Health and Sport Committee

Meeting date: Tuesday, September 27, 2016

Official Report 548KB pdf

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General Practitioner Recruitment

Good morning and welcome to the sixth meeting of the Health and Sport Committee in 2016 in the Scottish Parliament’s fifth session. I ask everyone in the room to switch off mobile phones as they can interfere with the sound system. We have apologies from our convener, Neil Findlay, so I will convene the meeting.

Agenda item 1 is an evidence session on general practitioner recruitment. We welcome to the committee Gerry Lawrie, deputy director of workforce, NHS Grampian; Lesley McLay, chief executive of NHS Tayside; Dr Miles Mack, chair of the Scottish council, Royal College of General Practitioners; and Dr Alan McDevitt, chair of the Scottish GP committee, British Medical Association.

We are not expecting any opening statements, so I move directly to questions. I will kick-off. We have heard a lot about there being a GP crisis. What is it about the current position that makes it a crisis?

My college has been campaigning on the issue since 2013, when we predicted increasing problems for general practice and that we would see GP numbers falling. Unfortunately, that fall seems to be happening, and it is causing us a real problem in delivering the GP service that we want to deliver. A third of practices in Lothian are unable to take new patients; increasing numbers of practices are being taken over by health boards, often with devastating results for patients; and there is increasing difficulty in recruiting GPs into the profession and retaining them for a long-term career. Those are important issues, and the situation seems to be completely at odds with the Scottish Government’s ambitions for its 2020 vision and now for realistic medicine.

Physicians in the community deal with elderly people with increasingly complex problems and enable them to be looked after and cared for at home. We take great pride in our work and believe that having good, long-term relationships and really meaningful conversations with our patients is crucial in ensuring that the care that they get meets what matters to them. We provide continuity and are the first point of contact.

On that basis, it is crucial to look at the issue to ensure that we are taking the right steps, particularly by tackling the falling percentage of national health service funding that is going to general practice. The amount was set at 9.8 per cent in 2005-06, but it is down to 7.4 per cent in the latest figures that we have. That is despite the ambition of the previous Cabinet Secretary for Health and Wellbeing in asking health boards to spend more money on primary care, which was a commitment that was made to us in November 2014.

We continue to call for investment in general practice. We have clear evidence that we need it. I draw Helen Irvine’s work to the committee’s attention. Independently of the college, she has made it quite clear that investment in primary care will reduce inequalities, provide services for patients at home and reduce the requirement for accident and emergency and elective healthcare services.

The BMA has been doing a GP practice survey every quarter for some time now. Our latest figures, which are from September, show a 28.6 per cent vacancy rate in general practices around Scotland—it was the same rate in June. We have seen a substantial change in the number of posts that are still vacant after six months—from 42 last year to 80 this year—so we are getting clear evidence of a major recruitment problem. In addition, practices cannot obtain locums to cover for GPs who are on holiday, sick leave or maternity leave. As Miles Mack has said, the result is that many practices are having to somewhat restrict the services that they provide. The problems that we are seeing now are very real and are beginning to affect patients. That is when it becomes a crisis—when patient care begins to be affected by the numbers of GPs that we have.

Although I often talk about the role of other professionals in helping general practice, it is also about making sure that general practice medicine is available to our patients and that in future patients can access a GP, as a doctor, when they need to. Today is as much about that as it is about the total redesign of primary care.

The key thing is that the crisis—the shortage of GPs—is now manifest and we are working very hard to change the fundamental nature of general practice to make it attractive for doctors both to stay in and to come into as a career. That is one of the fundamental reasons why the BMA is now renegotiating the contract with the Government: we want to try to resolve some of the underlying problems that have made general practice a less attractive career to stay in and to come into initially as a young member of the medical profession.

We are all very aware of the workforce pressures that the profession is under—pressures that relate to demography and the recruitment of new GPs. In particular, the number of unfilled vacancies seems to be the single most difficult problem that we face. Does the panel think that the use of the term “crisis” will contribute to a solution? I have found in conversation that, when the term is used again and again, a perception builds up that can be quite off-putting.

I was interested in what Dr McDevitt said—his language was more temperate to begin with, when he spoke about a “recruitment problem”. I ask the panel to unpack some of the challenges, beyond the contract renegotiation and GP recruitment. Do you think that we can reframe the language that we use? I appreciate where you are coming from in defining the situation as a crisis, but I do not know if that contributes to solving it. I am keen to hear your thoughts.

As we have been going round the country preparing for changing the contract, we have talked about changing the mood music. The first thing that we have to do is change the perception of general practice so that it is seen as an attractive career for young doctors. Unfortunately, the negative circumstances that we find ourselves in tend to make people say, “Well, I’d better not go and do that.” It is vital to change the mood music.

We can look forward to a very positive future for GPs in Scotland if we manage to achieve all the things that we aim to achieve, particularly through contract realignment but also through changing the role of the GP. A GP should be an expert medical generalist in the community who is part of a multi-professional team and can focus on what we call “undifferentiated presentations”—in other words, the patients who think that they need to see a doctor and that they might be sick. A GP should also focus on complex care—dealing with people with more than one condition—and being a clinical leader who is responsible for improving the outcomes for patients, working together with them to bring about what patients want to happen in their lives in relation to their health. General practice is a fantastic career and we have to make sure that the role and circumstances of being a GP in Scotland are as positive as they can be. That is how to change the mood music.

The word “crisis” is not helpful. When does something become a crisis? Recruitment has been building as an issue and will remain an issue for some time to come, even when we are fixing things. I am not hugely fond of the word “crisis”, but I am responding to the way that people are describing the situation. Call it what you like, but there is certainly a major problem and it will take some time to turn around. We will all have to work very hard together to fix it.

I believe that we are in an absolute crisis in terms of GP recruitment and am comfortable with that language, not least because no new medical centres have been built in my constituency for 45 years, despite the year-on-year proliferation of new housing and the fact that some surgeries have had to close their lists. I am very supportive of the call by the Royal College of General Practitioners for investment to be increased to up to 11 per cent of the health budget.

I want to explore the trainee issue. We know that not all the trainee vacancies that have been made available have been filled. Perhaps more alarmingly, the committee heard last week that not all those trainees are domiciled in Scotland and may not all go on to practise in Scotland. Can the panel bottom that out and give us an idea of the extent of that issue?

It is an interesting point: the trainees who are coming through now are not like the trainees who came through when I started in the national health service. Their expectations and career aspirations are very different. For example, in Grampian we have a predominantly female workforce, some of whom choose to work part time. We have some evidence that the male workforce is choosing to work part time as well.

Alan McDevitt referred to how GPs are marketed and sold. The image of GPs is not particularly positive and their portrayal in the media, particularly in television soaps, is negative. We do not portray becoming a GP as an attractive opportunity for people.

I bring to the committee’s attention the think GP campaign that the Royal College of General Practitioners has just started. We are very keen to ensure that general practice is portrayed in a positive way. We have four videos of GPs across the United Kingdom that show young doctors working at fantastic levels—the variety and challenge in what they do and the responsibility that they have.

It is clear to me that being a GP is, and should be, a fantastic job. We should be batting people off because so many want to get into general practice, as was the case when Alan McDevitt and I started our careers. There were far more applications for every post then, which meant that the best medical graduates got into general practice.

I take the point about using the word “crisis” and talking things down, and I regret that we have had to talk about general practice in negative terms. However, I believe that we have to tell the truth. If the doctors who are training in general practice hear from my college that all is rosy, that there is enough money and that the future is sound, but see with their own eyes that doctors are working 10 or 12-hour days and feel that their ability to work and provide safe patient care is being compromised by a reduction in the workforce, that gives me, the college and the solutions that we have come up with no credibility.

I point out just how much positive work the college has been doing on the issue. We were ahead of the game with remote and rural recruitment back in 2012. We also explored the ideas that we have now brought forward as the GP career flow, in which we say that we cannot think only about the 100 new places but must also look downstream at what the GP career will look like in the future and how we can retain people.

We also have to look upstream. For example, I have just written a blog for the General Medical Council describing some of the issues around the bad-mouthing of general practice and psychiatry in medical schools. That just should not be happening, but it seems to be happening and is the sort of thing that we really need to challenge because it is not fair on the profession and is severely damaging it.

We need to ensure that we are training in the right way. I am delighted to say that yesterday I had sitting in with me in my surgery a fourth-year medical student who is spending 10 months of his fourth year in my practice learning general practice. I admitted to hospital two of the patients I saw as duty doctor yesterday, and the student has the opportunity to join the post-receiving ward round at Raigmore hospital tomorrow—to see what happens to those patients in the ward—and to follow them back into the community. If we want a joined-up approach to medicine, that is the way in which to train doctors and the sort of support that we need. That student is part of a pilot that is run from Dundee, which is exactly the sort of thing that we are talking about in our GP career flow.

I apologise if I seem negative, but one part of my role is to tell the truth and to ensure that there is a consistent approach across the board to providing the resources for the initiatives that we put forward in the blueprint document that we provided last June and in the manifesto.

As an NHS board chief executive, I want first to say that I fully acknowledge the challenges that exist in relation to general practice and recruitment. We have a number of workforce challenges, but the board and the health and social care system have a number of strategic plans that we implement locally.

NHS Tayside serves a population of about 400,000 and we have about 330 general practitioners. Our vacancy level is pretty constant at about 5 per cent. We are fully aware of the age profile issue, which is challenging the health and social care system across a number of specialties. Just now, about 15 per cent of our GP workforce are over 55, so that is clearly a challenge.

Locally, we are doing a number of things. For example, the board has a five-year primary care strategic framework, which our clinical leaders have put together. We are looking at the whole healthcare system. We have taken on board the opportunity to form clusters, which allow a clinical leadership model to form locally. In NHS Tayside, we have 13 clusters. A level of maturity is being established, and there is engagement across general practice. By looking at our data and information, we are supporting practices to tackle some of the challenges that they face.

We are doing a lot of work on the extended role of the multidisciplinary team. I am clear that GPs are the clinical leaders and that they sit at the heart of our vision for the delivery of primary care and community services over the next five years, but I highlight the importance of the wider multidisciplinary team and of the agency team, and the contribution that the staff in those teams can make in meeting the demands and the healthcare needs of the population that we serve.

10:15  

Dr Mack, you indicated earlier that the current crisis was predicted. What did not happen? Why were those predictions not heeded? What lessons can we learn to resolve the current crisis?

Obtaining an increased percentage of funding for general practice lay at the core of our campaign strategy. That was what we brought to the previous cabinet secretary. We believe that we made that argument quite strongly. Giving the resources to general practice to provide the necessary staffing is the single most important thing that needs to be done. I am referring not just to general practitioner staffing, but to other members of staff. As Alan McDevitt suggests, we now need to think about having a wider multidisciplinary team to deliver care, because there will probably not be enough GPs in the immediate term. However, it is clear we must have the aspiration to increase GP numbers.

According to a Scottish Government press release, there has been a 40 per cent increase in consultant numbers. That has not been matched in general practice over the same period—there has been almost no increase in the number of GPs. Indeed, the workforce survey suggests that we have lost 2 per cent of GPs in the past two years. It seems that the workforce planning has gone awry and that we are not investing in the workforce in the right place. At a time when we are talking about the 2020 vision and the provision of more community care, it seems wrong to increase consultant numbers by 40 per cent without bringing about a concurrent increase in the number of GPs and additional staff.

When I came into general practice, we had only our reception staff. Now, we have slightly more staff. There are six GPs for a practice of 10,000 patients, and I have one whole-time equivalent practice nurse and half a healthcare assistant. Those are the only staff I have to deal with the acute demand as it comes into the practice.

We have a wider multidisciplinary team, but there has been a lack of investment in the structure that supports general practice. At the same time, the work that we do has become much more complex. As we have driven up quality, that has created increased demands, particularly on GP time. There has been a lack of investment in meeting the broader needs of patients as they present to general practice, which is where 90 per cent of patient contact occurs. In the main, the place where you and your family come into contact with medicine is general practice, but we have not invested substantially in supporting how that medicine delivers the best outcomes for patients. That strain is now telling in the enormous workload on GPs. We have no one else to share that with.

We need to find new members of the workforce. New GPs will be part of that, but we know that they will be slow to come on stream, so many other professions will need to join us in meeting the immediate patient need and demand on the front line. We need to have the right professional to deal with patient need, but we have not previously had the capacity to enable that to happen.

An example of how strange the situation became was that, if a patient who was at home needed a blood test, we were told that that could not be done by a district nurse because blood was part of the GP contract. It was a need that the patient had, but because of the way that people thought about how we worked under the contract, teams were prevented from working to meet patient needs appropriately. We need to get rid of all that and start working properly as professional teams, so that the right professional can meet the right patient need. There needs to be a much greater number of professionals available to share the workload that currently is dealt with mainly in general practice, because that is where the bulk of the work occurs.

That investment is an absolute requirement, and we call on the Parliament and the Government to invest in that way. I know how stretched the public purse is, but that is an absolute requirement. If you want to fix the issues and have general practice for your families and mine, investment in the new model of general practice is required now.

We are absolutely open to the kind of general practice in which the other professionals play their part and we have a greater offering to the public. Currently, general practice is the hub where most people come into contact with the NHS. We want to build up the hub so that a greater offering of professionals is immediately available to the public to meet their needs at the front line. We are up for making that the way forward, but the Parliament and the Government have to make that investment, even though times are hard.

I have listened intently to the points that Dr McDevitt has made, and I agree that we have to look at that approach. To use a word that has not been used for a long time, let us reduce the demarcation and work together to solve the problem. It is not just about money. I agree that the money should be looked at, but it is about making a start. We need to start now to get more people in to become doctors. I am working on a particular case for a constituent who wants to be a doctor but who, unfortunately, is a few points short of the requirement to get into university. I have been to see the university and I hope that it is listening to me today. We have to train doctors in, I think, five or seven years—

It is five years at university and then subsequently another five.

Yes; basically, we have to start now to train the doctors that we will need to resolve the problem. With the greatest respect, we have to look at each and every situation. Throughout the country, we have doctors who work in surgeries that they own, doctors who work in health centres, doctors who are paid by the NHS and doctors who basically manage their own practices—I think that they should be doctoring, if I can use that word, rather than managing. We have to look at the whole situation and resolve it. We have to look at money, but we also have to look at workforce and how we can encourage people. If anyone out there can help me to get the boy that I mentioned into university, I would be pleased, because he wants to be a doctor and his family is going through a terrible time because he cannot get in there because of a few points. Should universities look at that? Should we also look at demarcation within the gamut that you have spoken about?

Governments are rightly looking to ensure that recruitment into medicine represents the population. We know that people are more likely to serve their local populations, whether they be rural or deprived, so universities should absolutely ensure equity of access and Government should be involved in that. It will always be hard to get into medicine, because it is so competitive. Although the numbers of GPs have dropped, it is still the case that far more people want to become doctors than can become doctors. It will always be hard to get in, but we have to ensure that there is equity of access to universities across the social spectrum. A lot more work has to be done on that, because the current work is clearly not having a major impact.

Are you saying that there are more people out there who want to be doctors but who cannot be doctors?

Yes.

Yes—that has consistently been the case for a long time.

The numbers applying to medical school are still consistently very high, although it is really sad that they are dropping off at later stages. Alan McDevitt is exactly right about where people come from. We understand that only 50 per cent of entrants into medical school are now domiciled in Scotland. Our international evidence, which is borne out by the remote and rural work that we have done, is that people tend to return to their place of domicile after university. That needs to be looked at.

I think that Richard Lyle is hinting at the idea of contextualised admissions, which I heartily applaud. There is very good evidence on reducing the grade requirements for people from particular backgrounds who find access very difficult; some of that evidence is from the Scottish Government’s own work on removing barriers to education. That is not just about people from inner-city areas; it is a big issue for remote and rural areas. In some remote secondary schools, pupils do not have the opportunity of doing all four sciences and by default might not have the grades that are needed. They may also struggle to get experience of nursing homes, for example. We have had a real issue with remote and rural recruitment because of that. Contextualising admissions seems to be a clear way forward. It seems to pay dividends and probably means that we are more likely to get the doctors that we need.

I will say one thing about demarcation: there are real risks to it. We need to do whatever we can, but we also need to be clear about what the primary care team is. I am very proud of work that we did with the Royal College of Nursing, the Royal Pharmaceutical Society and the other primary care members to try to define what the primary care team is and what we can provide. We do not want artificial barriers, but we will need a network group of professionals who understand what their job is and what they can expect from others and who have really good communication links. That will involve defining what we do as doctors. It is important that doctors are clear about what our unique job is, and what nurses, advanced nurse practitioners and pharmacists can do.

I would like to build on that point. There are really good examples in workforce planning and development relating to the extended primary care team. The principle is about not the people who substitute, but looking at the workload and demand and allowing certain healthcare practitioners to work to the top end of their licence. In the nursing profession, particularly in primary care, we now have a number of advanced nurse practitioners and nurse consultants. Previously, a lot of the nurse consultants worked in quite specialist areas in secondary care, but nurse consultants now work in medicine for the elderly. In one of our deep-end practices in Dundee, for example, we have a nurse consultant with that background who works out in primary care.

There are really good examples of our allied health professionals and physiotherapists working with the clinical team and running particular clinics where they can be independent with an agreed scope of practice. That is being done collaboratively with the GPs.

At last week’s meeting, the panel touched on the role of the pharmacist. Certainly in NHS Tayside, we have had pharmacists attached to GP practices for at least the past 10 or 15 years. That does not take away the challenges, but it helps address the demand and the workload, and allows pharmacists to undertake work that GPs do not need to do.

There is still a lot more work to be done, but really good examples are developing and emerging in the primary community care service, where there is real strength. I refer not just to the healthcare professionals. There are great examples of the third sector inputting and supporting: for example, by bringing to the practice patients who can be transported but have no access to transport they save the need for home visits.

Working on what that multidisciplinary team is is absolutely core, but we should recognise the opportunity that health and social care integration is bringing and the relationships with the third sector. It is about looking right across the whole health and social care system to support the increasing demand from the population.

How many training places do we have in Scotland for people to become doctors? I want to get that on the record. Do we know?

I think that this year’s intake was 353.

That was for GP training.

I am sorry; I beg your pardon.

Do we know how many students are going to university to become doctors? I am looking for another one to do so, but do we know how many there are?

I certainly do not have those figures to hand. When I was at the University of Glasgow, the figure was 200 a year. That was one of the biggest medical schools.

I have exactly the same problem in helping the children of some of my patients to get into medical school. We have recognised that it is very difficult for some students to get access to experience with a GP because they do not know doctors, as Miles Mack said. We are trying to arrange a swapping arrangement in our area with another practice so that we can facilitate local children getting experience of general practice to try to help people from our communities to get into medicine. That is something that we share with you. I suspect that, at some point, we have all been involved in trying to help children to get into medicine. However, it is a difficult area, and it probably always will be.

Could everyone please keep their answers slightly shorter?

10:30  

In Grampian, we have been offering a scheme called doctors at work for school pupils who are on the academic route to becoming doctors. We have opened it up to the whole of Grampian and we take some students from outwith Grampian too, including those from Orkney and Shetland, who might not otherwise have access to such a scheme. It is running successfully. The pupils come for a week and spend time interacting with doctors and shadowing doctors, so everybody gets better access. One thing that is surfacing is about individuals’ values and intentions. It is not just about academic ability, but about values, what you believe in and your commitment to becoming a doctor or a GP in future.

Another thing that I would like to mention on the back of the multidisciplinary team relates to physicians’ associates, which I do not see mentioned. In Grampian, we run a course with the University of Aberdeen and are in our sixth cohort. We offer those individuals bursaries. They come from a different supply; they are generally science graduates and they do a post-graduate degree and then become part of our workforce. We are highly successful in placing them. In fact, we could place more, and those in primary care who have them are very enthusiastic about them. There needs to be more work and support around physicians’ associates.

I will direct my first question to Miles Mack. When you spoke earlier, you talked about the devastating results for patients when practices were taken over by the NHS. I may have misunderstood that, and I will look back at the Official Report to check, but I would like to explore that mixed model further, if I may. Gerry Lawrie said that part-time working is more attractive to both men and women, which will obviously have an impact, but I want to understand whether the Government could be doing more to offer salaried positions, or whether you have any concerns about that model?

There are a number of issues to do with that. Salaried posts do seem to be more attractive, particularly when doctors are concerned about the general medical services contract not being fit for purpose and about their workloads. I do not have clear evidence for this, but people seem to want to be salaried to health practices rather than health boards. We have concerns that some of the practices that have been taken over by health boards seem to cost an awful lot of money to run—sometimes twice as much—and we are not sure whether that is because of underestimates in the past or because self-employed doctors are an incredibly efficient way of running a practice.

The multidisciplinary team is important, but those of you who have a scrutiny role should make sure that you are aware of a review by the University of York centre for reviews and dissemination that was published in June 2015 and which pointed out that there is not clear evidence that such arrangements reduce the overall need for GPs:

“Role substitution is being widely promoted, but the extent to which that will reduce GP workload is unclear.”

The review also points out that other ways of working, including telephone triage and other things, are more about shifting work around than making life easier for GPs, so we have to be clear about what we want to achieve. The multidisciplinary way of working is not a cheap option. The members of that team cannot see patients at anything like the rate at which GPs can, and they need supervision. We need to build in the additional time that GPs will need to spend interacting with the other members of the team.

You are saying that it is important that we look at the multidisciplinary team model—Dr Elaine McNaughton gave evidence last week and said that it was not new to her, although it may be in some other areas—but while we are looking at it we must not lose sight of the fact that we must ensure that we have enough GPs, because that model is not a substitute for general practitioners.

The Scottish Government has told us that the number of GPs has increased by 7 per cent. I know that there are three members here who represent Lothian, but we have been told that we have 39 restricted lists in Lothian, and deep-end practices in particular seem to be suffering terribly. Are the extra 7 per cent of GPs that we are hearing about having any impact on health inequality?

The extra GP posts are headcount rather than whole-time equivalent. We have clear evidence from the workforce survey that the Information Services Division performed that we have lost 2 per cent of GPs in two years. It may be that the headcount is increasing, but the whole-time equivalent—the actual number of GPs who are on the ground to deliver care—is not increasing. The trend is actually downwards.

Dr McDevitt, in your letter to the committee, you raise concerns about a suggestion that more GPs might work between primary and acute care. Could you comment on that?

That comes out of one of the many variations of hubs that are around, particularly in the Forth Valley area. We have worked to get an agreed position on that suggestion, but the idea that the future of general practice is a doctor who also works in secondary care and dips in and out of primary care is not one that we find attractive. We think that we need doctors who work in primary care as general practitioners—expert medical generalists in the community.

We have a very scarce workforce. The idea of sharing it in some intermediate role, as is indeed happening in Forth Valley, worries me. We cannot recruit people for the core general practice jobs but we are getting new jobs that take people away from general practice. Forth Valley was one of the first areas that had a major crisis in staffing general practices. There are things that we can learn from the pilot in Forth Valley, but we certainly do not see that approach as the future for general practice in Scotland. It is quite clear that having GPs in the community—expert medical generalists who are available to everyone in the community—is a fundamental part of the future for general practice in Scotland, as opposed to some other invention of what general practice could be.

I am interested in developing that point further. Dr Miles Mack spoke very animatedly about the opportunity for his medical student to work in a rural general practice and to follow the patient into the hospital, go on the ward round and follow the patient back into the community.

As a clinician myself—although I am a pharmacist and not a medic—I found that what attracted me to my job was the quality of care that I was able to deliver and the clinical challenges. I thought that being able to move GPs into more complex care might make the job more attractive, so I would be interested to hear what—

I am smiling slightly, because I reckon that my job is pretty complex. We deal with people from new babies to the elderly, pregnant patients to people with mental health problems—because you cannot separate mental health from the physical illnesses that affect people. GPs deal with all that every day.

In one surgery I will go through the whole spectrum of age and the whole spectrum of disease, and I will have to manage that all along. In addition, people have multimorbidity now. They do not have just one illness or one problem; they have heart disease and diabetes, have had a stroke, are depressed and have had a recent bereavement. One of the beauties of general practice is dealing with the whole person. That is the element of complexity that engages me. It is about real people with their real problems.

As well as that, we have an increasingly complex elderly population who we need to look after at home. If we continue to deal with older people with complex health problems by sending them to hospital, we will not be able to build the hospitals fast enough. We need to look after people close to home. There is no doubt about that; everyone is in agreement.

Taking on that complex medical workload is a real challenge, not least because right now there is not time to do it. As well as that, we have to continue to build our skills. As part of the GP contract in future we plan to build in regular time that is non-patient-facing for GPs to continue to upskill themselves in the role that they are taking on. It will be a much more complicated role, making sure that people with complex medical problems are cared for at home in the way that they wish to be. The advances in medical technology will allow that to happen much more often. That is a very complex part of our work.

Most GP training occurs in hospitals. We would like more of it to happen in general practice—that is an issue that we need to discuss—as we have plenty of experience of hospital medicine. What is needed is general practice medicine in the community, so we have to make sure that that is what we are trained in, what we are experts in and what we train young doctors to do.

I have no qualms about saying that that is complicated enough to engage me for my whole career.

So you do not see the potential for GPs to care for people in community hospitals?

I am saying that they do that now. That is about buildings again; as someone else mentioned, we should not get too tied up on buildings. The sort of patients with complex problems who are in community hospitals are similar to those who are at home. Increasingly we will find that the complexity of your problem will not determine your location as much as your nature will. Basically, we are getting much better at dealing with things at home that in the past would have had to be done in a hospital or in a community care hospital.

There are many parts of the country where, for example, community hospitals are invaluable to the way that the geography works. Sometimes it is better to bring the patient to where the professionals are; at other times, in a bigger area such as a conurbation, we bring the professional to where the patient is. We need to be absolutely flexible about that.

The placement of care should be irrelevant; the issue is the complexity and quality of care that we can provide. The presumption should be for care in the patient’s own home; we have to start with that and go from there. The patient should go elsewhere only when elsewhere will definitely improve the outcome.

I raise the flag for rural medicine, where GPs are commonly looking after hospitals and doing amazing work. They obviously need extra skills for that and David Hogg, who is in the GP video, is an example of that; on the Isle of Arran, the GPs provide all the hospital care as well.

One of the big problems is that the recruitment crisis has put community hospitals at risk, as the committee members are aware. We have seen Lockhart hospital closing with the practice unable to cover that as well as the general medical services workload. The same thing happened to my practice. It was with deep regret that we had to stop providing care to the Ross Memorial hospital because we were unable to recruit the GPs needed to do the day-to-day work safely.

You are quite right; GPs have lots of skills and are invaluable to the NHS. At a time when we are short of GPs, we need to focus them where they are essential because no-one else is qualified to do the work that GPs do.

For the record, there were 898 medical undergraduate places in August 2016. Do panel members want to comment on whether that is enough to provide the GPs and the medical staff of the future?

It is probably more about retaining those into careers and making sure that their career flow is appropriate to where we want them to go. We can probably improve the conversion rate into general practice for Scotland if we undertake some of the ideas in our GP career flow proposals.

Alison Johnstone asked most of the questions that I was going to ask. I have an observation that picks up the points that Maree Todd made about the potential for a GP to work in both general practice and acute services. I visited a community hospital in the Highlands and Islands that was operating what I think was called a rural fellowship. The anecdotal evidence was that a great attraction was that that GP could work for two days a week and then work at the local hospital for three days a week—or whatever the balance was. That mixed working was what made that job particularly attractive. Have you any observations on that?

We have always done that. I was a clinical assistant in respiratory medicine; I have done medical politics; I have done all sorts of other jobs as well as being a GP. That is fantastic and is what we call a portfolio career—Dr Mack and I are what we call portfolio career GPs. That has always been part of general practice, but that is not what GMS and general practice are about. The core job is the two sessions that that GP does—that is what being a GP is. The rest is other things that doctors can do. There are lots of those, such as working for the Benefits Agency or the Government. There is always going to be the capacity for GPs to have other roles. What is often forgotten is the need to make the core role of the GP attractive; that is the reason why people come into general practice. If everyone who becomes a GP spends only half the time doing it, we are certainly going to need an awful lot more than we are already talking about.

We must make being a core GP a fundamentally attractive and interesting future career; just saying that it is okay because you can do other stuff is not the way to make it the future. It is interesting and good that being a GP allows flexibility in a career and allows other interests, but it is still being a GP that we need to make the biggest attraction to bring people into the profession.

I will pick up Maree Todd’s point and build on it a little. I bring to the panel’s attention some of the work that we are doing in Tayside that we classify as enhanced community support. We are putting that in as core service provision that builds on the GP practice population and brings in the consultants for medicine for the elderly and psychiatry of old age—individuals whose jobs plans have them working in the secondary care sector and also in primary care.

10:45  

We have good evidence from the initial pilots, which were targeting unscheduled care. We know the challenges for older people and unscheduled admissions. A rapid assessment is necessary from the team. That includes dedicated GP time, the psychiatry of old age consultant, the medicine for the elderly service, the pharmacist, the senior district nurse, social work services and the allied health professional going into the individual’s home. It is an example of the GP working with other senior medical colleagues to undertake a rapid assessment. Often, they take the decision that the person needs to be admitted but they manage their admission and discharge.

We have had a lot of success. We have reduced the number of unscheduled care admissions and, when people have been admitted, the length of stay has been reduced. After piloting that approach, we are rolling it out fully. It is about helping and supporting the GPs and working with wider primary and secondary care colleagues to manage the patient journey.

Thanks for coming along. You said that you are keen to increase the percentage spend by 2 or 2.5 percentage points. Clearly, that means that somebody else will have a reduced spend. I throw that out to see what you want to say about it. To put that in context, the Scottish Government is talking about a shift to primary care, so I assume that, when you talk about GP spend, you are saying that, although there is money going to primary care, it goes not to GPs but to somewhere else in primary care. Is that correct? I am trying to get to the concept of preventive spend. We have heard before from GPs that, if we invest money in their services, we save money in accident and emergency. Can you put some flesh on that and say how we quantify it?

My second point concerns GP workload. We are talking about multidisciplinary teams and taking work away from GPs. I know that the witnesses have reservations about some parts of that, but the quality and outcomes framework has been done away with and pharmacists to whom I have spoken are happy that repeat prescriptions, for example, are coming away from GPs, so there are measures that are reducing GPs’ workload. Has any analysis been done of how much of a day in the life of the GP is the stuff that they should not be doing and can go elsewhere? How much ground have we gained along that road?

I am happy to speak about the percentage spend. I am sure that the Scottish Government will want to invest in the health service. It has been doing so consistently, but we need to ensure that we invest in the right place. For instance, we were disappointed with the most recent budget, in which the real-terms increase for territorial health boards was 3.8 per cent but the GMS rise was only 1.9 per cent. That seemed to be strange because of the issues that we had already observed. There will undoubtedly be investment in the health service in general; we just want to ensure that it is invested in the right place.

We have clear evidence from Deloitte surveys about the effectiveness of primary care. That is backed up by the work that Helene Irvine has done in Glasgow, which shows that the issue is not lack of resources but resourcing the wrong things and that, by investing a large amount in elective healthcare, we make inequalities worse. That backs up long-standing evidence from Barbara Starfield and others that shows that investment in primary care reduces inequalities and mortality. There is no clear evidence that that always happens when we invest in secondary care.

I am very grateful that the QOF has been replaced and proud that the royal college came up with some of the concepts that have replaced it, particularly the peer-led and values-driven approach. It will be a major way forward. It will give us the structure to provide leadership and consider not only the intrinsic quality of practice but the extrinsic factors of how we work within the NHS, which is a key part of the work that I have been doing over the past two years.

Percentage spend is not always the most helpful way to discuss the matter. We certainly need an absolute investment in general practice in particular. By that, I do not necessarily mean the GMS spend, which is technically where it would normally sit, because we do not want to expand the number of staff whom we employ. We want to have other staff who assist us in doing the work that comes to the practice, but that does not necessarily have to come through my accounts, for example, because we want to reduce the burdens of being independent contractors to make it a more attractive future for GPs.

We need to find ways to ensure that we can agree between us the money to support general practice in its new role—if we get to that stage with the new contract, as we hope. Hopefully, we will come to an agreement with the Government about the investment to support general practice, because—as Miles Mack said—Helene Irvine has shown that a lot of the investment that has gone to primary care has made no difference to general practice and the work that we do. That is due to a different focus on how that spend works and the outcomes that it is trying to achieve. We definitely want investment that improves the outcomes that we achieve through general practice. That will require a new look at how investment is counted as spending that goes towards supporting general practice as well as that which comes directly through the GMS spend.

I did not get the answers to my questions. First, if I spend a pound on GPs, how much do I save at A and E? Secondly, has there been any work done on how many hours GPs spend doing stuff that they do not need to be doing?

On the second question, there has been a lot of different work done, but it is difficult to pick it apart. Patients do not usually come to their GP with just one issue—like in supermarkets, they come with more than five items—so it is difficult to say what GPs should not do. GPs are extremely efficient and they are almost certainly the most efficient single group of people to deal with all those issues. Cost effectiveness is a good argument for dealing with those issues with more GPs because they are remarkably cost effective.

I am sorry to interrupt you there, but you touched on a point that Dr McNaughton brought up at last week’s meeting. She said that the cheapest and most cost-effective way was to get GPs to do absolutely everything—her expression was that they could

“do things all in a oner.”—[Official Report, Health and Sport Committee, 20 September 2016; c 27.]

However, that would not give the patient the best service.

I disagree. I think that it gives the patient a very good service. Anyway, we cannot do that as there are not enough doctors, so we are changing that approach. New aspects of quality of service are brought in by other professionals who bring skills in addition to those of the GP.

In terms of cost effectiveness and improving outcomes, GPs are remarkable cost effective at what they do. Based on a number of different people’s opinions, it is probably true that about 25 per cent of the work that I do every day could be done by somebody else—and could possibly be done better. That is the scale that we are talking about and that might free up 30 per cent of my time to deal with complex care—the new agenda for care for patients—and to make the job more humane.

Many of our colleagues say that the workload is inhumane and they are choosing to get out of it in one way or another by either going part time or leaving the profession; 259 GPs under 50 left the profession in the past five years and 200 of those were under 40 when they decided to get out. We have to change the GP’s role to make it a good job that is manageable in humane terms despite dealing with the new complex workload. It is true that GPs are happier working in a proper multiprofessional team and I am fortunate that I still have one, as it is a great team to work in. The demarcation issues that Richard Lyle hinted at disappear when a team works well and everyone knows what each other’s role is. We know how we are best placed to deal with things and we contribute equally to that effect. Once you get a good team working, the demarcation issues disappear.

I have some specific figures for potential savings that Deloitte came up with for us in 2014. In reduced A and E attendances and social admissions, the saving was between £26 million and £37 million; in reduced ambulatory care sensitive conditions admissions, it was between £12 million and £27 million, depending on low and high ratios; in decreased alcohol consumption, it was between £4.7 million and £7 million; and in smoking reduction, it was between £5.6 million and £9 million. The estimated totals give a range between £48.9 million and £81 million. Those figures, produced by Deloitte, are on our website.

Those figures are based on an investment of how much?

I would presume that the basis for that was noted in our campaign call, but I need to check that.

If you could send that to the clerks, that would be super.

I would like to go back to Richard Lyle’s point about recruitment, especially with regard to how universities are helping to meet the demand. How do you feel about how the university sector is planning the workforce? I was told yesterday that the University of Aberdeen has 160 places for medical students and that they have reduced the number for Scotland-domiciled students by 12 places for the current academic year. Can we do more and say to the universities in Scotland that they have to take a larger percentage of Scottish students to study medicine? Given that we fund Scottish universities and that international students pay £30,000 a year to take that course, is the Scottish Government failing to do that?

When I started my career in the NHS and I was involved in the induction of the new junior doctors who were leaving medical school, I asked how many of them had trained locally and about 95 per cent put their hands up. Twenty years down the line, I am lucky if the figure is 50 per cent among the new graduates who start with us. I am disappointed that the University of Aberdeen has reduced the number of places, because we are struggling to recruit not just in primary care but in other areas. I would strongly emphasise the need to get local students into the Grampian area—when I say “local”, I mean from the north of Scotland, including from Shetland, Orkney and Highland, because there is movement between those areas.

To what extent will Government incentives such as the £20,000 that is being provided and the 100 additional training posts make any difference?

That £20,000 is allocated only to certain training schemes, and we have only three in the north. We have recruited relatively well this year for our GP training scheme, but that does not mean that it is always going to be that way.

I am not an expert on this, but it seems to me that universities are almost just educational businesses and it is for the Government to influence how they operate. As you have hinted, there are other routes through which they can get funding. It is also true—Miles Mack has done a lot of work on this—that the feeling in universities and medical schools is not positive towards general practice, and it is fundamental that we change that.

On the flow of new GPs coming through, there are lots of places where our potential GPs drop off, including getting into university and their choice of specialist training once they have come through the foundation years. We also need over 50 per cent of junior doctors to choose to become GPs, and they are not doing that. Even when they do make that choice, they are often lost to our workforce at the end of their training. There are lots of places where we lose potential GPs, and we need to fix that.

We have asked the Government to address the matter, and the minister announced at our conference this year that she will produce a workforce plan, part of which will focus on how we can produce the number of GPs that we need for the future. That will be difficult because we are changing the role, the demands of the population are changing and all the other workforces come into play. Trying to predict how many GPs we need is therefore a bit of a black art. We certainly need more now, and we need to produce more than our system is currently producing. However, it is a work in progress to say how many GPs we need to produce, and the universities are a fundamental part of that.

There is good evidence that training doctors in general practice provides good value. Not only does it provide more GPs, there is evidence that doctors who end up in hospital posts have better communication skills, are better able to deal with risk and make better use of resources because of the training that they have had in general practice.

I fully recognise all the factors that determine where people will end up after their training. Notwithstanding that, however, I still think that there is a role for the healthcare system in engaging as early as possible with undergraduates across all the disciplines to entice and encourage them. We must work hard at that to retain them in our system.

I thank the panel for coming along this morning to speak to the committee. It has been enlightening for all of us. I suspend the meeting briefly for a change of witnesses.

10:58 Meeting suspended.  

11:02 On resuming—