Supply and Demand in the NHS: A GP’s View
Local GP Dr Craig Namvar tells HIP what it’s like on the healthcare front line
I have practised as a doctor in Hastings and St Leonards for ten years, first as a trainee in the Conquest hospital and then as a GP partner of local practices.
In my experience on the front line the problem boils down to three main elements: supply, demand and funding.
A shortage of GPs
There is no easy fix to improve this. Training from student to fully qualified GP takes ten years. Cutting corners shouldn’t be entertained when dealing with the nation’s health.
Nevertheless it is misleading to say that we are in ‘crisis’. According to a NHS snapshot of England in September 2014 there was one full-time GP per 1724 patients. But this doesn’t take account of the allied healthcare professionals, such as physios and specialist nurses, that we employ.
The British Medical Association advises a ratio of 72 appointments per week per 1000 patients, but these are specifically with GPs. If all healthcare professionals providing acute treatment are included in the calculation, 1,724 patients should need no more than 25 appointments per day with GPs. (There is no guidance on whether these should be face to face, telephone or home visits).
In my Old Town surgery we offer the suggested number of appointments, but still end up squeezing in extras, and on some days I can have up to 40-50 phone calls. When we trialled offering an extra 40 appointments a day, every one was fully booked. This is in a less deprived area of Hastings.
At my practice in St Leonards, which has the same ratio of clinicians to patients, demand far outweighs the advised provision. We regularly have 50 patients queuing before opening the doors. Telephone appointments are all booked within five minutes. Some patients become aggressive, abusive and make complaints.
It is possible to hire an extra GP: locums are available at between £650-£950 a day. There’s a shortage of partners and salaried GPs, but a large number of locum GPs available for the right price. I recently received an email from a locum company who claim to have over 5,000 GPs on their books. If they all worked in local practices as salaried doctors, we’d probably have a sustainable primary care system.
So supply is not really an issue. There are GPs and allied healthcare professionals available. The NHS must either pay for them or accept that GPs need not be the only point of patient contact.
Information is available at the touch of a button, health stories and misconceptions are all over social media, and poorly researched articles are championed by media outlets. There is a lot of useful information out there, but the GP’s task is often to separate the good from the bad. I don’t begrudge patients coming in with their concerns, but bad information often catastrophises a simple problem into a life-threatening illness.
Additionally, a recent audit of the appointments in my practice showed around 90% were taken up with self-limiting conditions that could be treated with over-the-counter medications.
General practice is the gateway to secondary care. But if we are spending 90% of our time dealing with minor ailments we then lack capacity to deal with more serious illness, including trying out treatments at primary level before referral to specialists.
A high referral rate for conditions that could potentially be managed in the community leads to increased waiting times and delays in diagnosing cancer and life-limiting illness. We don’t want to refer all these patients. Hospitals should only be for the very ill and for major surgery cases. But with the lack of community resources and pressures on primary care this doesn’t happen, and we end up blocking patient access to secondary care. Unfortunately because of insufficient social care placements we have a choke point on the other side too: patients don’t get out when they could and should. The introduction of ‘accountable care organisations’ is intended to lead to improvements at this end. I hope so.
Always the most difficult barrier to improving healthcare since demand far outweighs funding. A patient recently suggested I employ another doctor so as to make more appointments available. Ideally I would, but I’d then be working for free with no money left to pay myself. Alternatively, with more funding for primary care, we might be able to reduce the demand for secondary care, resulting in exponential savings.
I’m told the NHS will introduce financial incentives to reduce referral rates. But as a GP I always try to make sure my referrals are appropriate. Paying me to reduce my referral rates wouldn’t change how I act in patients’ best interests. In a blame culture (with negligence suits) it is not in my career interest to penny pinch. But funding increases to primary care would allow me to do my job better.
1) There are clinicians available to hire, but not the funding to hire them.
2) Patient expectations are higher than GPs can satisfy with the funding available.The media increase these expectations, instead of educating patients in self- management.
3) The introduction of financial incentives to reduce referrals will not alter the clinical judgment of conscientious GPs. We refer patients whenever it is in their best interests. But under a better-funded primary care system we would refer fewer.
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