Why is your GP Practice now unable to do everything they once were?

Many GP practices in Grampian are faced with unmanageable workloads coupled with a rapidly
shrinking and exhausted workforce. The COVID-19 pandemic has generated a vast backlog of care
which is so far largely unmeasured in General Practice. It is exerting increasing pressure on a wider
system that is already at breaking point.

Grampian LMC’s GPAS (General Practice Alert State) has consistently reported Amber 2 (equivalent to NHS Grampian’s G-OPES 3) since launch. Amber is defined as “moderate to severe working pressure, sustainable only in the medium term”. This worrying alert state forewarns of a General Practice in crisis.

How did we get here?

In 2017, the Scottish Government, after negotiation with the SGPC, introduced a new contract starting in 2018 and to be fully implemented within 3 years. At the time, the then Health Secretary Shona Robison MSP said, “we equally recognise the fundamental challenges faced by General Practice, not least growing workload and increasing risk.”

We have experienced particular challenges with the recruitment of the Multi-Disciplinary Team to
deliver the contract in Grampian, likely linked to our geography. Unfortunately, in past years when
Health Boards haven’t been able to spend the money that they were given to employ additional
Pharmacists and other professionals to support General Practice, the money has been clawed back by Scottish Government rather than being able to be spent supporting your local practice to fund covering the significant gaps in services left through non-delivery of the contract.

Scottish Government committed to the payment of transitionary payments to practices whilst the
contract was in the process of being delivered, however withdrew this commitment in March 2023
despite the contract having only been partially delivered and with significant gaps in service still being covered by General Practice. This left GPs in a position where they were being asked to carry out work that was no longer contractual, and no longer funded.

There have been many further challenges since then:

• Funding for practices comes through a national formula and doesn’t reflect how many times
  patients are seen. Practices are paid the same whether you are seen once or a hundred times
  per year. The average patient used to contact their practice 3-4 times per year. This has
  increased to 6-7 but funding and therefore staffing in General Practice has not increased
  proportionally to this. (1) Furthermore, the annual funding uplifts for General Practice have been
  consistently and substantially below inflation since 2017. GPs see over 90% of all patient
  contacts in the NHS yet are allocated less than 6% of the national NHS budget. (2) This is not
  sustainable.
• The reasons for increased patient contacts are multiple and include an ageing population,
  patients with more severe, complex and often multiple illnesses, and the huge mental health
  fallout from the COVID-19 pandemic across all age groups. The growing hospital waiting lists
  have also had a big impact, with a significant proportion of GP appointments being taken by
  patients suffering from progressing physical and psychological symptoms whilst waiting to be
  seen in secondary care.
• In March 2023, Scottish Government transferred the responsibility for the provision of routine
  blood tests, many nursing tasks and ‘non-essential’ Pharmacotherapy work to NHS Grampian
  from GP practices. Significant gaps still exist in NHS Grampian’s delivery of these services
  through community hubs or by health boards in practices, but they have decided not to
  provide transitionary payments to practices to cover these gaps. Ongoing involvement in these
  activities by your practice may now be limited to only what is required by GP practice
  contracts.
• We all know how much energy costs have risen over the last couple of years and for GPs who
  own their own buildings there is no additional funding to cover this increase. Money spent on
  rising energy bills means less funds going into services practices wish to offer their patients.
• Part of the funding which comes from government every year is earmarked to uplift the pay
  of non-GP staff e.g. receptionists, nursing staff, and practice managers. This has always
  matched what was given to staff working elsewhere in the NHS, e.g. in the hospital. But for
  the first time last year, the Scottish Government decided to break this link. As a result of
  Scottish Government’s actions, many practices had to fund this shortfall in pay themselves or
  risk losing staff to other services. Again, funds used to cover this shortfall means less funds
  going into the provision of patient services.
• The number of GPs in Scotland is falling. (3) As part of the 2018 contract the Scottish Government promised that GP numbers would rise by 800. However, when doctors in training are excluded from the figures, the numbers are actually reducing! Since 2013, the GP WTE (whole time equivalent) workforce has fallen by 5.35% – a fall of 196.7 WTE GPs. In that same period, the number of practices has fallen by 9%, average patient list sizes have increased by 18% and the total patient population has increased by 7%. 42% of practices in Scotland report at least one GP vacancy. The number of GP partners has reduced by 14% between 2012 and 2022. (4) In the last 20 years the ratio of GPs to hospital consultants has halved, despite many things which used to be done in hospital now commonly being done in practice. (5)
• In many areas, practice buildings are too small and are outdated. Unfortunately, Scottish
  Government has now cancelled all funding for new builds, leaving many GPs working out of
  buildings that are no longer fit for purpose. Scottish Government has also suspended
  sustainability loans, a scheme introduced to mitigate the risks for GPs who own their building.
  This leads to increased financial liability which again impacts on the services they can deliver
  to their patients.
• With fewer staff and more work, better IT solutions would help improve efficiency. Our IT is
  outdated, cumbersome and unreliable which often impacts detrimentally on the care of our
  patients and is damaging for staff morale. We are the only country in Britain still using paper
  prescriptions – this alone costs a huge amount of clinical, administrative, and patient time.
• In order to make systems better and to keep our medical knowledge up to date, we need time
  to learn and develop. We used to receive ten half days per year of Protected Learning Time
  (PLT) to work with our teams on making practices better for everyone. The support for this
  was withdrawn by NHS24 and Scottish Government have done very little to reintroduce any
  form of reliable support.
  
  Incredibly, despite all that we have just described, your GP practice remains absolutely committed to providing the best service that it can with the available staff and resource.
  
  However, if you’re not satisfied with the service you receive, look beyond the practice, and instead hold those in positions of power to account. Scottish Government needs to do more to directly support General Practice, the bedrock of the NHS. Please contact your MSP. Their contact details can be found at Members of the Scottish Parliament (MSPs) | Scottish Parliament Website.
  
  Grampian Local Medical Committee
  18 July 2024