People have been asking me what I think the biggest threat to the NHS is in the next five years. My answer is simple: workforce.
I have been talking about if for the last few years. It is a crisis. I am glad it is now hitting headlines although we must resist the temptation to think that fixing what is broken is either simple or quick.
We simply don’t have enough people in the NHS or social care and we don’t have them in the right places.
There are issues everywhere you look. Lets start with the bit I know best: GPs. So many things have come along that conspire together to encourage those already in the service to leave: revalidation, changes to pensions, reducing incomes, increasingly busy days, endlessly negative press ( and yes that does get to you after a while)All the while fewer are joining us. Why? Well some of the issues are the same.. negative press, busy stressful work, other less stressful options. In a meeting I attended a while ago with someone from GP Education they said the issue with GP work stress was “decision density” I have never heard it called that before but completely get what he was talking about. AS a GP you make so many decisions every day: in every consultation, every phone call, every visit, every path result. This is often done with limited clinical information. Referring patients on to hospital unnecessarily risks flooding an already creaking system, wait and you risk missing something significant. It is stressful .A GPs work is much more decision dense that other areas of medicine. Now I am no longer a practising GP I miss the patients very much but I don’t miss the intensity of work you do every day. As more nurses and other professionals enter general practice they do more of what was GP work and GPs spend a much higher percentage of their time doing the really tough stuff. It is good use of their skill base definitely but it is stressful too.
Our area is very rural, another issue now. Young doctors used to choose to work here: pretty countryside, good schools, nice market towns. Now most of them are settled before they leave medical school ( we worked such long hours that we lived in hospital accommodation and socialised with each other for years after qualification) so they mostly choose to stay close to where they trained, which of course is in cities. So suddenly we have fewer people on our GP training courses and then fewer still who are choosing to move to work here afterwards.
At the same meeting someone asked if the fact that a greater proportion of GPs are women now has meant that as fewer want to be full time and this creates a further issue. The evidence apparently shows that neither male nor female GPs choose full time practice anymore, in equal numbers. So the issue is not that women don’t want to be full time GPs but that neither men or women do.
So as older GPs retire there aren’t people queuing up to take their places….
Okay then.. find other people to fill the roles, you may say.. .well we are trying but it turns out that isn’t easy either. There aren’t lots of trained unemployed advanced nurse practitioners, paramedics or physician assistants. To add to the mix practice nurses demographic data shows us an older group of nurses who are also close to retirement and not a surge of younger nurses coming in to the service to take their places. We know there are similar issues with nursing recruitment and retention. And having nurses in first contact roles gives them the same pressures and issues as GPs. A practice told me recently that the indemnity insurance for nurse practitioners had gone up from £750 to £7500 per annum in a year, no doubt to reflect the added risks they now take in these “first contact” ( seeing patients who haven’t been assessed by a GP first) roles.
This is just a snapshot of issues facing primary care.These and other issues exist in hospital medicine, nursing and caring. Most importantly the NHS isn’t seen as a fun or exciting place to work. It is seen as hard, poorly funded, tough work. So why join ? Would I join now? I have absolutely loved being a GP and feel so fortunate and privileged to have worked in the profession for 30 years but I find myself hesitating to recommend it and that makes me sad.
How do we change things? We need to openly and honestly accept the issues, and that they can’t be solved quickly, whatever the political rhetoric. It requires brave central action to increase medical training places, nursing places – perhaps consider more vocational routes into nursing, and the safe gradual development of other models of caregiver with full evaluation of impact...We need clarity about what the new roles are able to deliver and what are their limitations.
As a local economy we need to think about the building blocks that will entice new people to come to a rural area and those who grew up here to return, to make it an exciting vibrant place to live and work.
We need to make general practice medical and nursing roles and community nursing roles more attractive. After all we have no system to coerce people to work in unpopular areas ( as they do in other countries), not that I am promoting that idea but if we don’t then we have to make it a positive and attractive choice.
We need to fund it all properly so people get a fair pay for the job done.
This is a marathon not a quick sprint.
We need to be able to tell the story of why it is great to work here..and believe it.
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