'There is no NHS without GPs - you deserve better', RCGP Chair tells annual conference

Professor Kamila Hawthorne, Chair of the Royal College of GPs, has today given her plenary address to over 2,000 GPs and healthcare professionals at the start of the RCGP annual conference 2024 in Liverpool

You can read her speech in full here:

Good morning, Conference, it’s a real pleasure to be with you, here in Liverpool.

As we begin, I want to reflect on the fact that, by the time we finish this evening, GP practices around the UK will have taken care of one million people. This is what we do every day but it’s worth taking a moment just to absorb the scale of that responsibility. In fact, in these first few seconds since I started speaking, thousands of appointments will have already begun.

The Health Secretary Wes Streeting is quite right when he describes us as the front door of the NHS. For most people we are the first port of call when they need medical help. We’re there in every community, from the most disadvantaged to the most affluent. We  look after our patients in their earliest years, then see them through childhood and adolescence, are there for them as adults in their moments of need, not only for biomedical issues, but also through marriage breakdown, bereavement and crises with their children – and then we are there to take care of them when they are at their most vulnerable, at the end of their lives.

As a previous President of the College, the fabulous Iona Heath, put it: ‘in hospitals, diseases stay and people come and go, and in general practice, people stay and diseases come and go’. We pride ourselves on seeing the whole person, not just the illness. That is why patients refer to us as ‘my doctor, not the doctor,’

Everyone acknowledges that the NHS can’t function without us, and we’re encouraged by the commitment the new government has made to primary care - but we will need more than words. These are difficult times, and general practice is in crisis, largely due to the enormous workload we carry, with a dwindling workforce.

Throughout my career, I’ve tried to put patient care at the heart of everything I’ve done. This is what a GP does – I try to do my best for my patients every day. So do you! I have worked in surgeries in Nottingham, Manchester and Cardiff, mostly in disadvantaged communities, and I now work in Mountain Ash in the Welsh Valleys. 

My Mum was a South London GP, and my daughter is now a First5 GP. I saw, and my daughter saw, what GPs do and wanted to do it too.

So, I‘m partisan.

I think there is something special about being a GP. We get the chance to really know our patients. As one GP put it recently, ‘however hard pressed I am, I try to treat each person who comes into my surgery the way I would like the members of my family to be treated’.

When I became Chair of RCGP I promised you that I would work for a service that is properly funded, that allows GPs to do the best job we can and protects our own health and well-being.

For decades we have been working in a system that is under-resourced and over-stretched.

This is not good for patients because it makes it so much harder for us to do our jobs well – whether this is trying to speed up specialist appointments for patients on waiting lists, working out the best pathways for others when services get axed, or dealing with medicine shortages.

It takes its toll on us. I know many of you are hurting and feel undervalued, and you have every right to ask, ‘who is looking after our wellbeing?’ There is nothing selfish about this question because unless GPs are looked after we cannot provide our patients with the service they deserve.

Let me put it bluntly: without GPs there is no NHS.

We are not a dispensable resource.

I’d like to share what members are saying themselves.

Our most recent GP Voice survey speaks volumes about the pressures that GPs are working under. It’s pretty dismaying. And although the stats I am about to share may not surprise anyone working in general practice today – that doesn’t mean they aren’t shocking.

Almost 20% of GPs told us that most days they felt stressed and felt they couldn’t cope. More than 40% said they felt that way at least once or twice a week.

And it’s not hard to understand why. Let’s consider the hours you are contracted to work compared with the hours you actually work. Only 10% of those who took part in the survey are contracted to work 40 hours or more but 40% are putting in those hours regularly. That’s a lot of unpaid work.

Anecdotally, many colleagues tell me they choose to work part-time contracts just so they have enough time to do the job properly. They use their days off to catch up on admin and to try to be on top of things.

Everyone seems to be working beyond the hours they are paid for. And I have to ask you, is this sustainable?

I’m very concerned that it is not.

In our survey, more than 40% of GPs told us they were planning to leave general practice within 5 years. Retirement was one of the reasons for people planning to quit, but it wasn’t the main one. The two biggest causes were work-life balance and stress. Thousands of GPs are considering leaving the profession because of burnout and this is happening at all career stages.

At the heart of this is a workforce which has not kept pace with workload. We all see this in our day-to-day experience, but the stats show it is indisputable.

We are delivering 14% more appointments than we were five years ago, but we have fewer fully qualified GPs.

International data also shows how overburdened we are. Lord Darzi’s recent report concluded that we have almost 16% fewer, qualified GPs than other high-income countries relative to our population.

What does this mean in real life? It means too many patients are crying out for appointments. And for our members, it means dangerously high workloads. Almost 80% of GPs say their workload is impacting patient safety. 

We cannot continue like this.

The new government has come into office promising to save the NHS here in England and to shift resources to primary care and community services.

We were pleased to see the new Secretary of State visit a GP surgery on his first day in office and we applaud his commitment to primary care. We hope to hear more about this when he addresses conference tomorrow.  We also continue to press for an equivalent commitment in Scotland, Wales and Northern Ireland.

It’s decades since Barbara Starfield identified that countries with greater ratios of primary care doctors had lower morbidity and lower mortality rates. She demonstrated the relationship between strong primary care and positive health indicators.

But she also showed the importance of primary health doctors in cost control. A recent report by NHS Confederation showed that every additional pound spent on primary care could increase economic output by 14 pounds.

Investing in primary care makes sense for a government committed to the NHS, to financial responsibility and to economic growth.

Sometimes we need to step back and acknowledge how important our work is and what we do achieve. It’s not always easy to measure:

Last year, a young man came in to see me. He had disabling PTSD and overwhelming anxiety, which prevented him from going out. He described experiences in the army and from a previous relationship, which had led to this, and how repeated attempts to get better, had failed. He was getting married, and worried he would not make it down the aisle. We talked about his life and what made him relax – his motorbike (he came in with some very advanced motorbike gear and Bluetooth helmet!).

Over a number of consultations, careful combined use of medication and talking, he has used his motorbike to get out of the house, control his anxiety better, keep working, and get married. He still struggles to function normally. He has great difficulty explaining this to people and finds it hard to sit in our waiting room but being able to talk about it in a safe, listening environment has really helped him. People are complex, and very giving…to my surprise, he has offered me a motorbike lesson.

As a former moped user when I was a student, I’m still thinking about it!

Let’s not forget that it takes 10 years to train to become a GP, to be ready to look after the whole person and tackle the complexity of conditions we face in every surgery. And although it sometimes feels like the hardest job in the world, we all know how you walk with a spring in your step for a week after someone thanks you for helping them or simply for listening, sometimes it’s for handling the worst news they could hear, with sensitivity, and sometimes it is for diagnosing and managing a chronic condition. This is not a job for the faint-hearted, but every day we do a job that matters. 

Nowadays, to be a good GP requires a team – not just good, collaborative GP partners but also administrative staff and an interprofessional primary health care team. We are grateful for their contribution as valued colleagues. 

However, we also know they cannot be used as substitutes for GPs who have taken a decade to qualify. 

So, I’d like to say a word about Physician Associates. You’ll know by now that last month our governing Council voted for the College to oppose the role of Physician Associates in general practice. The driving force behind this decision were significant patient safety concerns about the way PAs are being used, that came through clearly during our consultation with members earlier in the year.

However, recognising that there are already almost 2,000 PAs working in general practice, it remains the College’s view that the PA profession must be regulated, and PAs themselves must be supervised by a fully-qualified GP, and work within a clearly defined scope of practice.

This is why we are still going ahead with producing guidance on induction and preceptorship, supervision and scope of role for PAs working in general practice, all of which were supported by Council, and will be published soon.

The truth is, what the NHS actually needs are many more GPs.

When I began in general practice, it was normal for a GP to have a list size of between one thousand six hundred and one thousand eight hundred patients. The role was busy and challenging, but it was manageable. Our analysis of the latest figures reveals the average is now 2,300.

The numbers have shot through the roof and so has our workload. And it’s not just because the patient-doctor ratio has got worse. It’s because, at the same time, the needs of our patients have become more complex as the population ages and many more people live with chronic diseases. I know this is an inelegant term – but what this means is that most people are now ‘under-doctored’. 

More worrying, in areas of higher deprivation, where the need is greatest, we’ve uncovered evidence of how much worse that ratio has become. 

Our latest research has revealed that GP practices with the highest level of income deprivation have far greater numbers of patients to care for than those in more affluent areas.

The most deprived areas have one fully qualified GP to cover 2,450 patients. That’s over 300 patients than in GP practices with the lowest level of income deprivation. And these are average figures.

In some cases, the discrepancy is even more stark. It can’t be right, for example, that a GP in leafy Kingston upon Thames looks after just over 1,800 patients while a GP in Kingston upon Hull, one of the most deprived places in England, is expected to cover twice that number.

This situation has become more challenging for all GP practices since 2018 and we would argue almost all are ‘under-doctored’. It is simply wrong that the most disadvantaged communities have seen the numbers of patients per FTE increase by nearly twice the rate of those with the lowest level of deprivation. 

It is more than 50 years since Dr Julian Tudor Hart, a famous fellow GP from South Wales (who I had the privilege of knowing), first defined the now-famous ‘inverse care law’ to describe how – perversely – people in deprived communities who need healthcare the most, are least likely to receive it. How devastating that nothing much has changed.

I have worked in areas of high deprivation, and I know how poverty leads to health inequalities. 

First, in central Manchester in the early 1990s, I saw how poverty and lack of choices led to patients ‘living for today’, as they felt they had no control over what happened to them in the future. But I also learnt there, from a wonderful Health Visitor, that with kindness and listening, some patients did get themselves into a better place and learned how to make better choices in life. 

Then in city centre Cardiff, I saw how homelessness, alcohol and drugs ruined lives. But I also saw how a single GP’s dedication saved and changed lives. I joined her and worked with her, again seeing how showing respect and understanding lessened confrontations and allowed us to work alongside some of society’s least advantaged people. 

Finally, in the Welsh Valleys, I’ve met poverty of a different sort – long established communities, with incredibly high levels of multiple chronic illnesses, and late pathology presentations that I thought would have disappeared 50 years ago. There is so much to do, and poverty has many faces!

Surely, as a country, we cannot allow such inequality of health provision to continue to grow.

From the outside, it might look as though young doctors don’t want to work in disadvantaged communities. Nothing could be further from the truth. Newly qualified GPs are showing a huge commitment to working in areas where the need is greatest

In fact, what is happening on the ground to our newly qualified colleagues is a scandal.

At a moment when patients are struggling to get appointments and GPs are struggling with the pressure of work, new GPs are being trained but not able to get jobs. 

Our survey of GP registrars due to complete training between July and September this year found that almost half of them still hadn’t got an NHS GP job. The vast majority said they were struggling to find an appropriate role, and, on average, they had applied for around 13 jobs each. 

And guess what? GPs are struggling hardest to find roles in areas that have higher levels of deprivation – potentially further entrenching health inequalities.  

I think it is unforgivable that the poorest communities are once again being hit the hardest.

The Additional Roles Reimbursement Scheme in England has previously meant that funding for Primary Care Networks could not be used to hire GPs.

As College Chair, I have consistently highlighted this issue and am pleased the new government has listened and provided a new pot of ring-fenced money (£82 million), to employ GPs in substantive roles.  This is a positive step, made in double-quick time, but implementation will be vital.

I don’t need to tell you, conference, that workforce problems are by no means confined to recruitment. We believe that equal weight must be given to retention. Numbers of fully qualified GPs in our workforce are falling when they need to be rising. Even with more trainees coming through, we won’t see that trend being reversed if the job is so exhausting that current GPs are getting burned out and leaving the profession.

We simply can’t afford to lose family doctors at the height of their expertise and experience. The very people we need to mentor newly qualified GPs entering practice, and to keep partnerships stable.

But at present, that’s exactly what’s happening. And it’s happening across the board – we’re losing people approaching retirement, we’re losing colleagues mid-career, and we’re even losing young GPs in the early days of their careers.

As a College, we are lobbying the new government to rethink the NHS Long Term Workforce Plan. Recently, almost 10,000 of you joined me in writing to the Secretary of State to protest against the detail of the current plan. We cannot support a projected increase in GP numbers of only 4% compared with a projected rise in hospital consultant numbers of 49%.

The Plan needs to have a much greater focus on GP retention – on keeping the highly skilled family doctors we already have, at all stages of the GP career. We must stop the disastrous level of burnout affecting our profession.

We need a comprehensive programme to nurture newly qualified GPs as they settle into their responsibilities, to support GPs during the most demanding mid-career years when they are also caring for their own families, and to value the experience of older colleagues.  And the last thing we need is the axing of initiatives like the New to Practice Fellowship Scheme which can help with retention.   

We know it will take time to address years of underfunding and poor workforce planning, but some problems need to be tackled urgently. We cannot afford to lose the 40% of GPs who told us they were planning to quit within five years. We need a nationally promoted plan underpinned by easily accessible retention schemes across all local areas to ensure that many of them feel able to think again.

Let’s not forget the scale of the problem facing general practice. Less than 10% of the total NHS budget in England is currently spent on primary care, and, as the Darzi Report confirmed, that share has been falling, despite an increasing workload and the movement of extra services into the community. 

We were encouraged that Lord Darzi recognised that ‘General Practices have the best financial discipline in the NHS family’ and that ‘some practices have embraced extraordinary innovations that are improving access and quality of care for patients while relieving pressure on hospitals.’ 

Next year’s ten-year plan must set out a pathway for delivering a health service that is fit for purpose. Our current health system, with its focus on hospital care, is still geared to fixing the problems of the 20th century – the single, biomedical illness.

Medical advances mean that we can now treat diseases like heart attack and stroke that used to kill us before we reached the age of 70. Today’s challenge is in treating an ageing population with a host of co-morbidities, and doing what we can to prevent chronic illnesses.

So, we are asking for greater investment in general practice and a commitment to channel more spending to areas of greatest need, as well as supporting initiatives to increase the number of GPs. We’re urging the government to honour its manifesto commitment to halve the gap in healthy life expectancy between different regions of England within 10 years. We know none of this can be done overnight. But we need more than fine words. 

We need more GPs to do the work that is needed in primary care. We need action that starts right now. In return, of course we can deliver the reforms the government is asking for – GPs have always been versatile and innovative, but the government must work in partnership with us and allow us, as ‘eyes on the ground’, to contribute to the plans for the NHS.

Please help us to get this message out by emailing your own MP – or parliamentarian in Scotland Wales and Northern Ireland – calling on them to take action to support general practice. Speak to the team on the RCGP stand to find out how.

Finally, on a personal note, I want to thank every one of our members for the burden you carry on behalf of the NHS and the patients we care for. We don’t provide the most visible signs of strain that television cameras love. We don’t have ambulances queuing outside our surgeries and it’s hard to capture a visual image of the quiet anxiety of the patient who can’t get an appointment or the gradual wearing down of a family doctor who does their best every day but is pushed to breaking point. 

I remain committed to working to ensure newly qualified GPs get the jobs they have been trained to do and that their more experienced colleagues are motivated to stay in the profession. I want my own daughter and every other young GP to be able to look forward to a career of service and professional satisfaction. 

GPs are the bedrock of the NHS.

The NHS could not function without you.

You deserve better, and so do your patients.

Thank you.

Further information

RCGP press office: 0203 188 7659
press@rcgp.org.uk

Notes to editors

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.