Workforce: why this needs to be explored.

I'm continuing my campaign to bring compassionate and creative debate to the challenges of the NHS and in today's article I want to raise a very simple challenge that needs a creative solution.

When hospitals are wrestling with workforce planning, they have some very clear data: the number of referrals and waiting lists/waiting times. This might be impacted by GP behaviour, but at least hospitals have a marker of the number of people needing their services at any given time.

General Practice on the other hand has always served the local community, and isn't governed by referrals. You register with a practice, and the practice provides a service. In the past, Practices had enough capacity and so could see the fluctuations in demand. As the on-call GP you would be able to discuss with your colleagues the number of additional "urgent same day" requests you were getting, and we had regular discussions about whether we were providing enough appointments to meet demand and how to adjust our service to try to see everyone. We tried out different systems - see everyone who requested an appointment (open surgeries, you sit and wait as long as it takes), or a mixture of pre-bookable and same-day appointments so that patients chronic diseases (such as pain, diabetes, heart disease) could pre-book their appointments, and patients who became unwell could still book something "on the day". There were lots of debates about whether being "too available" was actually creating demand, but most patients only attended when it was needed. Generally we were meeting demand, but there were days where you could tell that capacity had been reached. You would sometimes get a complaint from someone who attended A&E because they hadn't been able to get an appointment, and that was concerning.

Something important has changed. The workload has rocketed (both patient numbers, patient complexity, and additional tasks handed back by the hospital), so that there are almost never days when demand is less than capacity. The system is always full to overflowing. Hospitals have become super-specialised so that nobody is taking care of the "whole patient" except the GP who is struggling to piece everything together. And importantly, there is no way for a practice to measure how many patients didn't manage to get through, how many postponed their cervical smear because there were no appointments, how many are sitting on symptoms because they don't want to bother the doctor. There is no mechanism to measure the unmet demand, except for complaints and people slagging off their doctor on social media or in the press. We can look at A&E attendances, but maybe they are going up too? We can ask the out-of-hours services for anecdotal data on the patients who are going there because they couldn't get through to their GP. But what about patients whose first language isn't English? What about people who are not coming forward at all because they can't get through to their practice.

Speaking as a patient, I find this very concerning, because my practice doesn't know how long I've been sitting on my symptoms. When my Dad was dying and we couldn't get hold of anyone to help nurse him, nobody knew. Nobody is collecting the data on all the gaps and the unknown unknowns. This is not the fault of GP practices who are already working beyond capacity just to deal with the patients, but it is a situation that needs to be addressed.

Speaking as an ex-GP I find this situation very scary. You can't meet the health needs of your practice list if you don't know how much capacity you are not meeting. So you constantly fail your patients, even though you are working beyond capacity every day.

My ex-colleagues are exhausted, and the system is failing patients, and yet we don't actually have a way to measure how big the problem is. If we're going to solve this, what would success look like? 100 extra GP's? 1000 extra GP's? 10000 extra GP's? If NHS England or the Department of Health, or GP leaders are really looking to solve this, a good place to start would be to make a realistic map of demand. Otherwise workforce planning looks a lot like work-force guessing. Are there any ways to be more accurate about this? I hope so, because we all rely on our NHS and for it to survive, Primary Care needs to survive.