GP Recruitment and Retention

Jim Shannon Excerpts

Wednesday 28th March 2018 Westminster Hall

[Jim Shannon (Strangford) (DUP)]

Thank you, Mrs Moon. I did not expect to be called quite this early, but I am very pleased to speak at any time in this Chamber, as everyone will know.

I thank the hon. Member for Houghton and Sunderland South (Bridget Phillipson) for setting the scene and giving us the chance to participate in the debate. Its title is “GP Recruitment and Retention”, and I am very pleased to speak on this topic. The title does not refer to a particular area, which gives me the opportunity to talk from a Northern Ireland angle—although as most hon. Members will know, that would not prevent me from speaking from a Northern Ireland angle anyway.

During the debate on the Northern Ireland Budget (Anticipation and Adjustments) Bill just last week, I raised the issue of GPs, out-of-hours services and so on. I highlighted the fact that we need to improve the accessibility of GPs and enhance the capability of GP out-of-hours services to help with the immense pressure that our accident and emergency departments are under. The fact is that we are an ageing population, which increases demand on GP services, and at present we seem unable to meet the demand.

The Minister and I seem to meet in this Chamber on many occasions, and also in many Adjournment debates in the main Chamber. He is obviously a very popular Minister, but he also has a remit that includes many of the issues in which I and other hon. Members have an interest.

In Northern Ireland, this issue has certainly been a big concern. GP practices have been moving away from the old surgery system to a new system in the hope of triaging demands on doctors and surgeries. Health is a devolved matter, but I want to give a Northern Ireland perspective to this debate. Thankfully, the Department of Health’s permanent secretary in Northern Ireland has released funding for a scheme that was approved by the outgoing Minister of Health but not implemented before the untimely demise of Stormont, which is now in limbo-land. It saw the investment of an extra £3.9 million, following investment earlier in the year of £1.9 million for elective care and £3.91 million to continue the roll-out of nearly 300 practice-based pharmacists. I know that the Minister is deeply interested in this subject, not just because he is the Minister responsible for it but because he has a genuine and sincere personal interest. I hope that details from Northern Ireland might be of some help in considering what is done here on the mainland and in other parts of the United Kingdom.

The permanent secretary said at the time:

“Given the current difficult financial position, investing nearly £10m more in GP services, the largest additional investment in recent years, reflects the Department’s commitment to the continued development of sustainable and accessible primary care services…The Department is also introducing changes to…eligibility to the sickness leave scheme for GPs.”

That is another thing we have looked at in Northern Ireland, and perhaps the Minister will comment on it. The permanent secretary continued:

“It is estimated that these changes will save GPs more than £2.5m per year in sickness leave insurance premiums.”

The thrust of the debate so far, and undoubtedly of the speeches to come, is about how we can retain GPs. The hon. Member for Houghton and Sunderland South clearly made that point, and I too think that that is what we need to try to do.

The move to which I have referred was made in a very uncertain political climate back home in Northern Ireland. Few other decisions to implement schemes have been taken by any Department’s permanent secretary. We are slowly moving towards what will perhaps be a hybrid system of government in Northern Ireland, whereby we can ensure that the health schemes move forward.

I have spoken to former GPs, who have illustrated to me how much the system has changed and how happy they are to retire. Some have begun to do a few hours in GP out-of-hours services, which takes a bit of pressure off the ordinary GPs, but it is important that we have a system that sustains itself, and the pressure and stress that services are under has seen most GPs walk away from that system. We are trying to stop GPs walking away—that was the point that the hon. Lady made in introducing the debate, I fully support it. The simple fact is that our doctors cannot cope and we need to help them find a new way forward.

In 2016, 36% of the 15,430 people who died in Northern Ireland were aged under 75, compared with 50% 30 years previously. The resident population of Northern Ireland rose by 10,500 people to reach 1.862 million in the year to June 2016. Every GP surgery knows that the people on their books who need the most attention are the grey vote and the young families. Our GPs are great, and we support them greatly. We understand their position—we know the pressures that they are under and we have the deepest respect for them.

One of my local surgeries has heavily invested from its own budget in a machine that can determine whether chest infections are bacterial through the practice nurse taking blood and analysing it on-site. That innovation stops the surgery sending people for analysis in hospital and facilitates the provision of better care in the GP surgery. It allows antibiotics to be prescribed and means less pressure on the hospital. Such a machine would help every surgery. Sometimes we have to look at a different way of doing things. If we can do them better, let us do that. We should be making funding for such innovations available, for the benefit of all of us across the whole United Kingdom of Great Britain and Northern Ireland.

Due to the stringent nature of benefits assessments, many practices in my area now refuse to give support letters for benefits. That is another pressure on GP surgeries all the time. I am constantly contacting GPs on behalf of my constituents, saying that they need a letter about their health condition to support their application for disability living allowance—personal independence payment, as it is now—and employment and support allowance. The GP says, “Let them write to us; we will reply,” and they do, but they usually send a list of the constituent’s appointments with the GP, which is not what PIP is about.

I am adhering to your timescale, Mrs Moon—I have worked it out, so I know what time I will have to stop.

A retired doctor I am very friendly with suggested to me—I know the Minister is sympathetic to this idea—that we have a bursary scheme whereby if a medical student will commit to doing five years or more at a surgery, they will have some or all of their student debt written off. That would encourage people to get into GP surgeries and make a difference for five years or so. I am given to understand that the Department are looking into schemes like that, and I hope so. I am interested to hear the Minister’s response to that idea, because I think that might provide encouragement for some of the young student doctors who wish to go on to general practice. If we provide that incentive through a bursary, I think it will be a massive step forward in addressing the issues, as the Department proposes to do by reducing the pressure on GPs and increasing their number.

Have any discussions taken place with the regional devolved Administrations so that they can respond? The Scottish National party spokesperson, the hon. Member for Central Ayrshire (Dr Whitford), has vast knowledge of medical issues, and I know that her contribution to this debate will make clear what has been done in Scotland. Yes, it is a devolved matter, but the NHS is nationwide and this scourge in our surgeries is in every area. A focused, co-ordinated approach is the best one to take, and I ask that the Department focuses on this vastly important issue. We need good GPs, and we need to support GPs. If we do not do that, there will be a domino effect on our hospitals and all other NHS institutions. We need to encourage our first line of defence, which is GPs, and ensure that defence is sure and certain. At the moment, the fact of the matter is that it is struggling.

--- Later in debate ---

[Dr Whitford]

I absolutely welcome them. Similarly, in Scotland the new graduate medical programme will take on people who have done other degrees, and that is particularly aimed at encouraging those people to go into general practice and rural practice.

[Jim Shannon]

May I gently ask the hon. Lady whether Scotland has a bursary scheme? Both I and the hon. Member for Caithness, Sutherland and Easter Ross (Jamie Stone) referred to that, as we feel that such a scheme might help.

[Dr Whitford]

Obviously, in Scotland we do not have tuition fees, so that is a considerable difference in student debt, particularly for a five-year medical course. We do not, as yet, have a system of bonding or tying students down. The worry is that that would create a feeling of being trapped, and that as soon as the bond finishes, the person runs away. I am sure that all Governments in the UK are thinking about such things, but it is about working out whether such a scheme is beneficial or negative in the long term. We do have a GP bursary scheme for those entering a traineeship, so that when someone moves from a hospital where they work on-call, and becomes a GP trainee, the drop in salary is compensated.

As the hon. Member for Caithness, Sutherland and Easter Ross (Jamie Stone) said, in Scotland we have a particular issue with the provision of rural services. We have a much higher ratio of GP per head of population, with 91 GPs per 100,000 people, as opposed to 71 in England, 73 in Wales and 70 in Northern Ireland. What often gets forgotten when people look at the weirdly angled weather map, is that although Scotland is one third of Great Britain’s landmass, it has 8.3% of the population. Anything that involves providing services across an enormous area is a challenge. We also have 70 inhabited islands that require services. Our recruitment and retention fund is putting additional money into this issue. The Scottish Rural Medicine Collaborative involves 10 health board areas, and relocation money—the golden hello for trainees or indeed any GP moving into practice—has been increased from £2,000 to £5,000. Any GP moving into rural practice will have a golden hello of £10,000, and trainees will have £20,000. That has been rolled out from the 44 island practices to all 160 rural and remote practices.

One key issue driving this problem, which perhaps is not often recognised, is the change from full-time to part-time working. Headcount for GPs is up by 5% in Scotland, but down by 4% from 2013. The change seems to have been in the last five years—indeed, there is a real culture change as the next generation comes in. When my husband became a GP, he was the first part-timer in his practice. They interviewed all the women before him, because it seemed so weird to have a man who wanted to work part time—that is because I was always in the hospital. Now, out of eight GPs, only two are full time. The number of patients in the practice has not changed, but instead of six actual GPs, there are eight. Therefore, the average GP is working considerably less. In England, the change in headcount of those looking to work full time meant that numbers went from 39,000 to 27,000. That shows the dramatic difference between the full-time equivalent and headcount, and it means that the average GP is working about 70% of what a full-time GP worked. The problem for any Government is that they then need to train 30% more GPs to cover that.

The key, however, is satisfaction. At the deep end, the 100 most deprived GP practices in Scotland face the inverse care law: people do not demand, and therefore service is not delivered. Govan health centre is running the SHIP project—social care and health integrated partnerships, and that innovation is now being picked up elsewhere. It means that GPs have extra time, and a significant multidisciplinary team, but in those areas, 31% of patients will have four or more conditions.

We have an even deeper problem, however, which is the attitude to general practice. Other specialisms look down their nose at it, and therefore a student may not be encouraged to enter general practice. Students are not getting enough exposure to general practice, either as students or in their foundation years. We also have a particular problem with the two foundation years since “Modernising Medical Careers” came in. We pour all our young doctors into a hopper—a computer—and they get divvied out. They will struggle to be with their family or where they were living before. In 2011, 29% of young doctors left after the two foundation years. Last year it was 50%. They do not feel part of the team or have a sense of continuity—things that are utterly crucial to general practice. Therefore, although we may be putting in more money and coming up with schemes, we must also reform the foundation years so that we do not have an entire lost generation.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Steve Brine)]

It is a pleasure to see you on your throne this afternoon, Mrs Moon.

I have a lot of time and respect for my shadow, the hon. Member for Burnley (Julie Cooper), but what a counsel of despair that was. As the sun comes out after a day of rain in London, let me see if I can bring some sunshine to our proceedings.

I congratulate the hon. Member for Houghton and Sunderland South (Bridget Phillipson) on securing the debate. She spoke passionately, as always, about her constituents and her area. The hon. Member for Strangford (Jim Shannon) said that we are often in here together and share many of the same subjects. That is true but, to be fair, he is in here even more than I am.

I note the Prime Minister’s announcement yesterday that she intends to bring forward a long-term plan for the NHS with the Secretary of State, Ministers and our partners. That will build on our record of extra funding for the national health service in England year on year since 2010, to deliver a NHS that is fit for the future. I agree with the shadow Minister that this is about the wider NHS, and that we cannot see primary care in isolation. We are able to do what we have done for the past eight years because of the state of the economy, which we have got into a better place. When the economy fails, the NHS catches a cold or much worse, which is important.

[Jim Shannon]

rose—

[Steve Brine]

I will not give way at the moment.

As everybody has said, we recognise the importance of general practice as the heart not only of our NHS, but in many ways of the country. It is as much about prevention before people get into the NHS as it is a gateway to it. That point was made well by the hon. Member for Central Ayrshire (Dr Whitford), who spoke for the SNP. As others have kindly said, I am absolutely committed to ensuring that the NHS has the resources, workforce and Government backing to make it fit for the future.

As the hon. Lady said, it is a great success that we are living longer, but an ageing population and more people living with long-term conditions, or so-called comorbidities, means that general practice will become more important than ever in keeping well and living independently for longer. On Friday, I spent a morning sitting and observing—lucky patients—a general practitioner in Hampshire, not in but near my constituency. I watched him do his morning surgery. It was a brilliant thing to do as the Minister with responsibility for primary care, but I would recommend it to any Member who has that relationship with GPs in their area. By sitting and watching, it is possible to see what comes through the door and the pleasures of general practice, which is not dissimilar to the surgeries we hold as MPs.

The number of people over the ages of 60 and 85 is set to increase by about 25% between 2016 and 2030, and the number of people living with long-term conditions is increasing. In 2017, almost 40% of over-60s had at least one long-term condition. I am sure we can all think of people in our families who are in that position—I certainly can. We recognise that that places general practitioners in England under more pressure than ever before, and are taking comprehensive action to ensure that general practice can meet the demand.

The NHS set out its own plan for general practice in the general practice forward view. We have backed that with additional investment of £2.4 billion a year by 2020-21, from £9.6 billion in 2015-16 to more than £12 billion by 2020-21. That is a 14% increase in real terms. That is not made up—those are genuine figures, on the record. As has been said, we have also announced our ambition to grow the medical workforce to create an extra 5,000 doctors in general practice by 2020, as part of a wider increase to the total workforce in general practice of 10,000. We recognise that that is an ambitious target—it is double the growth rate of previous years—but it shows our commitment to growing a strong and sustainable general practice for the future.

This debate is about recruitment and retention, so let me break those down. NHS England, which we work with—it is approaching its fifth birthday—and Health Education England are working together with the profession to increase the GP workforce. That includes measures to boost recruitment, address the reasons why GPs are leaving the profession and encourage GPs to return to practice. We recognise that GPs are under more pressure than ever, but we want them to remain within the NHS and are supporting them to do so.

The hon. Member for Stroud (Dr Drew) made the point about recruiting and then following through. As I said at oral questions last week, there are things we can do, but there are things the profession can do too. If doctors in general practice are a counsel of despair, it is little wonder that people do not want to follow them. There are some good, positive voices in general practice, ably led by Helen Stokes-Lampard, who leads the Royal College of General Practitioners. She is a brilliant example of the cup being half full. That kind of positivity is very important—it is a partnership.