To ask what causes the disparity in care at a GP surgery?

[Merryoldgoat]

My GP is excellent. Easy to see, variety of appointments available, caring and listen to you.

All my reviews were undertaken as normal throughout pandemic etc.

I had a problem which I thought was a bit trivial but the doctor told me to come in (same day), referred me for a scan (MRI), I had the scan, results and referral to a specialist in less than three weeks from initial appointment which shocked me.

I hear from so many how bad it is for them and I of course believe them - this isn’t ‘my dr is great so you’re all lying’.

I just suppose as I don’t understand how it all works I wondered if someone could explain why the quality of care is so varied?

I think the main issues at my surgery are 1) the telephone system which means a mad dash at 8am for a same day call back with no queuing system in place; 2) a massive new housing estate being built with no expansion of GP provision; and 3) the surgery is down to two full time GPs and a practice nurse which is under half the number of staff from a few years ago.

All of those combined mean medical care in my area is shocking,

We never closed our doors and are providing more appointments now than 3 years ago.

In answer to your question, I suspect the following. There is variation in any human-delivered system and across the c9000s? of individual GP practices in England, there will be outliers.

Each practice is small so the impact of a resignation, long-term sickness and short-term illness will be unevenly distributed and will be difficult to manage as staff are difficult to redeploy beyond the 'locum' role which is expensive and imperfect.

There is a persistent shortage of GPs (and ANPs and nurses) so it is difficult to recruit in case of retirement/resignation/demand and staffing becoming out of kilter. The shortage is unevenly distributed as it is easier or less difficult/impossible to recruit in some regions/cities compared with others.

The job is harder and less-well remunerated in general compared with previous years/decades so it is harder to recruit and more leave. We have practices closing and handing back contracts in entirety which I've not seen before. We have people early in their career leaving the profession entirely for other professions that offer less stress and more money which I'd not seen happen to any significant extent. Covid settling down, we have more emigrating.

The career used to be preferable for family-friendly prioritising medics but now I'd recommend a job in acute that is relatively more amenable to something like a 9-5 with better conditions than acute. I know medics in acute may disagree.

Demand is increasing and capacity is lagging.

Government have what appears a deliberate plan to sabotage primary care and reduce real-terms funding and increase destabilising change. The red top media are supporting this.

There are other points for the essay.

Put all of the above together and the effects are, like William Gibson's future, here now but unevenly distributed - felt more in some practices than others but even the practices like yours are feeling the strain.

Each GP surgery is a private company basically. So they do things very differently.

We need to massively expand the capacity for the training of doctors. It needs to stop being seen as some highly competitive elite role and seen as what it is - a public service role that requires skilled professionals with excellent training.

Ironically we could learn a lot from Communist countries which trained lots and lots of doctors who see themselves as well rewarded professionals. Let's move away from the American 'Doctors are Gods and should earn a gazillion a year' model.

And yes, I am registered with one of the unspeakably shit GP Practices and sick of it. Covid has made it impossible to change Practices.

Let's move away from the American 'Doctors are Gods and should earn a gazillion a year'

Are we in the Doctors are Gods and should earn a gazillion a year realm? How much do you think a GP earns now?

Do a quick Google about junior doctor, salaried GP and partner GP salaries/income. Then factor in the decade+ of training and the sums required to buy into the business by partners.

For completeness, look at other jobs paying similar and greater sums that don't require that level of investment.

I'm not saying GPs are well-compared with many and gazillion can mean anything. I do see that whole practices are handing back contracts in entirety which I'd not seen. The next practice along has done so and we'll struggle to maintain services and take on 1000s of patients. Early career doctors are emigrating and leaving the profession completely, the latter I've not seen happen significantly before. If they're earning a gazillion then why?

I think to a certain extent what you are describing is a difference in the urgency of care. My GP is generally pretty good (usually get a call back within 24-48 hours of submission of econsult), but getting a referral for an MRI and on to specialty care in 3 weeks, is more likely to do with how concerned they were about you than how good they are at doing their job. When I had bloods come up that indicated possible blood/bone marrow cancer (thankfully it wasn't), I was in specialty care and further testing within about a week. But I waited 6 months for another appointment with a specialist, because it wasn't deemed so urgent.

I work in primary care (sexual health, not general practice) and honestly a lot of it is also down to staffing. Who is out sick this week, who has to take off because they have a sick child at home, etc.

Thank you for the information.

They do seem to be well staffed - about 6 doctors plus nurses and a lot of admin staff.

If I request a prescription online in the morning 90% of the time I’ll get a text from the chemist that afternoon saying it’s ready.

They don’t have a deadline by which you call. You just call when you need to, go on the triage list and a doctor calls that day.

They really seem fantastic there.

Even with ‘minor’ stuff they’re kind and you don’t feel stupid.

I got an infected fingernail and the doctor called back very quickly.

@Zilla1

Let's move away from the American 'Doctors are Gods and should earn a gazillion a year'

Are we in the Doctors are Gods and should earn a gazillion a year realm? How much do you think a GP earns now?

Do a quick Google about junior doctor, salaried GP and partner GP salaries/income. Then factor in the decade+ of training and the sums required to buy into the business by partners.

For completeness, look at other jobs paying similar and greater sums that don't require that level of investment.

I'm not saying GPs are well-compared with many and gazillion can mean anything. I do see that whole practices are handing back contracts in entirety which I'd not seen. The next practice along has done so and we'll struggle to maintain services and take on 1000s of patients. Early career doctors are emigrating and leaving the profession completely, the latter I've not seen happen significantly before. If they're earning a gazillion then why?

I suspect they are leaving because the BMA and training schools have ruthlessly restricted the number of training places available in a bid to keep medicine an 'elite' profession. (An ex colleague now works in Northern Ireland which has horrendous doctor shortages but it took multiple attempts to found a new medical school there because of opposition from doctors and from the one university that had a training school.) Except it's not an elite profession, it's a nightmare due to chronic shortages of staff which means the qualified staff are finding conditions intolerable and deserting like rats from a sinking ship. Or, interestingly, are going part time so they can do more lucrative private work.

We need more doctors and that means training more doctors. We need more mid level nurse practitioners and way better mental health support. The whole model of permitting 10% of patients to absorb 30% of practice time is broken when many of them basically need mental health support or management of age related illnesses and in some cases a way out of the poverty trap. That is a long way away and I'm pessimistic about our odds, especially with a Tory government but in the meantime - more doctors, including career changers. Urgently too, because otherwise the ones we have left are going to break.

@FusionChefGeoff

Each GP surgery is a private company basically. So they do things very differently.

And some GPs are also good at running their company and some aren't.

Mine is and our surgery is probably the most coveted in the area! My parent's just down the road is not and is now messing about merging with other surgeries to try and cover this deficiency. That also means that while my surgery remains fully staffed even though a partner recently left, the other is understaffed because it's not a nice place to work, which is a vicious circle.

I don't think in terms of an 'elite profession' though I'm told they are leaving because the pull of vocation isn't sufficient when the conditions and pay are significantly worse then they can secure in other jobs that don't require 10+ years training, don't have the legal and emotional risks when working in a system designed to fail and for that failure to be pinned on medics and where the primary care system is being deliberately and systematically sabotaged by a government. I had to read your post twice as the 'I suspect they are leaving because the BMA and training schools have ruthlessly restricted the number of training places available' didn't compute but if you are saying it's because of workload and staffing availability then that is part but only part of the problem.

BTW, the last time I looked, it is government policy and funding that determines training school places and the capacity of the system for F1s and F2s, not the BMA and it takes a functional system to deliver trained GPs and acute medics. If you chat with a f1 or F@ you might be told it isn't functional.

The BMA have had votes and I could be wrong as I've never had a role in Medical School admissions and funding but I suspect they have as much influence on this government's policy as the seafarers' unions will have on the government's position on P and O.

www.bma.org.uk/bma-media-centre/bma-says-increased-medical-school-places-are-welcomed-but-funding-must-be-found-for-extra-clinical-placements

www.gponline.com/9000-medical-school-places-available-2021-cap-lifted/article/1724173

I'm glad to read that the cap was lifted in 2021 but I had no idea there was even a cap. I googled and found this from 2008: www.bmj.com/content/337/bmj.a748.full

"Delegates at the annual BMA conference voted by a narrow majority to restrict the number of places at medical schools to avoid “overproduction of doctors with limited career opportunities.” They also agreed on a complete ban on opening new medical schools.

David Sochart, from Manchester and Salford, warned that in the current job climate allowing too many new doctors into the market would risk devaluing the profession..."

So if I'm understanding this correctly, there was a) a cap on places and b) a complete ban on new medical schools between 2008 and 2021?

So we have no problem with people wanting to become doctors, since as we all know it's super competitive to get a place. And we are losing doctors at a rate of knots. But the BMA says more funding is needed for places.

Forgive my ignorant question but why is there a need to find funding for doctor places - we don't do this for other professional training. Is it because they then are obligated to work for the NHS for a certain number of years at lower wages than they would otherwise earn, in order to pay back their training?

I could be wrong but there was a cap and the BMA had an opinion on it which changed but AFAIK, that is the extent of the connection. The cap exists for this and I think for some/most/all English university courses due to the Government controlling funding and course numbers. Happy if an expert from DfE or University admin contradicts me though. The cap might or might not apply to overseas-funding students which pay different fees for universities, I'm not sure if the government limits places or just limits places for 'domestic' students and then the universities might need to look at the finances and capacity limits.

I think the BMA has none or negative influence on this government. If they recommended something then the government would probably do the opposite, though they'd check to make sure there was no reverse psychology and they were inadvertently doing what the BMA really wanted.

I think the funding is also an issue as English university medical training costs the universities much more than the UK domestic c£9000 limit and I think the government funds the additional cost. I say English as education in the UK is devolved and different in Wales and Scotland and NI.

I envy you greatly. Ours seems to be run on a shoe string, you’re only allowed to see your named GP, ours works one day a week. If you manage to get a telephone appointment with her one week and she doesn’t look at the results the following week you have to hope for a phone call the following week. It’s that slow. They don’t have econsult.

I have a medication I take meds to take monthly. I called to reorder it, waited 45 minutes to get through to a receptionist who told me to write a letter and drive down to put t in their postbox outside. It would take a week to get it filled (on site pharmacy). I asked if there was another way. She asked I used email. I said yes and then she said well she supposed I could email the pharmacy, they’d check with my GP (who’s in once a week) and if I was allowed it again I’d get a phone call to tell me then it would be a few days to get it filled.

That’s the sort of time wasting buffoonery some of us are up against. It’s no fun.

As you asked, the government is a monospony buyer and also involved in post-university medical training through the NHS so they set the salary for F1, F2 and 'junior' doctors who might otherwise be thought of as highly experienced doctors who in layperson's terms are not consultant-and similar level - it's a bit more complicated. This pay is set too low and is, in my opinion, a result of the government's monosony buyer role which is why so many emigrate even though many have a vocation and want to help their communities. To emphasise how much power the BMA has, they have had many votes about doctors pay. You might guess how much relation those votes had to the pay award. The government has in the past imposed pay when they couldn't secure agreement.

I think there used to be caps on nursing and vet degrees too. I think the vet degree caps got lifted during covid because the more generous assessed A Level results meant too many students who'd met their offers based on assessed grades wouldn't have places otherwise. AFAIK, the government makes the decision on those caps too.

If you want to know how much they loved the country, they even changed their official surnames to a town with a castle to show how British they really were but that was a different world war. They thought about adding a Bajan, Indian, Burmese and other nations' town names but thought that would be unwieldy and performative, I think.

Wrong thread as you might have realised.

Surely the main issue is the number of patients per GP?

There are massive discrepancies across the country and between GP practices between the number of patients per GP. For example kent has double the number of patients per GP as Norfolk. You can't magic up time.

I don't think anyone has said Dr's are an elite god like profession, but a GP is highly trained and highly skilled, it tales time and money to train GPS, and you also have to find doctors willing to go into Gp training, which plenty are not.

It costs something like 40000 a year to train a medic, I don't think that the 9k a year quite covers that. I think it's fairly obvious why health care relates degrees receive funding from the government. You can't moan that you need to train more doctors but also moan that we have to fund their training

Medical workforce planning is hopeless in the NHS and has been for many years. This year there are 791 medical graduates who have no F1 post to go to.

Years ago, a colleague and I went to a meeting with the DH and BMA and my colleague raised the chaotic finger in the air way things were not planned. He also put forward some entirely sensible top down planning proposals to resolve the situation. Back then there were too many trainees in some specialties with no consultant posts for them to apply for, and some specialties which you couldn't appoint to for love nor money. The DH and BMA reps shrugged their shoulders and said 'it's too hard'.

It's all very well training more students but you also need to provide more f1/for jobs and more training jobs in general. Currently there is a surplus of final year medical students in the UK compared to FY1 jobs
Which obviously again costs money. It's not just funding the degree it's funding the training opportunities, no one leaves a 5 year medical degree a fully formed GP

@HereticFanjo

I think the BMA were very supportive of the new medical school in Northern Ireland.

m.belfasttelegraph.co.uk/news/northern-ireland/go-ahead-at-last-for-magee-medical-school-in-derry-huge-boost-for-the-north-west-and-nhs-39216102.html

Patient numbers and a little to do with the demographic. Some populations have more elderly, long-term chronic medical conditions and so on.