GPs in England at ‘Breaking Point’ Amid ‘Collapse in Morale’

Primary care doctors in England are feeling “despondent” and feel unable to provide adequate care given the current pressures on workloads and funding, Byline Times has been told. 

GPs and emergency doctors are picking up the pieces amid long waits for operations, as well as a crisis of mental health underfunding, according to testimony shared with this newspaper.

And a significant number of GPs are leaving permanent positions for locum roles (filling in for those ill or on leave), or leaving clinical careers altogether amid unsustainable workloads and heavy admin burdens.

Dr Kath Fielder, a GP in the north-east, told an EveryDoctor survey for Byline Times: “Everyone I know who is a GP is very tired, despondent and weary. I actually think the predominant emotion is sadness. Nothing works like it should and it’s truly heartbreaking seeing patients receiving substandard care from the entire NHS. 

“We in primary care have become a holding bay: for people waiting years instead of months for urgent procedures; managing people with significant mental health problems because they aren’t ‘bad enough’ to reach the threshold for a massively under-funded CAMHS [Child and Adolescent Mental Health Services]; writing appeals for PIP [Personal Independence Payment] because so many people are losing their benefits.” 

She compared the situation to “handing someone a thimbleful of water when their house is on fire”. 

“I rarely send patients to hospital but, when I do, I am truly shocked at how many are sent straight home again,” she added. “And this is not criticism of the hospital staff. I know they will be under incredible pressure not to admit anyone and there won’t be any beds for them to lie in. Whilst this is happening we are having increasing restrictions in what we can prescribe; where we can refer and impossible targets to attain.”

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Some GPs are now “unable to work” given the conditions, and many more are swapping permanent posts for temporary or ad hoc work.

Asked what the biggest challenges for her practice are right now, she added: “Not being able to give the care we want. It’s that simple.” 

Dr Nicholas Souter, a GP based in the south-west, said GP practices had increasingly been incentivised to hire less-qualified Associate Physicians or Advanced Nurse Practitioners (ANPs) over GPs as they were cheaper to employ. 

It comes as a new British Medical Association survey of 18,000 doctors found that 55% of respondents said the employment of PAs (physician associates) and AAs (anaesthesia associates) in their workplace had increased their workloads, rather than reduced them. 

Just 21% of doctors responding to the survey said the presence of these staff had reduced their workload.

Along with complaints over increased workload, the BMA’s survey also highlighted serious concerns about the use of PAs and AAs regarding patient safety.

Among doctors working in primary care (typically GPs and A&E doctors), 90% told the BMA the way that PAs were being employed in the NHS was a risk to patient safety, with 82% believing PAs frequently or often worked beyond their capabilities. 

Dr Souter pointed to a recent case of two ANPs analysing a patient’s bloods, which they said “showed a build up of toxic substances”. One told the elderly patient that her life was under threat and she must go to hospital. 

Dr Souter said: “I looked up old bloods and noted this lady had chronic kidney disease.” Her blood toxin levels were always that high – in fact, they were usually higher. “She did not have acute renal failure… So this ANP-to-ANP discussion was all a misunderstanding – the Advanced Nurse Practitioners was reviewing bloods taken by another ANP and neither knew the difference between chronic renal failure and acute renal failure.

“The poor woman was stressed, her family was stressed, an unnecessary ambulance had been sent, an OOH physician had been kept busy.” 

The GP said practices should “never” be allowed to have less-trained ANPs outnumbering GPs “but of course, while the Government is under-funding GP practices there is no way to resolve this”.

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However, one GP said that recruitment of Physician Associates – which was ramped up following the 2019 Government contract with GPs – followed “years of practices struggling to recruit salaried doctors”. 

Another added: “The GP contract has generally speaking buggered up our practice as the funding has not matched the demand. That said, so many factors are making GP a nightmare to work in (and manage) that pulling out one strand is very difficult. PAs in the surgery are very hit and miss. We have had two that have been utter disasters, making more work by wanting constant intervention on the part of their supervisor for the days, having a long list of things they won’t do, and referring all kinds of things that don’t need referring. 

“We have, however, had one who is an absolute legend and has been a pleasure to work with – we wouldn’t lose her for the world. The problem is that you don’t know what kind you are going to get.”

Six other GPs who spoke to EveryDoctor, and who wished to remain anonymous to speak more freely, echoed these concerns – noting GP practices are struggling to recruit salaried doctors, leading many trainees to choose locum positions for a better work-life balance. This has left full-time partners working extensive hours with additional unpaid admin work.

GPs also pointed to the Government’s 2019 contract with GPs, which they claim has not matched funding with demand. 

Several GPs said the current workloads were destroying morale: “On top of my daily appointments, home visits, supervisions, quick reviews, [and] prescribing for the team, I regularly have five to eight sick note requests to action, 50 [test] results and 20 to 30 letters to look at. District nurses tend to send me messages multiple times a day too.

“There has been a huge exodus of GPs in our area so anyone I’m working with is usually newly-qualified. They can’t seem to work at pace, having been trained in the pandemic. I’m frequently having to mop them up too when exhausted or upset over vexatious complaints. Our biggest challenge is retaining GPs because of the above. One has just resigned and is going abroad.

“Morale is terrible. I’m lucky because I have been at my practice for nearly 10 years so most patients are appreciative. But the general public view is we’re rubbish but at the same time want us to do everything/fix everything… and so do secondary [specialist] care.” 

In another practice, a doctor described how they have seen a large rise in turnover of GPs: “We have managed to recruit several GPs to replace them… but not in full capacity, because we cannot afford to recruit as many as we need. The new GPs are very recently qualified and so need peer support.” 

And they claimed that the recent 6% pay rise for NHS staff in England is not being fully funded by NHS: “[It does] not cover our costs by a long way. Someone at NHS England decided staff costs are about 40% of income. [It’s] more like 60 to 70%. As a result, you are left with a huge dilemma. Our hard-working staff deserve a pay rise but we can’t afford it without losing staff to pay for it?” 

A&E specialist doctor Dr Huw Evans, based in the West Midlands, said workloads in NHS hospitals meant care expectations had fallen through the floor. His department is constantly under-staffed, with significant vacancies among specialists, he said.

The failure to invest in infrastructure after years of austerity is also visible, with Dr Evans noting: “There are numerous buckets under holes in the roof” of the hospital. 

“Patients are missing out on the professional relationships that used to be commonplace in the community. As a result, they come to [Emergency Departments] – we never close – where problems that could be dealt with in a few minutes take many hours to sort out.”

The breakdown in primary care, including huge delays to get GP appointments, in turn slows down care for those who really need emergency help, he said: “The sight of queued ambulances is the most visible aspect of this. We are not able to offer the level of care that we would wish and have given up on the ‘Gold Standard’ aspirations. It used to be that a four-hour breach would cause castigation. Now, any patient who is not a 12-hour breach is a cause for celebration.

“I have worked for the NHS for over 30 years. The NHS is sinking like the Titanic, holed by the iceberg of under-investment. Captain Sunak [is] putting his telescope to his blind eye, telling us he only sees clear water ahead.”

Dr Julia Grace Patterson, EveryDoctor’s chief executive, told Byline Times that the Government’s “political actions” had “decimated” the NHS.

“NHS GPs are absorbing an enormous amount of pressure currently,” she said. “They are doing everything they can to keep patients safe, but this becomes more and more challenging as the situation evolves. The Government is not supporting the current GP workforce, they are often scapegoated for problems that they have not caused, and there is now a move to flood the NHS with non-doctor clinical decision-makers, which is exacerbating the situation. 

“Every healthcare professional has a role, and within a fully-functioning NHS with abundant resources, physician associates would be a welcome addition to clinical teams. We definitely hear about some places in the NHS where they are highly valued. However, in many NHS facilities, the burden of responsibility for supervision of their work falls to doctors. This is hugely labour-intensive and even dangerous, given the pressure on the NHS, the rate at which staff must work, and the potential for diagnoses to be missed and patient safety problems to be caused. 

“Morale amongst GPs is very low, and the situation must be urgently tackled. The Government must listen to frontline GPs and healthcare leaders to rectify the situation. Politicians are profoundly failing NHS staff and the patients they are devoted to caring for.” 

Commenting on concerns over the roll-out of Physician Associates, a Department of Health and Social Care spokesperson said: “The role of Physician Associates is to support doctors, not replace them, and they make a significant contribution to the NHS. PAs work alongside doctors providing medical care as an integral part of the multi-disciplinary team. They carry out clinical duties such as taking medical histories, carrying out physical examinations, and developing and delivering treatment and management plans.

“Regulation of these roles has cross party support and will boost patient safety, with the General Medical Council operating strict fitness-to-practice procedures and setting education and training standards.”

The Government’s Long Term Workforce Plan aims to increase the Physician Associate workforce in England to 10,000 by 2036 to 2037, and the similar Anaesthetic Associate workforce to 2,000 over the same period. 

Officials say new regulations will give the General Medical Council responsibility and oversight of doctors, PAs and AAs, allowing it to take a “holistic approach” to the education, training and standards of the roles. 

The testimony from GPs and patients was gathered by EveryDoctor

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