GPCE chair to new health secretary: ‘Let’s work together to rebuild general practice’

Dear Wes,

How we can work together to rebuild general practice in England

Many congratulations – not only upon your appointment in Sir Keir Starmer’s Government, but also for how the election campaign was fought and won. Also, genuine thanks – for the bravery and honesty in admitting what those of us who work at the coalface have known for some time – the NHS is indeed broken.

Having travelled up and down the country speaking to countless GPs and visiting many practices, you will have felt enormous frustration at the loss of over 2,000 GP practices over the past 14 years and of over 5000 ‘home-grown’ GPsⁱ whose training has cost taxpayers in the region of 2-3 billion, number of registered patients in England has increased by 6.4 million in the past 5 years alone, the average number of patients per full-time equivalent fully qualified GP has risen by 18% to over 2,300. General practice activity is at an unprecedented high, whilst erosion to the national practice contract baseline funding value is at a nadir. General practice – the most efficient and productive part of the NHS – is collapsing.

CPI erosion of core GMS contract funding since 2018/19 totals £659 million. A DDRB uplift of almost 11% would be needed this year for real-terms funding to return to where we were in 2018/19, let alone how running costs and staffing expenses are significantly higher now. I do not envy the challenges you will face with the DDRB report on the departmental in-tray. I have heard your call to be creative in looking at how existing resources can be deployed differently to bring better patient outcomes and stability of services. I look forward to this conversation.

I have been heartened by your campaign messages around how the proportion of NHS spend needs to shift from reactive hospital-based care to proactive care in the primary and community setting. In England, general practice receives almost 7p in every NHS pound. At an individual patient level, an average General Medical Services (GMS) core contract payment equates to £107.57 per annum, around 30p per day. It’s no wonder practices are closing. This is why GP contractors/partnerships are returning their contracts to commissioners – they’re no longer financially viable.

As GPs have become more stretched, the previous Government, DHSC and NHS England have chosen to wrongfully diminish patients’ access to their family doctor by focusing on funding staff other than GPs and practice nurses. Fewer appointments in general practice are now directly delivered by GPs themselves, which is leading to a significant drop in patient satisfaction. There has been much talk around ‘GP access’. I genuinely see the real issue as patients’ access to their GP.

I believe this is where Labour’s promise to ‘bring back the family doctor’ has chimed with the public. Barriers to accessing a GP have impacted patient outcomes and perpetuated the inverse care law across our most deprived communities. This has been compounded by policies seeking to penalise those very practices delivering care among our most vulnerable populations. I have some immediate solutions to recommend.

As you yourself have said, general practice is a people-based service – with exceptional, caring people delivering it. We cannot ignore the very human cost in moral injury to GPs and their practice teams which has taken place in recent years. Our survey of GPs in England, completed by more than 11,000 colleagues in January, confirmed that England’s GPs are at breaking point. 22% said it would be unlikely they’d still be working as an NHS GP in three years’ time. I’m desperate to change that statistic, and I know you will be too. You’ll be aware that April saw a third consecutive imposed contract upon practices in England, which led to our referendum where over 19,000 GPs and GP registrar members voted to reject the contract (99.2%). GP partners are currently being balloted ahead of potential collective action next month, in an act of sheer desperation.

As recently as September 2022, the House of Commons Health and Social Care Committee published a report on the future of General Practice, which set out the values of GP-led care focusing on prioritising both continuity and the gatekeeping role of the GP as the expert generalist as being key to controlling activity and demand on the wider NHS. Considerable academic evidence demonstrates how GP-led continuity of care reduces overall NHS activity and improves patient self-care; prevents avoidable and costly crisis interventions; delivers better patient and public health outcomes; and reduces NHS costs and provides greater job satisfaction. Unfortunately, recent years have seen successive annual GP practice contract changes in England move further away from this model of delivery, and I look forward to working with you to reverse this.

The British Social Attitudes Survey 2024 showed 91% of voters want to keep a health service free at the point of use. To do that, we need to go back to protecting and promoting the GP’s role as expert generalist gatekeeper to the wider NHS. Undermining our role or diminishing access to us has led to wider instability across systems and rising demand outstripping capacity. If we protect the gatekeeper and rebuild general practice, we have the best chance at fixing the NHS. Thank you for addressing your understanding around this in the pre-election period, together with signalling the importance of our meeting soon.

In advance of such a conversation, I promise you candour, transparency, and respect. In that spirit, I share our proposed solutions so we can hit the ground running when you have an opportunity to meet me:

1. Commitment towards a universal GP-led continuity of care model for England NHS general practice with a minimal general practice investment standard

• Stop disinvestment in practices which has led to the loss of almost 25% of practices in 14 years. Reverse the decline of the past five years of GP practice contract funding value erosion with a roadmap towards a minimum general practice investment standard. Start a journey to increase the NHS proportion of funding to general practice by 1% year on year, incrementally moving towards a proportional funding floor of 15p per NHS pound for primary medical services including neighbourhood health centres.
• In the immediate short-term, work with us to develop a practice-level reimbursement scheme whereby we can begin to redistribute network resources transparently into core practice funding to enable recruitment and retention of GPs and practice nurses. Our amazing practice nurse colleagues deserve parity of terms with their trust-employed colleagues.
• In our recent survey of unemployed GPs, 80% of respondents stated they want to do more NHS GP work but are struggling to find it. Getting these highly qualified GPs into practice roles must be an absolute priority for everyone, and we have solutions for this.
• Remove harmful red tape preventing practices employing the roles they need, and patients want. Continuity of care saves lives, and patients want to see a GP – if possible, their GP. Let’s listen to patients and bring back their family doctor.

2. Work with the BMA’s GP Committee England to agree a 2025 Family Doctor Charter

• 1964 holds startling parallels to 2024: An NHS in decline following years of austerity patient demand outstripping capacity; the profession undertaking once-in-a-generation industrial action, not to mention a Labour victory in a general election. The following year, the Wilson Government heralded the 1965 Family Doctor Charter together with the BMA’s GP Committee. This charter agreed principles that paved the way for the 1966 Red Book contract and heralded a transformation of general practice. A 2025 Family Doctor Charter would signal much needed hope to patients and the profession alike in agreeing heads of terms for a new substantive contract for England’s general practice to be delivered within this Parliament.
• Labour has spoken of no major new investment without major reform – we gladly accept this challenge – let us work together to fix the contract to provide the necessary transparency to invest, to permit GP contractors and partnerships to have the resources to transform, rebuild and reinvigorate general practice at a neighbourhood level, and to restore general practice as the jewel in the NHS crown.
• We have a unique opportunity to be bold and shift NHS focus towards proactive, preventative, public health-data driven primary medical care in the community, away from a reactive and expensive hospital-focused crisis care model, which will save money for re-investment, as well as lives.

3. Practices need GP to patient list size ratios to ensure manageable workloads and patient safety

• Patient list sizes have grown far beyond safe levels across England. The BMA’s Safe Working Guidance, based upon UEMO (European Union of General Practitioners) guidance recommends that GPs deliver no more than 25 appointments per day – on top of all other responsibilities to safely manage pathology results; clinical correspondence; prescribing; patient tasks; home visits; palliative care; clinical training and supervision; associated clinical governance and non-NHS (e.g. Local Authority, DWP, DVLA, safeguarding) work. Our survey showed that only 10% of respondents deliver 25 or fewer appointments on a typical day. 88% of respondents deliver 26 or more, with 52% delivering between 31 and 50. Improving general practice capacity to facilitate continuity of care through safe patient list sizes will provide the best, as well as the most cost-effective care for our nation
• Build neighbourhood and community health transformation around the value for money, productivity and efficiency of general practice, which guarantees accountability via a named GP and the registered patient list at the core of the NHS, and which is the natural anchor point around which social care can be linked in.
• Provide profession and patient confidence in the integrity of the GP patient record via better and wider data-sharing via platforms such as OpenSAFELY. Support GP contractors as data controllers by extending the Clinical Negligence Scheme for General Practice (CNSGP) to provide protection for practices when sharing data in good faith for NHS purposes.

4. Build real-terms re-investment into General Practice to retain and return our GPs to safe numbers to guarantee continuity of care for the population

• Despite clear evidence from the NHS Confederation that shows every £1 invested in primary medical care results in up to a £14 return of GDP growth, general practice has been significantly underfunded in England. The equivalent ‘full restoration’ of real-terms core GMS contract funding in England would be staggering if comparing 2024/25 with 2007/8. The model of general practice is not broken – it has been intentionally dismantled by successive recent governments.
• We need to start conversations around transformative plans and funding for our ageing estates and infrastructure – neighbourhood health centres provide an opportunity. We also have resources which could potentially be repurposed from network level to practice level.
• We need to offer a lifeline to practices on the brink of closure and under-employed GPs by uplifting tariffs eroded in real terms since 2018/19. Likewise, wipe away bureaucracy and red tape that perversely affects those serving our most deprived communities by scrapping the personalised care adjustment to childhood immunisations.

In summary, I believe we need safety, stability and hope.

Safety now to prevent unemployment and practice closures. Stability for the next year, and hope for the future.

As a profession, we are so tired of having to fight to survive – we desperately want a Government on our side – to help us deliver the general practice our patients deserve, to start the journey to bring back their family doctor, and to reset general practice as the jewel in the crown of an NHS we can all be rightly proud of.

I can’t wait to get started.

Dr Katie Bramall-Stainer
Chair, General Practitioners Committee England
British Medical Association

CC:
Preet Kaur Gill MP
Dr Thomas Gardiner
Dr John Oldham
Mr Cameron Brady-Turner

i. Between 2015 and 2019, approximately 15,000 doctors accepted ST1 GP trainee places. Assuming the minimum training time of three years, around 8,000 of those ST1 registrars who started GP training between 2015 and 2019 had worked as fully qualified GPs by March 2024. Conversely, up to around 7,000 of those ST1 registrars who started GP training between 2015 and 2019 had not been recorded in NHS England’s National Workforce Reporting Service (NWRS) by March 2024, so have not yet been captured as working NHS GP practices. Some could be in non-NHS practice-based settings, have left to work elsewhere / abroad or, indeed, work in private settings.