College Chair Martin Marshall addresses RCGP virtual conference
Publication date: 27 October 2022
Good morning everyone, thanks so much for joining the College’s autumn online conference. I hope you’re finding it stimulating and enjoyable.
It feels like a momentous conference for me because it’s my last one as Chair of our College – I step down in a few weeks’ time after what can only be described as a tumultuous period in office. When I started in November 2019 my predecessor, Helen Stokes Lampard, sent me a lovely card wishing me the best of luck and containing the immortal words ‘may you have no crises’. Over the last three years we’ve experienced the worst pandemic in a hundred years and the worst workload crisis in general practice in 60 years so I’m going to be very careful to wish no such curse on my wonderful successor, Kamila Hawthorne.
I’m going to use my speech today as an opportunity to look back more than 30 years to the start of my career as a young GP in Devon, not too nostalgically I hope, to describe how general practice has changed and the nature of our current crisis. I’m also going to describe how the College has been helping our members over the last three years to address the crisis, and what we think government needs to do to turn things around.
So, let me start by taking you back to the 1980s. I didn’t begin medical school with any preconceptions about what specialty I’d go into but by the time I’d qualified I was certain that general practice was the right career for me, for similar reasons to those I hear from many GPs.
First, I loved every medical specialty I studied at medical school and used to irritate my then girlfriend, now wife, by stating with the certainty of youth that I was definitely going to be a paediatrician, then a psychiatrist, then a physician, depending on what I was studying. I really didn’t want to give up practicing any branch of medicine. Second, I also discovered early on that I didn’t like hospitals very much. I’m a typical GP, a free spirit, the idea of working in a highly structured and hierarchical organisation filled me with horror. And third and most importantly, I realised that I found people far more fascinating than diseases. Or at least I’m intrigued by how people respond to ill-health. I find ‘the human condition’, as it was described by Hannah Arendt in 1958, endlessly fascinating.
We all have examples of patients who make us think ‘wow, where did that come from?’
I had got to know Mavis pretty well over the decade that she had been registered with me in Devon. Her only child, a drug addict, had regularly abused her until he’d been sent to prison. A lifelong heavy smoker, Mavis presented to me coughing up blood and losing weight. A chest x-ray showed a suspicious shadow, so I prepared her for the worst and to my surprise she handled it really well, smiling and telling me not to worry, she was fine. But after extensive further investigations the oncologists gave her the all clear and I had the pleasure, I thought, of imparting the good news.
Her reaction? She broke down in tears, not of relief but of genuine distress. I soon realised that her reaction had a certain logic to it. She wanted to die. She felt she had failed in her role as a mother. She had nothing to live for. She wanted a respectable way out and death by cancer was it. I was the bearer of bad news; I had removed her hope of an honourable death.
I don’t remember being taught how to deal with the Mavis’ of this world at medical school. There are plenty of Mavis’ out there in our communities.
Or how about John, a man in his early 40s who I saw recently with pain in both of his shins for several weeks. I knew that he was a keen ultra-marathon runner and was training for a big race. He decided to go online to get some advice and he entered his symptoms into a chatbot designed by an online consultation provider. Twenty-eight minutes and 36 questions later he was informed that the most probable diagnosis was either bunions or Charcot’s joints. He knew he didn’t have a bunion and having read about the link between Charcot’s join and syphilis, he wasn’t too impressed with the computer programme.
So, he booked in with me, his in-vivo GP, and I asked what he thought the problem was. He replied that he thought he had shin splints and I told him I thought he was probably right. I asked the question that all GPs would ask: if he had anything else on his mind. After an embarrassed pause he confided that a friend had recently died of a sarcoma which presented with leg pain and he just wanted a bit of reassurance. No scan, no referral, just a chat with someone he trusted. We had that chat, I examined him and I reassured him with confidence.
I don’t remember being taught at medical school how to deal with the Johns of this world either, and there are plenty of Johns out there in our communities too.
In one key respect general practice hasn’t changed at all over the years. Patients like Mavis and John come to us with a concern or problem relating to their health, we explore their ideas, concerns and expectations, and we do our best to help them. Sometimes we intervene with a specific intervention, sometimes we simply listen, witness and, when we can, reassure. It was the same a hundred years ago and will be the same in 100 years’ time.
But as far as the organisation and delivery of general practice is concerned, it has changed dramatically. This change reflects the pace of change in wider society. In Future Shock the social commentator Alvin Toffler reflected on modern society. He described how we travel more and faster; how we relocate more frequently to new residences, which are built and torn down more quickly; how we contact more people and have shorter relationships with them; how we are faced with an array of choices among styles and products which were unheard of the previous year and may well be obsolete or forgotten by the next. He said novelty, transience, diversity, and acceleration are what modern society is about.
Of course, general practice is part of modern society, so it can’t and doesn’t stand still. The extent and pace at which GP has changed in response to the rapidly changing environment is truly remarkable, a testament to the flexibility and innovation of GPs and our teams and our desire to do our best for patients.
And boy oh boy, has general practice changed. Let me describe what a day in general practice looked like in Devon in 1990 when I started working as a GP. I was one of four partners in our practice, two full time and two three-quarter time. We looked after 7,000 patients and had a very strong commitment to personal lists so we knew our patients well and they knew us well too, foibles and all. The core clinical team comprised us four doctors plus two nurses, though we worked very closely with a team of district nurses and health visitors who shared our building. The doctors were responsible for dealing with about 90% of all patient contacts.
I started my morning clinic at 9am and was usually finished by 10.30. I would then do three or four home visits and on most days would then head home, go for a run and then have lunch. On some days of the week, I’d do a maternity or child development clinic mid-afternoon and then my afternoon clinic would start at 4 and usually finish by 5.30 so I was home before 6pm. Admin work was done in between these clinical commitments and I worked a one in four out of hours rota. On an average working day I rarely saw more than 20 patients and it was unusual for patients to have to wait more than a few days to get an appointment to see me.
It all sounds pretty good, doesn’t it? And it was. A commentator in the BMJ in the 1960s described in a rather grand fashion how ‘the practice of medicine should be a leisurely activity’ – not leisurely as in easy or quiet, but leisurely as in having time to really care for our patients. Victor Montori, a primary care doctor, social commentator and word-smith from Boston US, describes the importance of ‘unhurried consultations’. General practice 30 years ago was, relatively speaking, unhurried and we were able to do a good job with pride.
No one needs to be told that we are now a million miles away from my description of general practice in 1990. In the span of my career, general practice has for many GPs moved from a satisfying and enjoyable profession to an undoable job.
The crisis in general practice has been building for over a decade, catalysed initially by the Treasury’s austerity measures, then by the pandemic and now by the economic turmoil and the cost of living crisis. It’s a simple problem to describe – need and demand are out-stripping supply. But the solutions are far from simple because in the absence of a plan, or even much interest from policy makers in general practice, the crisis has been allowed to become so multi-faceted and so deep, and because successive governments have been unwilling to acknowledge the scale of the problem.
You’ll all be familiar with the data. Need and demand is going up because the population is growing, it’s getting older, more diverse and in many cases sicker. There’s more that general practice is able to do than 30 years ago as a consequence of impressive scientific advances, and much of the work traditionally done in the hospital sector has been transferred to general practice - without the associated resources. And public expectations and demand is rising, in line with the more consumerist, 24/7 society that we live in and the demise of traditional support in families and communities.
The number of consultations delivered by practices is rising month on month in comparison with pre-pandemic levels and those consultations are more complex and more intense - on average three problems are presented in 9.8 minutes.
So that’s the demand side of the equation. In terms of supply, the number of health professionals has failed to keep pace with the increase in demand, and in the case of GPs the numbers of whole-time equivalent, fully-trained GPs has fallen by nearly 1,800 or 6% since 2015 when government promised 5,000 more GPs, and by 2.5% since 2019 when government promised 6,000 more GPs. And please note, whole-time equivalent GPs are what matters to patients, so please don’t be taken in by misleading stats quoted by the centre which are based on headcount.
I’ve been criticised by some people for calling out this crisis so vocally when I speak to the media. They say that I’m scaremongering, talking down general practice and that I risk damaging public trust and turning off the next generation of GPs. But I’m quite clear that I have a professional obligation to say it as it is, not how we’d like it to be. Martin Lewis, the money saving expert, said recently that he was criticised for catastrophising the cost of living crisis and he replied ‘I only catastrophise it because it’s a catastrophe’. General practice isn’t a catastrophe yet but it’s heading in that direction and we have limited time to turn it around.
How is general practice responding to the workload crisis? We have a reputation as a profession for sometimes being a bit grumbly, but actions speak louder than words and what practice teams have done, around the country, is work both harder and smarter in order to keep the service running for their patients.
The harder bit is obvious to all. Earlier I described my average day as a GP at the start of my career. Now the average working day for GPs is 11-12 hours rather than nine hours, we are responsible for more than 50 patient contacts per day rather than 20, and the amount of admin is growing by the month. We might not do as many home visits and we’re less likely to work at night and at weekends, but the sheer intensity of the working day is, according to recent surveys carried out by the College, responsible for 68% of respondents saying that they no longer have time to properly assess their patients, 34% saying that they are worried that they’ll miss an important diagnosis or make a prescribing error, and 42% saying they are likely to leave the workforce in the next five years because the job is no longer doable.
So general practice is undoubtedly working harder. We are less likely to be given credit for the extent to which we’re also working smarter, changing our operating model, and this is where the most significant change has happened in my career. In order to continue providing as high a quality service as possible, practices are more likely to be working at scale and collaboratively, more likely to be working in multidisciplinary teams, more likely to be using technology to improve communication and maximise efficiency, and more likely to be focusing on the health of populations as well as the health of individuals.
So, I have one, diplomatic, response to anyone who suggests that general practice is resistant to change, stuck in an old model; open your eyes. I’m not suggesting that there aren’t unintended consequences associated with these changes, but I am saying that general practice is doing everything it can to adapt and change in order to continue to meet the needs and expectations of our patients and communities. We’re doing what we can and now the centre should do what it needs to do, first and most important, increase the size of the workforce, and second have honest conversations with the public about what the NHS is able to do with the resources available to it.
The College has been working hard to support our members through the pandemic and through the workload crisis. Let me give you some examples. We developed a range of practical resources to support GPs during the pandemic, including a ‘Covid-19 Resource Hub’ with key information and clinical guidance and we opened up these resources to non-members. We are supporting the transformation of the delivery model of general practice, promoting the use of triage to manage demand and digital technologies to support remote consulting and lobbying government to help improve the tools and support available to practices. We have produced a range of guidance to support effective remote consulting and whilst doing so we have explained to the public and to critical journalists and politicians why these changes are necessary.
The College has supported practices to work at a larger scale and collaboratively with neighbouring practices and other health and care services by lobbying for additional resources to support transformation and through its consultancy work with practices and networks. We have encouraged and supported the development of increasingly diverse multi-disciplinary teams and we are supporting GPs to rethink where they add value as leaders and members of those teams.
At a time when health services are becoming increasingly transactional, the College has emphasised the importance of continuity of care, how GPs utilise trusting relationships with their patients to improve patient experience and outcomes as well as the efficiency of the NHS. And we have explained how relationship-based care needs to evolve to meet the changing nature and expectations of society.
The College has actively promoted the contribution that general practice can make to improving the health of communities, focusing on population health and the social determinants of health, using social interventions when the evidence suggests they are effective and addressing health inequalities. We have shone a light on examples in practices and localities across the UK of using social interventions to improve health, including innovative models of delivering the Covid vaccination programme. We’ve been passionate advocates of the EDI agenda, with work led by our Black, Asian and minority ethnic members following the Black Lives Matter movement. And we’ve been one of the leading medical professional bodies in our support and practical action on the climate change and sustainability agenda.
And underpinning this work the College has ceaselessly campaigned to improve recruitment and retention of the primary care workforce, to increase investment in estates and technology, to evaluate new ways of working, to ensure that changes in practice are based on best-possible evidence, and to ensure that clinicians have time to do their job – to care for patients.
Our College, like all professional bodies, is sometimes criticised for not doing more for our members and of course we can never do enough, particularly at a time of crisis. But this description of some of the activities that we’ve been focusing on in the last few years illustrates both the quantity and the quality of the support we are providing for general practice.
And the work that we do is practical – solutions for our members to help them cope and solutions for government and NHS leaders to implement. We say to policy makers and system leaders that there are no quick answers to solve a crisis as complex and deep as the one we’re in. We understand why politicians have short timescales but we appeal to them to think about the medium and long term needs of patients and the health service and to act accordingly.
We make it clear that the number one answer is expanding the size of the workforce, both medical and other health professionals and that this requires a commitment to both recruitment and retention. We tell them that they can free up clinicians’ time to care for patients by reducing unnecessary bureaucracy – a higher trust contract, a lighter-touch approach to organisational and professional regulation, investment in technology and estates. We highlight the importance not just of having a plan but investing in the effective implementation of that plan by providing support for teams and systems to work differently. And we emphasise the need to invest in two areas traditionally done badly by the NHS, preventing ill health and disease and addressing the deeply embedded inequalities that we see in many of our communities.
For each of these areas we make a strong data-driven case for investment, presenting case studies from the front line and research evidence. Are government listening? Not enough by any stretch. As a consequence of our and others’ lobbying work the toxic anti-GP narrative is at last turning around. Despite this, government solutions remain poorly informed and in-substantive.
So, challenging times for all of us and I’m not sure that the situation will improve in the short term. We have a general practice service that is dependent on your good will and selfless commitment. On behalf of the College I want to thank you for your professionalism. We know the personal cost on you, your teams and your families and we are making it clear that the situation we find ourselves in is not sustainable.
I’m one of those people who always looks on the positive side. I live by the Dalai Lama’s advice that we should be optimistic, because it feels better. History tells us that previous periods of crisis have always been turned around because politicians eventually realise that our patients, their electorate, value general practice, that communities rely on us and that the NHS is unsustainable without us. I’m confident that the turn around will happen and we’ll return to the days when being a GP was a stimulating, satisfying and doable job.
Thank you for listening. It has been a privilege to be your chair over the past three years. Enjoy the rest of the conference.
RCGP Press office: 020 3188 7633
Notes to editor
The Royal College of General Practitioners is a network of more than 54,000 family doctors working to improve care for patients. We work to encourage and maintain the highest standards of general medical practice and act as the voice of GPs on education, training, research and clinical standards.