A new report warns of the potential for more than half of the region's GP practices to shut their doors.
Its author, Fleetwood GP Dr. Adam Janjua, who is also CEO of the Consortium of Lancashire and Cumbria Local Medical Committees, spoke to local democracy reporter Paul Faulkner.
See more, including a response from the NHS in Lancashire, here - https://www.lep.co.uk/health/shock-warning-that-over-100-lancashire-and-south-cumbria-gp-practices-could-shut-within-two-years-4500618
Its author, Fleetwood GP Dr. Adam Janjua, who is also CEO of the Consortium of Lancashire and Cumbria Local Medical Committees, spoke to local democracy reporter Paul Faulkner.
See more, including a response from the NHS in Lancashire, here - https://www.lep.co.uk/health/shock-warning-that-over-100-lancashire-and-south-cumbria-gp-practices-could-shut-within-two-years-4500618
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NewsTranscript
00:00 [MUSIC PLAYING]
00:28 Dr. Janjua, this report you've produced
00:30 paints a really bleak picture for general practice,
00:33 doesn't it?
00:33 If you could distill down into a single issue for people,
00:36 what's the one thing that they really
00:38 need to understand about the challenges facing
00:40 GPs like yourself?
00:41 What would that be?
00:43 Thanks, Paul.
00:44 I think the one issue that we are facing
00:47 that has been a predominant issue over time--
00:49 and I think it's an NHS issue, but it's becoming particularly
00:52 clear that it is a big primary care issue, a general practice
00:56 issue, which is funding.
00:58 There just isn't enough of it.
01:01 The value for money has decreased over time.
01:04 And unfortunately, the funding hasn't kept up with that.
01:08 You make the point that GP funding has been significantly
01:11 outstripped by inflation in recent years.
01:13 According to your figures, the value of the GP contract
01:16 has gone up by 11% since 2019.
01:19 But to have kept pace with inflation over that period,
01:21 it would have needed to have risen by 28%.
01:24 Now, you've asked regional NHS commissioners
01:27 to bridge that gap, haven't you?
01:29 They've refused, but where are they always going to?
01:31 It was an unrealistic request, wasn't it?
01:33 Doesn't this need a national cash injection?
01:35 Aren't you talking really to the wrong audience?
01:37 I think it's a mixture of both, Paul.
01:40 If you look at it, our local ICB, the Lancashire and South
01:43 Cumbria ICB, we have a good relationship with them.
01:45 They're in a difficult position.
01:46 But if you look at their spending,
01:48 they're spending over 52% of their budget
01:51 on acute hospital care.
01:53 That's what we call secondary care.
01:54 So that encompasses the hospitals
01:56 that are in Lancashire and South Cumbria.
02:00 This gives them a position of number two
02:03 on a position of 1 to 42, 42 being the lowest spender,
02:09 1 being the highest spender.
02:10 So they're the second highest spender
02:12 on acute care in the country.
02:14 The average is usually around 48%,
02:17 whereas on general practice, they're
02:19 spending less than 8%.
02:23 And usually, 9% is taken as a national benchmark
02:26 of how much general practice spending is at the moment.
02:29 Can I just broach the issue of inflation and the 28%?
02:35 The funding gap amounts to almost 35 pounds per head
02:39 or per patient.
02:42 Now, that is just to have stood still and not seen
02:46 any actual funding increase.
02:47 That is just to compensate for inflation itself.
02:51 And we need to be realistic about the fact
02:53 that general practice is being asked to do so much more
02:56 than it did five years ago.
02:58 We're having to buffer the issues
03:00 that the hospitals are having with their waiting lists.
03:03 7.8 million people are on a waiting list in this country.
03:07 And all of these people very genuinely
03:10 are presenting with needs that are not
03:12 being met by the hospital.
03:13 So they then present to general practice
03:16 where they expect the general practitioners to deal with them.
03:19 And rightfully so.
03:19 Somebody needs to be looking after these patients.
03:22 But that isn't-- initially, that wasn't the part
03:25 of the remit of general practice.
03:28 So you can see how access is now suffering,
03:30 because you have the people that are waiting, who in the past
03:33 would have been seen very quickly by the hospital,
03:35 dealt with and sorted.
03:36 And their problems would have been in the past.
03:38 And then you have people with newer problems.
03:41 But what we're having now is representation
03:43 of people with problems that are not
03:45 being sorted by the hospital and the new people
03:47 coming through as well, which is causing
03:49 a perfect storm of very little access,
03:52 because everybody wants to be seen.
03:54 If I had an A&E doctor sitting in front of me,
03:56 isn't there a chance they'd say exactly the reverse
03:58 and that it's general practice not
04:00 being able to see people that results in patients turning up
04:03 inappropriately at A&E?
04:06 Look, I think it's a fair reflection of what
04:08 some clinicians are seeing.
04:10 I mean, there was a study done some time ago
04:12 where they asked patients in A&E why they're presented.
04:15 And a lot of patients said, we couldn't get a GP appointment.
04:18 But when they actually followed through with that
04:20 and checked whether that person had actually ever
04:23 had any contact with general practice for that encounter,
04:26 they found that that wasn't necessarily the case.
04:28 So when you put people on the spot,
04:29 they will say different things to try and sort of make it
04:32 seem like there was no other option.
04:35 But I should mention, statistically,
04:37 there hasn't been a huge increase in A&E attendances
04:40 if you look nationally.
04:42 Those numbers have remained static or even
04:44 decreased somewhat.
04:45 The problem with A&E itself is because the hospitals are
04:49 so full, they're not able to discharge people
04:51 because social care is so bad at the moment.
04:55 And therefore, there is a backlog.
04:56 And if you can't get people out of the hospital,
04:59 you won't have any beds to get people into.
05:03 The problem with that also is that we
05:04 have had a huge bed reduction over the past 10
05:07 years in this country.
05:09 So if you look at the bed numbers now compared
05:11 to 10 years ago, you'd be surprised to see
05:14 that there was almost a sort of double the number of beds
05:17 before.
05:18 So we can't have a situation where you reduce beds
05:21 and then expect hospitals to be able to function
05:23 the way they were.
05:25 You mentioned in the report about inappropriate workload
05:28 coming the way of GPs because of hospitals.
05:30 What is it that, in your opinion,
05:32 hospitals aren't doing that it's then
05:34 landing back up at your door?
05:36 Well, the BMA agreed a contract with hospital doctors
05:40 in general that they needed to do their own work.
05:42 So for example, if you see a consultant in clinic
05:45 and they want you to start a particular medication,
05:47 it's their job to counsel you on that medication.
05:50 It is their job to start you on that medication.
05:52 And then it is their job to make sure you're stable on it.
05:55 Only when you're stable on it will
05:57 that particular prescription transfer to general practice.
06:01 We're seeing that's not happening.
06:03 In 90% of the cases, we are being
06:05 sent letters that take weeks to arrive where patients are being
06:08 asked to be started on a medication.
06:10 The patient gets frustrated thinking that we are delaying
06:12 it, but we are not.
06:13 We're just not getting the letters on time.
06:15 And it isn't our job to start those medications.
06:18 There are also instances where if a consultant sees you
06:22 and they feel you need a referral to another specialty,
06:24 that should be being done by the consultant.
06:27 We are clearly seeing that that is not happening as well.
06:30 We're getting letters back saying,
06:31 could you please refer this person for another test
06:33 or to another department?
06:35 And that goes against the contract.
06:36 So we're getting all sorts of workload being--
06:39 it's a bad expression to use, but being
06:41 dumped on general practice.
06:43 All whilst we're trying to deal with the, like I said,
06:45 the perfect storm of access issues
06:47 because you have new people coming through.
06:49 The people on the waiting lists are not being seen
06:51 and need sorting as well.
06:53 So we're being hit by a crisis on three sides.
06:56 And it isn't something that we are
06:58 going to be able to sustain for very long.
07:01 We've explored some of the reasons there.
07:03 But if you have a look at the reports and some
07:05 of the consequences or the projected consequences,
07:07 in Lancashire and South Cumbria, seven practices
07:10 who responded to your survey said
07:11 that they were at immediate risk of closure.
07:14 And another 94 were in such financial stress
07:18 that they predicted if things weren't resolved or improved
07:20 over the course of 18 months to two years
07:23 that they could be in the same position.
07:26 Is there a tipping point coming, do you fear,
07:28 that's going to take people by surprise?
07:30 And if so, what do you think it is?
07:33 I think there is.
07:35 I think there's a very real threat of practice closures
07:38 in the very near future.
07:40 I hope it doesn't transpire because that would mean
07:42 that either my practice or my colleagues' practices
07:45 will close down and that will severely hamper access
07:49 for patients that think that the access is already quite poor.
07:52 I think that if there isn't an immediate
07:56 sort of effort to try and help the situation,
08:00 with funding in particular,
08:01 but also looking at the other aspects
08:03 that we have talked about, the workload dumping,
08:06 I think we're going to see lots of practices close.
08:09 And I think it's going to be a watershed moment.
08:11 And by that time, it'll be too late.
08:14 I think patients won't be able to sort of protest
08:17 and stop those kinds of closures
08:19 because it will just have gone under the radar
08:21 until it doesn't.
08:22 And that's when the crisis point hits everyone.
08:27 - There's a line in the report that says,
08:29 I'm paraphrasing slightly,
08:30 but access has really been prioritised
08:33 over continuity of care.
08:36 Just explain what you mean by that.
08:38 - I think government rhetoric hasn't helped.
08:41 You will see your GP when you want to.
08:43 You can see them face to face or whichever way you want.
08:48 You'll be able to see the same GP.
08:51 It's impossible to guarantee these kinds of things
08:54 if you don't have a stable workforce,
08:56 a workforce that can actually deal
08:58 with the consequence of the workload
08:59 that is being put on it.
09:01 Now, it's very easy to say these things,
09:04 but you can't fool the public for too long.
09:07 They will realise that these are just sound bites
09:10 to try and get election votes.
09:12 And I'm not trying to pinpoint any particular party.
09:16 In fact, I'm really struggling to see
09:17 who I will vote for in the next general election
09:19 because all parties seem a bit mute to the points
09:24 and worries that we have in the NHS firstly,
09:26 but also they come up with these very crazy solutions
09:30 that just try and win votes,
09:32 but won't actually help anyone in the long run.
09:34 So what we need is good political leadership
09:37 from both sides to make sure that, you know,
09:39 this crisis can be navigated through.
09:41 It's not a joke.
09:42 This is the NHS.
09:43 It's an institution that's been surviving
09:44 for over 75 years now.
09:46 We can't have it erode and just fall off
09:48 because people are playing silly political games.
09:51 It just isn't appropriate.
09:53 - The report talks about recruitment challenges
09:55 and it even suggests that maybe you should be allowed
09:57 to use some of the funding that you've been given
09:59 for these additional roles in general practice
10:01 that people will be familiar with over recent years
10:05 to recruit GPs.
10:07 Do you think those additional roles
10:09 have been some kind of a stop basically,
10:11 that, you know, as long as you've got an appointment,
10:13 you've seen somebody that that will satisfy people?
10:15 Do you think we've actually gone too far down that road
10:18 of non-GP roles within general practices?
10:22 - I think before I answer that question,
10:24 I want to make it very clear.
10:25 There are some very, very good people working
10:27 in those non-GP roles
10:29 and they are making a huge difference.
10:31 But overall, I don't think it has had the impact
10:34 that the government intended.
10:36 I do feel that the government is using this
10:38 as a numbers game because if I put in 200 non-GPs
10:41 next to 10 GPs, I can then say that I have 210 people
10:45 working in general practice.
10:47 Whether that maintains the quality, the continuity of care
10:52 and the safety standards that are expected
10:55 of having 210 GPs, I would say, no, it isn't.
10:59 It's not meeting those standards.
11:01 And it is just making the public think
11:03 that there are more people working in general practice,
11:06 but it's clearly not the same level of quality
11:08 that you get from that.
11:10 - One of the issues that's raised in the report
11:12 where there'll be a bit of a crossover
11:14 between the vagaries of NHS finances
11:17 and the public's experience of general practice
11:21 is the issue of the telephone systems.
11:23 Obviously, there's been this pledge from the government
11:27 to end the eight o'clock mad scramble
11:29 and rush for a GP appointment.
11:32 And some of that is linked to technology, isn't it?
11:35 And the report mentions that some surgeries
11:37 have invested in that ahead of time, almost,
11:41 ahead of it becoming a national political issue,
11:44 but they've been financially penalized in some way.
11:47 In what way is that?
11:48 - Well, some practices were forward thinking.
11:51 They knew that they had had some issues
11:53 with their telephone lines
11:54 and people were sort of getting stuck
11:55 or calls were being dropped.
11:57 So they moved to new telephony providers that were digital
12:00 when this guidance came out,
12:02 thinking that there would be some help
12:03 because when the guidance came out,
12:05 there was talk about being help available for practices.
12:10 Now, in order to set up a new system
12:11 for an average practice,
12:13 it can cost between 15 to 30,000 pounds to set it up.
12:17 These practices did that on their own back
12:20 using partnership profits
12:21 to try and sort of get ahead of the game.
12:24 Now, only to be told that they should have waited
12:27 because they didn't wait,
12:29 they're not going to be given any funding
12:31 to reimburse them for the setup costs.
12:34 I also wanna mention that I think the eight a.m. rush
12:38 was a sound bite by NHS England
12:40 because anybody that has a modicum of common sense
12:45 will be able to think about the fact that,
12:47 yes, you could have a hundred phone lines,
12:49 but if you only have eight receptionists,
12:51 you're still gonna have a backlog
12:53 for them to be able to answer the phones.
12:56 So unless you get staff in to answer those calls,
13:00 you're still going to have the eight a.m. backlog of calls.
13:04 Now, the problem here is with less funding,
13:07 practices are going to tighten their belts.
13:09 That will mean that they will be looking at
13:11 maybe getting rid of some staff.
13:14 It's an economic reality.
13:16 And what will happen then?
13:17 There will be less people to answer those calls
13:19 and access will suffer further.
13:21 So it is a never ending cycle unless you choose to end it
13:25 by having good leadership, good ideas, good initiatives,
13:28 and increased funding.
13:30 That is the only way this will work.
13:31 - One of the most striking phrases in the reports
13:35 is that you feel that the NHS could be eroded into oblivion.
13:38 Is that really your belief that we are at that stage
13:42 or is that just a bit of doomsaying to make a broader point?
13:46 - No, I think it is a reality.
13:48 I've seen the rise of private GP providers.
13:52 I've seen a talk from the affluent in society
13:56 where they say, well, bring it on,
13:58 bring on private healthcare.
14:01 But I also have people that I know in the States,
14:03 in America, who even despite having
14:06 very expensive insurance premiums
14:08 are having to pay upwards of 500 to 1000 pounds
14:11 just to go and sort of have one visit to A&E.
14:14 So people won't know what's gonna hit them.
14:17 And it's going to hit the more, sort of the less affluent,
14:21 the people that are deprived in society.
14:24 I live in Fleetwood, which has a lot of deprivation.
14:27 My patients can't afford to go privately
14:29 or most of them can't.
14:31 I don't want them to go privately.
14:33 This is a great country with a great NHS institution.
14:36 We need to protect it.
14:37 And what's happening now is that the political willpower
14:40 just isn't there.
14:41 They're happy to let it slide into oblivion.
14:44 And it isn't scaremongering.
14:45 And I would urge all your readers
14:47 to actually access this report that we're talking about
14:50 because when we wrote it,
14:52 we wrote it so that it could be understood
14:55 by literally anyone who sort of has a general knowledge
14:59 of what's happening in this country.
15:02 We want you to make up your mind and decide for yourself
15:05 whether it's scaremongering or not.
15:06 But the facts that we have laid out in the report,
15:09 they're irrefutable.
15:11 Everything that's in the report is in the public domain.
15:14 Nobody's trying to scaremonger.
15:15 It is just the truth and the reality of the situation
15:18 that we're facing at the moment.
15:19 - You've almost preempted my final question,
15:22 but is there anything that gives you optimism at all?
15:25 - Yes, there is.
15:27 There is the resilience in the workforce
15:29 that we see in the NHS as a whole,
15:32 but in particular, general practice.
15:34 I mean, year on year, general practice
15:36 is seeing more appointments and seeing more patients,
15:39 whether that be face-to-face or telephone
15:41 or online consultations.
15:42 They're dealing with more patients per day
15:45 than they ever have before.
15:47 And that's increasing year on year.
15:49 But we can't expect that resilience to have no bounds.
15:53 Even a well will run dry if you overuse it.
15:56 So we mustn't take advantage of this workforce.
15:58 They will burn out.
16:00 They will lose the sort of,
16:02 the thing that makes them the pride of the NHS
16:07 and the pride of the country.
16:09 And once that happens, the spark's gone
16:11 and you can't bring it back.
16:13 - Dr. Janja, thank you very much indeed for talking to us.
16:16 - Thank you, Paul. Thank you.