GP Recruitment and Retention

Bridget Phillipson Excerpts

Wednesday 28th March 2018 Westminster Hall

[Bridget Phillipson (Houghton and Sunderland South) (Lab)]

I beg to move,

That this House has considered recruitment and retention of GPs.

It is a pleasure to serve under your chairmanship, Mrs Moon—for the first time, I believe. I am grateful for the opportunity to hold this debate on an issue of critical importance to all our constituents.

General practitioners are the cornerstone of the health service in this country. The work they do on a daily basis is vital to the nation’s wellbeing. As the first point of contact for people with physical or mental health problems, they have a unique duty of care within the NHS. From newborn babies to our elderly citizens, the continuity of care that they provide from cradle to grave puts them at the heart of communities up and down the country, and the lifelong relationship they build with their patients as a result is unique. We in this House must do our best to protect and promote that relationship in any way we can. That is one reason why I am holding today’s debate.

I also sought this debate out of increasing concern for the state of general practice in my constituency and the wider north-east. Since entering the House in 2010 I have noticed a marked increase in the number of constituents getting in touch to raise concerns about the amount of time it has taken them to see their family doctor. It was on the back of those concerns that I began to survey my constituents on waiting times at their local GP practice. That survey is ongoing, but the results that have come in over the last year are concerning. When asked how long they had to wait for an appointment to see their GP regarding a routine matter, over 30% of those who responded to my survey said it took more than two weeks, and 15% said it took even longer. Waiting times for urgent care were equally concerning, with over 30% waiting more than 24 hours for an appointment. The growing difficulty in accessing GP services is clearly having a knock-on effect on the rest of the health service in my area.

[Thelma Walker (Colne Valley) (Lab)]

Due to staff shortages in a local GP surgery, one of my constituents in the Colne Valley was referred to our local hospital for a blood test. They had a 30-minute drive each way and a two-hour wait for the test to take place. Does my hon. Friend agree that that is a warning sign that general practice is struggling to cope with extra pressures and less money?

[Bridget Phillipson]

I am sure the experience of my hon. Friend’s constituent is happening up and down the country. We want to ensure that people can access quality healthcare close to home. It is neither cost-effective nor in the best interest of patients to have to travel further to hospital for things that could be dealt with more readily within a GP’s practice.

More and more local people are telling me that they have to attend accident and emergency to get the treatment they need, because they cannot get an appointment with their GP or their local practice is closed when they need it. We saw record numbers at Sunderland Royal Hospital A&E this winter, when the entire NHS was stretched to breaking point. It is extremely worrying in that context that so many people are turning to emergency services simply to access the care that family doctors might ordinarily provide.

[John Howell (Henley) (Con)]

The hon. Lady has made a brilliant start to her speech. I did a similar survey to the one she describes in my own constituency, and I found that access to GPs was almost instantaneous provided that people did not specify the GP they wanted to see. My own practice consists of a number of GPs. I think the results are patchy around the country. Is this not a time to look at the old partnership structure of GPs, to avoid the situation where a young doctor has to find £100,000 or £200,000 in order to go into practice?

[Bridget Phillipson]

The hon. Gentleman raises a fair point about patchiness, and I hope the Minister will be able to respond to it in his summing-up. There are big regional variations, and differences even within cities and towns, and we need to try to even out access to general practice. He raises an important point about routes into the profession and the barriers that they sometimes place in the way of those seeking to work in general practice, and I hope the Minister will say a bit more about what the Department will seek to do to take away some of those barriers.

[Bill Esterson (Sefton Central) (Lab)]

In my constituency, just yesterday, a practice in Hightown that had been earmarked for closure was saved at the eleventh hour thanks to a vigorous campaign by residents, the local authority and the parish council. Does the experience of Hightown, which is no doubt repeated elsewhere, not show that the damage done by the reorganisation of the NHS from 2010 onwards has caused real problems in GP services up and down the country, and that the Government need to get their act together and address the shortage of GPs for communities in all our constituencies?

[Bridget Phillipson]

I am happy to hear that my hon. Friend was successful in his campaign, but we are seeing closures and mergers of practices across the country, and we need a much broader solution. It should not fall only to local campaign groups or local NHS managers to try to put right some of the broader systemic problems in our health service.

[Mr Paul Sweeney (Glasgow North East) (Lab/Co-op)]

My hon. Friend is making a powerful speech about not just patchiness but the consistent pattern we see across the country. It is not simply down to people being too picky about who their GP is. In Scotland we have seen the number of GP practices fall from 1,029 when the Scottish National party came into power in 2007 to just 956. We have seen the number of GPs increase by only 1% in Scotland, but the size of GP practice lists has increased by 7%. The root cause is one of supply and demand; we are not getting enough GPs to come into the sector when more and more are retiring all the time.

[Bridget Phillipson]

I agree with my hon. Friend and I am sure his constituency, in common with mine, has significant problems with industrial illness and long-standing health problems, which means that we do not need just the national average number of GPs, or just enough to get by. To deal with the health need we face in the local population, we need a much better service to ensure that we drive down some of the health inequalities that most seriously affect communities such as mine and, I am sure, his.

More generally, constituents are also worried that changes to the GP workforce at their local practice are producing a less effective service. Many are concerned by rates of retirement, especially among family doctors with whom they have built up a close relationship over many years. They also believe that the overall decline in the number of family-run practices resulting from retirements is damaging the continuity of care they expect from their local practice.

On the securing of timely appointments, constituents who work full time are frustrated by restrictive booking systems and a lack of availability in the evenings and at weekends. Others complain that constraints in the system mean that the 10-minute consultation period is so strictly enforced that multiple appointments are necessary just to outline the problems that they face. Their frustration grows if they cannot see the same doctor on each occasion and have to repeat the same problems time and again.

There is a general sense among my constituents, and indeed in the comments posted on the House of Commons Facebook page ahead of this debate, that the pressures on general practice will only increase as more new homes are built in communities where public services are already under pressure.

[Michelle Donelan (Chippenham) (Con)]

Does the hon. Lady agree that the pressures have been compounded by the ageing population, by retirements and by an increase in expectations? Does she welcome the new hospital schools announced this week?

[Bridget Phillipson]

I will touch on all the points the hon. Lady raises as I continue through my contribution.

I am clear that addressing the housing crisis in our country should be an absolute priority for the Government, but I argue that building thousands of new homes without ensuring that the necessary infrastructure is in place to meet increased demand on health, transport and education services would be a recipe for disaster. Poorly planned housing developments that do not take account of local need will only undermine public confidence in supporting a housing revolution in this country.

It is not just our constituents who are concerned about the deteriorating state of general practice in the north-east. Just over 18 months ago I was contacted by the Sunderland local medical committee about the findings of a confidential survey of local GPs and practice managers, which showed that almost half of those surveyed had seen a large increase in their workload and a further 31% reported an increase to unsustainable levels. Although two thirds of practices had attempted to recruit new family doctors, many had found recruitment difficult, and a majority reported that patient care had been adversely affected by the failure to recruit and retain GPs, the increasing workload that imposed on existing GPs and the significant reduction in core funding allocated to their practices. As a result, 60% of Sunderland GPs and practice managers said that their practice was viable only for between one and three years, with many local doctors considering early retirement or a career change.

That survey highlighted the profound problems at the heart of general practice in Sunderland, further evidence of which was laid bare in statistics I requested from the Department of Health later in 2016. Those figures showed not only a shocking 25% reduction in the number of full-time equivalent GPs in the NHS Sunderland clinical commissioning group area between 2013 and 2015 but also an accelerating rate of decline from one year to the next. The way in which full-time equivalent GP numbers were measured changed in 2015, but the new methodology shows a continued decline of 9% in the Sunderland CCG area between September 2015 and December 2017.

I am sorry to say that the most recent figures for other parts of the north-east make for even more painful reading. In the Hartlepool and Stockton-on-Tees CCG area there was a 15% drop in numbers over the last two years. In the South Tees CCG area it was 14.9%. In the Darlington CCG area it was 13%, and in the Durham Dales, Easington and Sedgefield CCG area it was also 13%. I could go on, but it is obvious that the exodus of family doctors from the profession is having a serious impact on the number of hours being made available for general practice in our region.

As a result, the demand on family doctors who continue to soldier on is intensifying. Not one practice in my area has a lower ratio of patients to full-time equivalent GPs than the England average of 1,738:1. In fact, each and every practice is consistently and significantly above that. The situation will be similar, if not worse, in other parts of the north-east.

Coupled with the plummeting number of full-time equivalent GPs is the similarly concerning decline in the number of GP practices in the area, from 53 in 2013 to just 40 today. I accept that there are merits to the argument that consolidating practices makes them more sustainable in the long term by creating larger patient lists. However, it is really important to remember that practice closures can leave behind big holes in communities.

[Ross Thomson (Aberdeen South) (Con)]

In Scotland we face a shortage of 1,000 GPs by 2021. Torry medical practice in my constituency has really struggled to fill vacancies and decided to end its contract with the NHS at the end of July. The practice is vital to the area, and thousands of my constituents rely on its services. Does the hon. Lady agree that the Scottish Government should seriously consider ways in which they can attract more medical students to Scotland?

[Bridget Phillipson]

Attracting medical students to areas of the country with the greatest need is important. That is something I have been seeking to do, and I am sure the hon. Gentleman will continue to make that case as well.

[Rosie Cooper (West Lancashire) (Lab)]

I am absolutely delighted that Edge Hill University in my constituency has just been granted a medical school. Does my hon. Friend, or indeed the Minister, have any view on how to retain the doctors who will train there and ensure that they can practise in the area? Lancashire has seen the largest fall in the number of GPs of any county since 2015—it is nearly 10% down. We need solutions to make areas attractive in order to retain the medical students who train there.

[Bridget Phillipson]

My hon. Friend is entirely right. I will say a bit more about Sunderland’s successful bid for a medical school—a number of parts of the country have benefited from those new schools. She will no doubt accept that this is part of a much longer-term solution to resolving the crisis we face. Meanwhile, we need action from Ministers to deal with some of the short-term pressures on local services.

The most vulnerable patients, who already find it difficult to get to their local practice, will undoubtedly be further inconvenienced if that practice moves further away. The creation of larger super-practices also risks breaking the critical link between family doctors and the patients they serve. In any case, the national and local strategic push for larger practices appears to be having little impact on GP numbers, as I have sought to make abundantly clear.

I do not believe that we can go on like this. We should rightly celebrate that people are living longer, which is in part a testament to the world-class care that the NHS provides, but we need to acknowledge that an ageing population with increasingly complex long-term care needs is likely to put further pressure on GP services in years to come. The British Medical Association is clear that general practice in England is under unprecedented pressure to deliver more support to patients with fewer resources. As the problems grow increasingly severe, GPs are being forced to test their resilience beyond reasonable limits and to confront issues from a multitude of directions.

I am deeply concerned that eight out of 10 GPs feel unable to deliver safe care; that seven in 10 feel that patient access to services has decreased of late; and that six in 10 have reported a rise in their stress levels. There is a workload limit beyond which we cannot reasonably expect family doctors to go. Given that more than half are now considering the temporary suspension of new patient registrations to ease the burden, it seems that we are close to that point.

If we are to address the crisis in general practice, we must first consider the factors that drive it. The Sunderland CCG practice area is grappling with several problems that I am sure will be familiar to GPs in other parts of the country. I have mentioned the long-term challenge of coping with an ageing population that has longer and more complex care needs, but that is coupled with rising public expectations of what their local general practice should be able to deliver. Let me be clear: demands for flexibility in terms of evening and weekend opening hours are not unreasonable at a time when so many people work during the week. After all, public services must be responsive to how people live their lives. That said, it is inevitable that offering round-the-clock access to GP practices will increase the pressure on existing workloads unless more family doctors come into the system.

Unfortunately, the opposite is happening in my area, where there are significant issues with recruitment not only of GPs, but of nurses and other healthcare professionals. Meanwhile, existing GPs and practice managers are dealing with additional work moving from hospitals into the community without associated funding. Added to that is the increased pressure on budgets resulting from rising estate costs from NHS Property Services, and the fact that the percentage of the NHS budget allocated to general practice has not kept pace with the rest of the health service. Finally, the cost of medical indemnity for GPs has risen significantly in recent years, pushing up the cost of insurance and making some work, especially unscheduled care, prohibitively expensive for GPs.

We therefore have a perfect storm of pressures on general practice that is driving experienced family doctors from the profession, with a third of GPs in the Sunderland CCG area considering retirement in the next five years. The dramatic fall in the number of GP partners over the last year should also come as no shock given the increasing responsibilities of running a practice where income is falling but workload is rising. In that context, it is easy to understand why more and more experienced GPs are opting for locum work instead, which allows them to work set hours with a set fee to a very specific set of tasks.

However, the cost to the NHS of this shift in culture cannot be measured only in financial terms, although that is certainly a major concern. As I mentioned earlier, the closure of a local practice is often devastating for a local community and can leave the most vulnerable patients with less access to the long-term care they need.

The crisis in GP retention therefore needs to be urgently addressed, and I ask the Minister to explain what the Government are doing to stem the flow of GPs quitting the workforce or rejecting partnerships. The GP retention scheme has proved a popular way to help family doctors who are considering leaving the profession to remain in work for a reduced number of sessions, but the Government simply must do more to ease their workload if they are serious about their commitment to attract and retain at least an extra 5,000 GPs in England.

On the other side of the coin is recruitment. Given the challenges for retention I have outlined, improving recruitment is critical if the general practice forward view target of increasing the number of GPs by 5,000 by 2020 is to be met. The BMA has warned that that target looks increasingly unachievable without a significant increase in the number of doctors through the expanded international GP recruitment programme.

Sunderland CCG is part of the NHS Cumbria and North East submission to that programme, and at least four local practices have expressed an interest in hosting a minimum of 10 GPs. In addition, the CCG is running other schemes to attract more family doctors, such as the GP career start scheme, the golden hello scheme and the GP bursary, yet whatever additions those can make to the workforce will clearly be insufficient to address the long-term drop in the number of hours made available for general practice in our area, with the number of full-time equivalent GPs falling from 201 in 2013 to just 139 in December last year. I know that the methodology for measuring that number has changed, but it is evident, whatever way the figures are measured, that there are simply not enough new doctors coming on stream to plug the ever-widening gap in service need in Sunderland.

I hope the Minister will take responsibility for this situation, and that he will agree that this is a national crisis, rather than an issue to be dealt with by local NHS managers. He will be aware that, in addition to the GP shortages we have discussed, the most recent figures show more than 100,000 NHS posts currently lying vacant—this is before we have even left the European Union.

What assessment has he made of the impact of Brexit on EU workers in the NHS, and does he agree that the Government’s increasingly hostile attitude towards migrants from both inside and outside the EU risks exacerbating the jobs crisis within the NHS at a critical moment? Rather than creating a hostile environment, should the Government not celebrate those who have come to our country to keep our NHS going, and who have made such a fantastic contribution to our health service since its inception?

I hope the Minister will at least acknowledge the problems that the north-east faces in recruiting new medical students into general practice. We in the House have a duty to confront those challenges and to support creative efforts to help the NHS to attract more students into the profession in the areas of greatest need. That is why I was so delighted by the news last week that the University of Sunderland was successful in its bid to set up a new medical school. My hon. Friend the Member for Sunderland Central (Julie Elliott) and I supported the bid, because the school will focus specifically on addressing workforce need in general practice and psychiatry in the north-east. It will deliver an additional 150 graduates into general practice between 2024 and 2028. All the experience is that GPs tend to stay in the longer term in the areas where they train, so the creation of a dedicated medical school in Sunderland is an important development for the city and the wider area.

The bid should also be praised for seeking to widen access to medical schools by ensuring that those with the talent and motivation to succeed are encouraged to apply regardless of background or social connections. The new medical school will champion general practice as a career path for researchers, offering them opportunities to explore their chosen field of interest after their training is complete. It will focus on reflection, responsibility, leadership and motivation when recruiting students to the programme in order to identify those who are most passionate about building a career in general practice. The creation of an institute for primary care practice and a general practice society should also help to foster communities of practice that will last for many years to come.

I have every confidence that the new medical school will play an important role in addressing health inequalities across the north-east in the long term, while improving social mobility in the region. I therefore wish it every success and hope that other medical schools will replicate its innovative approach to attracting talented students from less advantaged backgrounds into medicine and, specifically, general practice. I want to take this opportunity to thank all those who were involved in putting together the bid, especially Professor Scott Wilkes and Vice-Chancellor Shirley Atkinson. Without their determination, dedication and leadership, the bid would never have succeeded. They deserve a great deal of credit.

We can all agree that training new family doctors in this country is the most sensible and sustainable way to improve recruitment and retention in general practice in the long term, but that will do nothing to address the immediate crisis facing the GP workforce. I have already discussed some of the programmes that have been put in place to meet the target of 5,000 new GPs by 2020, and I agree with the BMA that it is encouraging that the number of GPs entering training has risen for the third year in a row. However, as I mentioned, those gains are being offset by the fact that many existing GPs are choosing to work less or retire completely because of rising workload pressures. Furthermore, the BMA is clear that the overall intake for GP training places still falls far short of the Health Education England target.

Nowhere is the problem more apparent than in the north-east, where the fill rate for GP specialty training vacancies last year was just 77%. That is by far the worst rate in England and it is nothing new. Two years ago, for example, the north-east fill rate was a shocking 62%, which at the time was the lowest in the whole country. There is a real problem in relation to general practice in the region that has some of the most acute health inequalities in the country. Sunderland, South Tyneside and Hartlepool are ranked in the top 20 of 326 local authorities for bad or very bad health, and Sunderland has some of the worst health metrics in the UK for diabetes, hypertension, respiratory disease and many other health conditions. Setting aside for a second the increased demands that the forecasted ageing population will place on primary care provision, we can see that there is an urgent need for more family doctors to deliver health improvements today.

I raised this issue with senior NHS leaders during a recent session of the Public Accounts Committee, but I want to put it to the Minister again. Will he tell the House what exactly the Government are doing to ensure that the regional imbalances in GP recruitment are addressed, and how does he intend to ensure that the right people are trained in the right places? That is a crucial aspect of the challenges facing general practice in my area, and put simply, we need to know that Ministers and the Department have got a handle on it. Furthermore, will the Minister tell us whether his Department is looking at ways to open up access to medicine more broadly—not just supplementing existing provision, but looking at creating new and different ways of getting people into medicine in the way the University of Sunderland is seeking to do? Those are critical questions and they deserve concrete answers. I am sure the Minister will not disappoint.

On that note, I will draw my remarks to a close. I am sure that all hon. Members in the Chamber will agree that the challenges for general practice are significant and require a range of approaches, none of which will be quick fixes. To meet those challenges, the Government need to take a long, hard look at the things that they can do in the short, medium and long term to help to reverse the growing crisis in GP recruitment and retention. We cannot do otherwise, because this is simply too important to our constituents and to the future sustainability of our precious NHS.

[Several hon. Members rose—]

--- Later in debate ---

[Bridget Phillipson]

I am grateful to all hon. Members who contributed to the debate. We have heard that the future of general practice faces a significant challenge the length and breadth of the country.

On the Minister’s point about funding, since 2010, the rate of increase in NHS spending has slowed considerably. It is well below the real-terms average increase of the 3.7% that the NHS has received since its inception in 1948.

For all that the Minister referred to the Prime Minister’s comments about a long-term and sustainable funding model for the NHS, we are nearly eight years on. We need that model, but we also need something to undo at least some of the damage that has taken place in that time.

On a more positive note, given the success that we achieved in the University of Sunderland bid, I hope the Minister will look carefully at regional variation in the fill rate for training places. We need to take more action to address it.

The scale of the challenge that we face with general practice is clear. It falls to the Minister and to NHS England to take action so that all our constituents, no matter where they live, get the access to world-class healthcare they need.

[Dr Whitford]

On a point of order, Mrs Moon. I have a factual correction to make. The hon. Member for Aberdeen South (Ross Thomson) stated that only 51% of students at Scottish universities were from Scotland. In fact, it is 70%.