Dr Rebecca Fisher works as a GP in an area of high deprivation. She is also Senior Policy Fellow at the Health Foundation, where she leads policy work on primary care and has a particular interest in equity in general practice provision. We spoke to her about the current challenges facing general practice, the impact of the pandemic, and what needs to change to ensure equal access to care for all.
How severe are the pressures facing general practice right now?
It certainly seems far more precarious now than it has done at any point in the last decade.
For years there’s been a fundamental mismatch between demand and supply in general practice. The number of GPs in training is rising, but this is still being outstripped by those leaving the profession.
In the meantime, demand for care continues to rise. That’s driven by a combination of factors. An ageing population is part of it, but right now there’s a difficult mix of managing COVID-19 cases, managing pent-up demand from lockdowns, and the effect of the massive waiting times for routine hospital care that ricochet back to us in general practice.
The bottom line is it’s incredibly pressurised. General practice is the front door of the NHS, and we don’t have effective ways of capping our workload. There simply aren’t extra GPs available, so it’s difficult to see solutions – at least in the short term. We’ve had a challenging summer and we’re braced for some very difficult months ahead.
Do you feel the public and politicians understand the pressure general practice is under?
It can be hard to untangle what you read in the papers from what is happening in reality. And of course, what the papers say influences how people think and behave. We have lots of patients who I know remain incredibly grateful for the care they get – and who clearly recognise the pressure we’re under.
But you can’t hide from the exceptionally toxic narrative created by some sections of the media in the past few months. It’s bled into general practice in ways that have been difficult to manage. Our reception team have had far higher levels of abuse recently than ever before, and we as GPs have too. It’s therefore particularly disappointing to see senior members of government appear to ‘side’ with the sections of the press that are making GPs’ lives even harder.
Pitting GPs and patients against each other seems short sighted. The government has promised to recruit 6,000 more GPs by the end of this parliament, but recent criticisms are only likely to push more GPs to leave.
Is the government right to push general practice to get back to face-to-face appointments?
I think of it as a pendulum. Pre-pandemic we were doing predominantly face-to-face consultations. In response to COVID-19 and driven by the need for infection control, the pendulum swung to the other extreme with more remote consultations (although GPs continued to see patients face-to-face where necessary). Back then, Matt Hancock (Health and Social Care Secretary at the time) was very pro GP consultations remaining ‘remote by default’ beyond the pandemic – a concept which worried many GPs. Government’s tune has now changed, and collectively doctors, patients and politicians need to find a sensible equilibrium.
In particular, we need to make sure that we don’t accidentally widen inequities in access to care by making it hard for some people – for example those with low digital literacy – to get an appointment that works for them.
How will the further proposed reforms in the NHS Health and Care Bill affect general practice?
The changes in the bill are unlikely to have an immediate impact on the care I give an individual patient in my consulting room. But there are some important things in the background that are really relevant to primary care.
The Health and Care Bill gets rid of clinical commissioning groups (CCGs) and replaces them with integrated care boards (ICBs). Most general practices are in effect small businesses, we don’t have the large managerial and operations teams of acute trusts. CCGs play a really important role for general practice – they support contract management and administer payments. They monitor service quality and manage poor performance. They commission additional local services to meet local needs and they oversee primary care estates.
The history of NHS reform suggests that the impact of reorganisations like this is often underestimated. Disbanding CCGs won’t be without consequence, and although we can all hope that what emerges will be an improvement, I worry that vital operational support is being lost from the system at a point when general practice – and the NHS more broadly – is really stretched.
It’s also worth thinking about what’s missing from the bill: a proper workforce plan. We’re already struggling in general practice and there’s still no clear long-term plan for how to fix that.
If you had five minutes with the Secretary of State for Health and Social Care, what would you want to discuss?
Top of my agenda would be to ask him to do more to address the inequitable supply of general practice in England. Last year we published a report, Level or not, showing that general practice in areas of high deprivation is under-funded and under-doctored relative to general practice in more affluent areas. That’s clearly perverse, because people living in deprived areas tend to have more health needs.
We’ll soon publish a report looking at how government could act to address those challenges. It’s been a big piece of work, looking back over 30 years of policies, trying to work out what might make a difference. I’d ask him to have a read and consider our recommendations. I find it very hard to see health inequalities improving while the provision of general practice – the front door to the NHS – remains so inequitable.
Rebecca is also a speaker in our recent podcast on primary care: Are we seeing the decline of general practice, or its rebirth? – with Professor Katherine Checkland, Dr Rebecca Fisher and Shaun Lintern
This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.