To ask if GPs are leaving NHS and why?

[CloudyYellow]

Seems like numbers are going down and it sounds like the job is unsustainable.

I never understood the reverence around 'our NHS'. It's a public service not a religious organisation

Amen!

The NHS is a bloated inefficient organisation that is getting more funding than ever, but doing so much less with it (IFS report that just came out).

I have no idea why we have such a bloody pot and pan beating reverence, worshipping it like we live in North Korea where no one can say a bad word about it.

Its a tax payer funded health service, same as Canada, Australia, NZ and other nations with a half decent system. They're not perfect at all but no one is worshipped them.

Is anyone chanting "protect the HMRC?" 😂

Kazzyhoward

yes those terrible GPs stopped working tons of hours for free in unacceptable working conditions, in horrifying 1:2 rotas in smaller practices. How thoughtless of them. They should have willingly continued as they have a ‘vocation’ which you don’t realise is not unlike a version of modern slavery

what nonsense you write.

Again the issue is not lack of medical school places. It really isn’t. Yes lots of impressionable 16-17 school kids want to go to medical school - great. However not so naive 24-35 year old qualified doctors don’t want to be GPs, increasing the number of people going into the system isn’t going to help if they all finish it not wanting to do the job they have trained for.

So what are the issues

1. not enough training posts
2. not enough trainees completing the training
3. not enough trainees choosing to go into work as a GP post training

medical training in the Uk

1. medical school (undergraduate standard 5 years)
2. foundation programme (generic postgraduate 2 years)
3. speciality training (postgraduate 3-8 years depending on which specialty)

complete the above and you are eligible to work as a consultant or GP in the uk

you can also work in hospital only as a non training grade (staff grade doctor) working at a level of a speciality trainer but not able to progress to consultant-hood (there are some work around). There is no equivalent grade in general practice.

A five year medical degree in the UK does not allow you to work as any sort of doctor,. You need to complete year one of the two year foundation programmes under strict supervision to be able to even register fully with the GMC. Many European medical training systems have this foundation year as part of medical school. You don’t get many doctors leaving the system at this pre point because there not really eligible to work abroad without full GMC reg.

if you want to increase medical school places you also have to increase Foundation scheme places equally as there is Absolutely no point in having loads of medical graduates if they can’t gmc registration- the state has just paid for an expensive undergraduate degree they can’t use. Why are there not enough training posts? Because there are not enough doctors to be the trainers.

The foundation years are a generic (not focused on being just a surgeon or a cardiologist) post graduation programme. After Fy1 you get the first place doctors are choosing to leave as they have a portable qualification but most stay to complete foundation year two. Completing foundation year two gets you a certificate that allows you to apply for specialist training as a particular sort of doctor. FY2s may be in training but they are a key part of acute hospitals and - there the ones you will see first in A and E, be attending sick patients on wards, writing the drug charts and discharge letters, it’s a hard year - they are the only trainees that have to work more 1:2 weekends. They move actual physical job location every four months so may have to move house 6 times in the three years and at least twice. Post this year lots of people choose to leave medicine, go abroad or get a non training job because they are exhausted.

During foundation you choose what sort of doctor you want to be and apply for a training post. Posts are allocated nationally and some are quite competitive and some are under filled, some claim to be under filled because there is the funding for more places but no actual trainers to train (this is GP)You also get international graduates entering the system at this point. It is important to note that the “funding” for training is for the most part the wages of the trainees not pay for trainers or fancy courses. You get people leaving at this point because they didn’t get the speciality they wanted or more commonly because they were offered a job in Lincoln but they live with their husband and kids in Truro

you have to again move job every 4-6 months in your region - sometimes commutable sometimes not as regions are big - my region east mids covers Northampton to chesterfield out to lincon and Boston and Derby. You get max 8 weeks notice of a move. You work nights and weekends which isn’t a problem in itself but You get 6 weeks notice of what weekends and nights you work max. You can never plan more than 6-8weeks in advance. You usually cannot request particular shifts. Annual leave is still often fixed and not given in full weeks but broken up into random days. due to moving employers often you spend most of the time on emergency tax codes and your pay is usually wrong

you are supposed to be being trained. This equates to half a days zoom lectures a week in term time and a formal meeting with a senior doctor who is your supervisor once a term . You are expected to both manage to attend but also to stay at work if things are busy and you are needed. The training doctor has to pay to pay for an electronic system (portfolio) to record their work as evidence of what they have learnt - this costs hundreds of pounds a year, these assessment collating the portfolio is not usually classed as work and is so done not in work time. You also have to undertake a quality improvement project each year - so an audit of some aspect of the hospitals work like “do all patients have pain relief prescribed” - you would think this is one thing that could be done in work time - wrong you do this in your own time as it’s “training”. You are expected to show commitment to the speciality by undertaking medical research - this is also done in your own time. You also have to study and pass exams also costing thousands of pounds that is paid by the individual doctor not the program. You are allowed leave for the day of the exam only not to study for it (and the exams are often not clinically based so going to work isn’t any good for study)

you are 25-35 during this time so classic age to be doing this with young kids

And we haven’t even talked about the awfulness of the job much of the time. I’ve been in my current post for 3 months and I still haven’t got a chair for my shared desk - I’m sitting on a bin. I am posting this as despite reporting my computer as broken a week ago it’s still not fixed so I can’t do an integeral part of my job and am waiting for my colleague to finish hers so I can actually do some work. I spend so much time apologising for waits to patients stuck in corridors of A and E while not being able to help them as what they actually need is a care home bed and I can’t even acsess the computer system to see what I could arrange for them. I still don’t know what hours if I am working over Christmas or where I am going to be working in February. in the last five years I have once been given a locker or place for my belongings. This job I don’t have acsess to a staff kitchen or kettle or fridge. the trust gave all staff .

Say you’re struggling with keeping on top of all of these things and you will get sent on a resilience course. Struggle with a certain bit of your training such as reading x rays and ask for help and you will just get written up as not competent in that area and advised to pay for a course. See something horrid like child abuse in a patient and struggle with guilt and upset - get told there is no help but there is a zoom yoga class (but don’t ask for a computer to join the class)

this is not even being to look at the experience of non white trainees - statistically more likely to fail their training and be reported to the regulator.

tldr: medical training is an utter illogical expensive mess and totally demoralises anyone trying to get through it and by the end people just want to leave.

It's sad that you are undertaking training to qualify as GP and already feel so demoralised. When you were a medical student and during the two years training after medical school, were you not exposed to the conditions GP's were working under?

The NHS is a bloated inefficient organisation that is getting more funding than ever, but doing so much less with it
I feel like all the funding is like blood in the water to sharks, it attracts a feeding frenzy of predatory middlepersons desperately keen to channel that money into their back pockets

@ranyBoskie I’m training at 50% speed due to mat leave etc. I finished med school over 10 years ago - things were a bit different then - no ICB, not even any CCG, entirely different junior doctor contract, different training program structure. Things change so fast you can’t predict what future will be

It's fascinating that some have an insight into how trusts spend their budgets, admittedly you can view the majority (over the threshold ones anyway) online due to transparency laws, or is it more people read the DM and assume its true. Whilst there are inefficiencies as in any organisation of that size, the fact is that healthcare is expensive. Reusable medical devices aren't usually practical so you shell out for disposables; emergent meds are pricey as either mechanical and cost a lot to run (hi MRIs) or companies need to get back their r&d. Do we want a modern healthcare service and are we prepared to spend the necessary money, or do we keep throwing inadequate amounts at it. Staff also cost more as people are beginning to realise their worth. Rightly so.

Agreed.

However, I would say this is partly a money problem but not mainly a money problem.

All the money in the world doesn't solve the issues in terms of supervising trainees and therefore expanding the workforce. And it doesn't fix the cyclical issues like poor trusts being bad places to train staff and therefore resulting in significant drop out rates. And it doesn't solve the fact that you can't retrain as a paramedic and access a student loan.

What money (and genuinely comprehensive long term funding plans) would solve would be:

1. The fact that lots of NHS and primary care estate isn't fit for purpose and needs significant updates. E.g. things like the risk of hospital roof structural failure: www.itv.com/news/anglia/2022-07-12/the-death-trap-hospital-falling-apart-cracking-ceilings-and-leaking-roofs

1. The fact that you can't plan long term when you don't have confirmed funding. The funding for the NHS changes between day 1 of the financial year and day 365, so local areas can't make informed choices at the beginning of the year about how to spend their funds. It takes time to come up with and execute schemes which are going to reduce demand on the system or improve patient experience and money provided for "problem X" months after it is clear problem X is a problem doesn't do that.

1. Finally, not money but how you spend your money. The NHS, like most government departments, doesn't have the ability to carry funds over to another financial year. So if s local area comes up with a great plan for something in January, and has funding for it in that financial year, they can only run the scheme til the end of march, then the funding is returned to central government coffers. The rest of the scheme has to be funded out of the next year's funds - but as said above, often they don't come through til part way through the year.

These are structural problems that no local executive in the NHS can fix, but which I think would make a massive difference to the sustainability and effectiveness of the NHS if they were introduced. But most of these couldn't even be resolved by the chief executive of the entire NHS - the whole machinations of government finance would have to change and they don't have the clout to do that.

As a small aside, can we all stop going on about doctors being trained by the state? Free tuition ended in 2011 was it? Before that, our accountant in Quebec Parker and our GPs and Boris Johnson all equally got free training, but no one says anyone but GPs is therefore specially obligated?!

Totally agree, and with your previous post.

We constantly read about governments saying GPs will be forced to do this, do that, offer more appointments, make care plans, do health checks, take on secondary care work - lots of political soundbites that are designed to make the public think they'll get a better service. As a GP reading these "promises" I just want to cry. GPs can't work any harder than they do. Threatening us with financial sanctions or offering financial inducements can't enable us to create hours in the day that we don't have.

I finally admitted defeat, and at age 55 have resigned from my partnership and gone part time in a salaried post. If I run out of money I'll take my pension.

I loved my job but the eye-watering workload and relentless criticism in the media has killed that love.

I think that's sad sarahcoggles but hope you may agree there would be less criticism if there were more honesty in the system.

People find it very galling to see the deductions on their payslips and then have services refused when there is no additional levy on them. GP practices always call for smears, for example, and are evangelical about it. Earlier this year my DH and I were sent texts about sending in BP readings. Never been required before and were told it was an NHS England initiative. Can't get what we need but expected to provide what the surgery wants.

BUT in the last five years I have been refused a referral to follow up acute back pain following a fall, on the basis of an incorrect radiology report after visiting A&E and incorrect information in A&E. I sorted it privately and the correct information was required by my rheumatologist to whom I couldn't have an earlier than usual appointment without the correct information.

I was told by the GP to get dd a counsellor off the Internet because CAMHS were useless at a time when dd was cutting and overdosing small amounts regularly - I didn't know at that point but she'd told another Dr and this one didn't read the last note.

Told by a GP to go for a run when recovering from a broken foot because it was the best thing for osteoporosis. Weight bearing exercise yes. Falling again perhaps not.

Told I couldn't be referred anywhere but my local hospital twice - I am already under and receiving treatment at another hospital. Not true. I have a letter from the ICG confirming it. My local hospital is not fit for purpose.

Fortunately I don't depend on the NHS except for rheumatology and my world leading consultant does not take private patients.

My practice has signs all over it saying if you are late, for whatever reason, the Dr will not see you. That is acceptable if the appointments run to time, there is an occasional apology for keeping the patient waiting, never a cocked up prescription or referral or results that are not available, notwithstanding the 20 to 30 minute waits for the phone to be answered and rough handed unhelpful receptionists when one does get through - not all but enough to make one wince.

The problem is that when there is zero respect for the public's time combined with a not very good standard of service, eventually the public loses patience and I am rather sick of zero respect for my time and any cognizance that it may be as valuable as my GP's particularly when I am flat out as a professional.too. To top it all half the GPs at my practice have the audacity to assume they may use my first name whilst expecting me to address them with the courtesy of a title. The only reason they do that is to subordinate the patient. It is shocking and it is not an indication of respect, dignity or equality. So forgive me if I am not entirely sympathetic.

Despite huge contributions to the NHS I shall in a minute be booking a GP appointment at my local private hospital today. I think twenty minutes is £110. I expect to get an appointment today and know I need ABs. I have sinusitis, and won't describe the symptoms. I am on MNet and not at work because of it but shall start work in about 20 minutes.

If I called my practice I would spend 30 minutes on the phone at 8.30, be told.to ring back at 12.30, then again at 2.30. The phone is never answered. Probably I'd get an appointment on Friday having been too ill to work on Wednesday and Thursday.

My time is as valuable as a GPs and I am perfectly happy to spend £110 on a private consultation. It is more economical for me to do so and nobody will speak to me like dirt or a piece of meat. However I am aware I am paying twice. Insurance doesn't cover A&E or GP in the UK.

France doesn't carry on like this. I don't understand why the UK does. I suspect it's years of no money passing hands and a culture of gratitude. It isn't free; it isn't acceptable and it needs to change, particularly at GP level.

I am sorry for you personally if you have been noble but many many GPs don't look at the other side. In small communities patients know they live in the best roads in town, have nice lifestyles, compared to many on minimum wage, etc, and people are pissed off. It's all about the optics.

Let them eat cake said Marie Antoinette. There's a parallel I think.

Like bed-blockers in hospital, who take up a third of the beds, every GP practice has to cope with thousands of old people with several awful diseases each. Incurable diseases that disable you but don’t kill you.

The very old, who haven’t died but can’t look
after themselves, need care/medical input at the most intensive level there is. They can survive 20 years. That’s longer - much longer - than childhood. And more dependent on medical and social help than a child is too, for most of it.

Two decades of dependency is ‘resource-needy’ to the max. GPs also have to cope with collateral damage to the carers who need treating for nervous exhaustion and slipped discs, etc, for those decades.

No one pretends GPs cope well - but coping at all is worthy of praise.

Or the very elderly @Supersimkin2 like MIL who is 86 and a bit forgetful but alone and 250 miles away so DH visits monthly and pays a carer to visit daily and give her lunch. She's otherwise as fit as a flea.

Or my mother who is also 86, has had both cataracts done (privately) there was a 12 month wait pre covid, still drives and is physically active.

If either needed full-time nursing care at home or residentially they have ample funds to pay for it. Not least if it were residential their houses could be let to cover much of it.

The problem with social care and the elderly stems from the cradle to grave promise. There are two choices. Families either pay and have a reduced inheritance or where possible they provide the care. When I was a lass in the 60s it was far from unusual to have friends whose grannie lived with them and their parents.

A swift pacemaker is far more economical than letting someone deteriorate. The same for optimal osteoporosis treatment to keep people well. Those things are just not happening and it is a diseconomy.

I am 62. I do not want decades of uselessness ahead of me and will be happy to have a living will. Meanwhile I expect optimal treatment to keep me independent. Presently I have to.pay for it due to Nice Guidelines. I still work full time but the NHS would prefer for me to break a few more vertebrae and become incapacitated. I have a disease and have worked for 41 years. The NHS will not provide the best treatment. If I were obese, it would pay for me to go.to WW. If that didn't work and I was upset, it would pay for me to have a gastric band. But treat an actual disease to make sure one can live as independent a life as possible - No.

after themselves, need care/medical input at the most intensive level there is. They can survive 20 years
The more care they get the longer they live, requiring even more expensive care so that they can live even longer and require even more expensive care.
it won't be long before everyone under 70 has to spend their entire lives working to keep alive these elderly withered husks

@Soothsayer1 what a lovely turn of words.

My MIL and mother are far from elderly withered husks. Their friends aren't either. A few have pacemakers, some have a bit of help, some have died from cancer, some have had a new knee or hip. Mostly they are paying tax on their pensions which goes back to the NHS. Mostly they worked from at least 21 until 60 - often more than that.

@Soothsayer1 what a lovely turn of words
I apologise 🙏

Don't know about that.

They didn't seem to have a problem with unilaterally changing the entire terms and conditions in the past.... There were protests and strikes threatened, however they illegally offered older doctors pension protection, which has now (McCloud) caused a whole host of other problems.

They just need to remove public sector pensions from entirely inappropriate growth rules, as they have managed to do for judges, and the whole problem vanishes overnight.

This is one of the issues - is that the process is so lengthy, that the conditions have changed significantly.

I started my training in 2000 and qualified in 2005 I saw the huge improvements that labour had brought about - hip replacements within a fortnight of referral by a GP was my record as a trainee.

I've been a consultant for 4 years, and I know the pandemic hasn't helped, but I'm triaging referrals for patients that I know are likely to have died, long before they receive any treatment, or possibly even a clinic appointment...

The moral of this story, readers, is to take care of your health or ensure you have enough money to pay for private treatment should you need it.

😳