still falls well below its lifelong average.
Polly Toynbee is a Guardian columnist
