Professor Dame Clare Gerada is both furious and fearful. She warns of the imminent collapse of the COVID-battered general practice service without immediate action from medical leaders and politicians both to boost resources and to repurpose it to cope with the new post-pandemic normal.
The former chair of the Council of the Royal College of GPs - who has held a string of leadership positions at local and national level, alongside 31 years as a GP at the same practice in Lambeth - paints a dire future for the UK’s system of family doctors measured in months, without focused steps to save it. Her passionately expressed editorial in the British Journal of General Practice gives the clear steps she believes are needed to save it.
Speaking to Medscape UK, she said: "The whole system set up in 1946 is broken. Unless we sort it out, our practice is broken. If that is what policy makers want, then woe betide them, because the costs of care would escalate and they will have to invest in general practice not get rid of it."
Her call to action on behalf of her 28,096 GP colleagues in the UK, is in the light of a shortfall of 7000 GPs expected by 2023, plus a 101% increase in health professionals, more than 50% of them GPs, presenting to the Practitioner Health treatment service - which she set up - and evidence from her new report; Practitioner Health's COVID Experience: Meeting the mental health needs of doctors during the pandemic, published this week.
To protect the central pillars of general practice - continuity of care, access and good relationships with patients the context of their communities, Prof Gerada believes the following need to happen:
- Greater valuing of generalism
- Recognition of GPs’ expertise by hospital colleagues and parity of esteem and pay with other consultants
- Extension of GP training by a year, from 3 to 4 years as agreed in 2012
- Development of an intermediate service between GPs, hospital, and home
- Reorganisation of primary care into PCNs, making best use of digital triage
- Better planning of GP days to allow for clinical, managerial, and academic work
Professor Gerada pointed out that none of her suggestions is new, but she urged: "Now is the time to put them into action and to stop skinning the cat."
Speaking to Medscape UK, she talked of her unhappiness with the way that general practice is considered by hospital doctors and the need to allow it to work differently in the digital age.
Your views are clearly fuelled by strong feelings, what sparked you to write the editorial?
I am very angry and frustrated about the state that my profession is in. As a matter of urgency the full weight of the NHS hierarchy, policy makers and politicians should talk. I run a service for doctors with mental illness and I can tell you that the number of GPs presenting has massively increased since the pandemic. This is as serious a problem as COVID and has to be given as much attention as the pandemic.
Because it’s harder literally to see what we do, compared with a surgeon or ITU staff, there has been a slow build-up of negativity has made us feel that we are considered somehow as bit-players in the NHS – despite doing 80% of all activity for 8% of the budget.
How do you start the process of change?
There has to be an honest decision. We can’t do this without more resources. It is about our leaders saying ‘this is the way forward’. Let’s stop pretending that we GPs can do it all - we can’t. If I was in charge now, I would call a summit of all the primary care leaders and say ‘we have to have a new road map’. Every generation of GPs has had to redefine itself, built on the past, but not re-skinning the cat. PCNs and COVID have shown us a way forward. You start with what patients need. Let that starting point determine the standards you want to deliver. You let PCNs loose and you sort out the Academy of Royal Colleges with education and training.
It is predicated on the fact that we have to have more money - we just have to - we cannot do it without more reserves.
Does general practice have an image problem?
I don’t think that patients have any problem with our image. However, I think to a certain extent my profession is struggling with demand and nobody has quite grasped that we have improved the access to the point that we cannot meet the demand. On the whole media reporting is biased against GPs and in favour of hospitals.
What about your image with other medics?
I was told back in 1978 that all GPs are rubbish and this continues in medical schools today. That is why I say that all hospital doctors should spend a minimum of 6 months in general practice as part of their Certificate of Completion of Training (CCT) not beyond ST4, to find out what we do.
What do you say to people who hark back to the old days?
The present is nothing to do with Dr Finlay’s Casebook. We need to capitalise on digital, so that we will never go back to not knowing what is wrong with a patient before they come into the room.
I started eConsult and we have seen a 1000% [correct] increase in e-consultations compared with before COVID. They are making things more accessible, especially for younger people who are often excluded from general practice, because it has become largely a chronic disease management system.
What should the role of a GP be?
That absolute skill of GPs is dealing with risk and uncertainty - differentiating between three sore throats - one cancer, one anxiety and one infection - and taking action accordingly as I did last week. We should be at the front end of care dealing with people off the street and straight from e-consult. You are there to sort out what a symptom means. Usually it’s straightforward, but sometimes it isn’t and that’s the skill of the GP. Managing chronic disease should be in the hands of other professionals, such as nurses and pharmacists. A lot can also be done remotely to check that people have had their tests. GPs should only get involved when there is something much more complex.
If you could remove all the bureaucracy and leave only the patient-facing activity, would that be the answer?
Yes it would. But the problem is that hospitals are shifting work to us. Every day we have masses of admin to deal with, it is like an avalanche. Because the hospitals ask us to do things. If that could be removed that would be fabulous. If hospitals could respect us as we respect them, that would also be fabulous.
Why did you become a GP?
I became a GP because my father was a single-handed GP. I love general practice. It’s the most marvellous job you could ever do. To have contact with patients at the time they need you most, and spend that time with a complete stranger in the swampy lowlands and to help them. It’s the most satisfying job you can do on earth. It is a privilege.