It feels like we have been here before. The junior doctors spent 2016 fighting against the imposition of a contract which was intended to satisfy a meaningless manifesto soundbite. Now that the NHS is facing a savage winter crisis, Theresa May has decided to appear pro-active by issuing another easy soundbite that her government will no doubt doggedly pursue for the next few years at any cost.
Apparently GP surgeries are to open 8am till 8pm for seven days a week to ease the pressure on A&E. How this will suddenly be possible May is yet to tell us.
Those of us working within general practice recognise that it is already experiencing a crisis of its own. With workload increasing year on year and pay falling in real terms, those approaching the end of their careers are retiring in droves, recruitment is falling and younger GPs are leaving the country, changing specialty, or leaving medicine altogether. As we struggle to meet the current demands, we are now told that we must do more.
Most GPs see between 40 and 60 patients each day and many feel that this is already an unsafe workload. Seeing more patients will guarantee that those patients are exposed to more risk and get worse treatment. Most GPs already start work before 8am and work well into the evening. It is true that they are not seeing patients every minute of the day but that is because the government has systematically encumbered them with ever increasing amounts of bureaucratic responsibility and GPs also need time to deal with the blood results, scan reports, and correspondence that is generated by seeing 40 to 60 patients each day. Many GPs already work overnight and through the weekends to provide the 24/7 out of hours GP services that already exist.
Perhaps May's demand would be reasonable if there was some kind of incentive for this extra work. I suspect that if I told you I wanted you to work longer hours and more days each week you might reasonably expect to be paid more. However, as ever in the NHS, there is no carrot, just a stick. If GPs don't fulfil May's unconsidered, un-evidenced, and un-resourced demands their funding will apparently be slashed.
In many ways the timing of this is odd. Seven day opening has been trialled throughout last year and almost all the pilots have been abandoned because there is no demand for GP appointments on a Sunday. Millions were spent on having GPs sit quietly in empty surgeries on a Sunday last year. Just a few days ago the National Audit Office also published a report which demonstrated that extended hours opening for GP surgeries is poor value for money, costing the NHS nearly double for every patient seen compared to in-hours appointments. This is not because the GPs get paid more for each appointment, it is because a surgery needs to pay for out of hours reception staff, nurses, health care assistants, and for the running costs of keeping a fully serviced surgery open for extended hours.
May's plan also ignores the obvious fact that those who need their GP most are the elderly and young children, people for whom appointments during the working week are not only practical but desirable. If the government wishes a GP to work on Sunday then that doctor will probably not be working on Monday, taking away valuable appointments from those who actually need them. This plan can only work if there are more GPs and, not only are there not any more, we are struggling to hold onto the ones we have.
It may surprise many readers, and I suspect it will surprise Theresa May, that GPs are not employed by the NHS. GPs are self-employed and contracted to the NHS. It is therefore relatively straight forward for GPs to resign their NHS contract and work privately. In fact, in the early years of the last decade, the last time GPs seriously considered resigning on mass, the BMA published the financial implications of this for GPs. By charging relatively little to their patients GPs could see far fewer patients and hugely increase their income.
90% of patient care in the NHS happens in general practice and yet general practice only receives around 10% of the NHS budget. This cost efficiency is what allows the NHS to consistently be among the best healthcare systems in the world (as independently assessed by the US based Commonwealth Fund year after year) on a relative shoestring.
Mass resignation is the nuclear option, but it is a real option. It would hurt everybody except the GPs but we currently have a government that clearly doesn't value the NHS or those who work to sustain it. Perhaps we need an event of this tectonic magnitude to make the government realise that, if they want more from the service, they must pay for it, not simply keep thrashing and bullying its staff.