Blog posts

NHS England’s plan to reduce wasteful and ineffective drug prescriptions

I published an article in the British Medical Journal in August 2017 on NHS England’s plan to reduce wasteful and ineffective drug prescriptions. In the article, I explain why national rules on prescribing are a better approach than the variable local policies being implemented by clinical commissioning groups (CCGs, the NHS organisations responsible for funding local health services).

The National Health Service (NHS) in England must produce around £22 billion of efficiency savings by 2020. A key component of the NHS budget in England is primary care prescribing costs, currently around £9.2 billion annually. Inevitably, the NHS has begun to look at the drugs prescribed by general practitioners to identify areas in which savings could be made; ideally without compromising patient care or worsening health inequalities. This process was initially led by CCGs, focusing on drugs that are either of limited clinical value or which patients can buy from retailers without a prescription (referred to in England as ‘over the counter’ preparations).[1]

However, this local-based approach is flawed.[2] Firstly, CCGs have no legal power to limit the prescribing of drugs by general practitioners. As CCG policies on restricting prescriptions are not backed by statutory guidance, this will inevitably lead to variation between general practitioners in the use of the drugs that CCGs are proposing to restrict, thereby leading to ‘postcode prescribing’. It also raises legal issues in that if there is a complaint about a refusal to issue a prescription, it will be the general practitioner who will have to defend any complaint made by the patient and not the CCG. Each CCG carrying its own evidence review, public and professional consultation, and developing its own implementation policy also results in duplication of effort and is a poor use of NHS resources.[3]

NHS England has now launched its own consultation process to identify areas where ‘wasteful or ineffective’ prescribing can be reduced.[4] However, although a national process is better than local processes, NHS England has not stopped CCGs from continuing to roll-out their own restrictions on prescribing, even though some of these will inevitably conflict with the guidance produced by NHS England when it completes its consultation process.

In its consultation document, NHS England proposes restrictions on prescribing for a range of drugs. Stopping prescribing in some areas – such as homeopathy and herbal remedies – will not be controversial but will also not save much money. Some other drugs that NHS England is proposing to restrict, such as liothyronine, have limited evidence for their benefits but some patients do find them useful, and there will be resistance from patients and from some clinicians about the proposed restrictions on their use.

The two most controversial areas will be around NHS prescriptions for gluten-free foods, for which there was a separate consultation;[5] and NHS prescriptions for drugs available over the counter. In the case of gluten-free foods, these are essential for people with coeliac disease and although gluten-free foods are now much more widely available from retailers than in the past, many patients with coeliac disease continue to receive NHS prescriptions and will resist strongly any restrictions on the availability of gluten-free foods through the NHS[6]. For drugs available over the counter, for example treatments for headlice or hay-fever, many patients will be able to pay for them out-of-pocket. Some poorer patients though will struggle with the costs of buying such drugs.

NHS England is to be congratulated for launching its public consultation and not just leaving decisions about eligibility for NHS treatment to individual CCGs.[7] However, it needs to ensure that its recommendations are accepted by CCGs and that the restrictions on prescribing that some CCGs are trying to impose fall into line with national recommendations. NHS England also needs to make the necessary changes to the National General Practice Contract and to the NHS Drugs Tariff to ensure that any prescribing restrictions it imposes have a firm legal basis. If this is not done, it places general practitioners in the invidious position of being at clinical and legal risk if they adopt NHS England’s prescribing guidance when this is finally published, at a time when they are already under considerable workload pressure.[8,9]

Restrictions on prescribing and the reduced availability of drug treatments on the NHS will have adverse consequences. For example, there is a risk of unintended effects such as codeine-based analgesics being used in place of simpler analgesics like paracetamol or Ibuprofen if the use of the latter is restricted. We also need to ensure that prescribing restrictions do not affect patients with very serious conditions. For example, if restrictions are imposed on NHS prescriptions of laxatives because these are available to buy from retailers, this will impact on patients with cancer, in whom constipation is a common and distressing symptom.

There will also be a risk that poorer patients, who are less able to pay for their own medication, will suffer disproportionately from these restrictions, thereby exacerbating health and social inequalities.[10] Ultimately, however, politicians  and the public must understand that the financial savings the NHS in England needs to make are so large, they cannot be made without substantial cuts to the provision of publicly-funded health services; and without patients making a greater financial contribution to the costs of their health care.[11,12]

doi: https://doi.org/10.1136/bmj.j3679

References
1. North West London Collaboration of Clinical Commissioning Groups. Choosing wisely – changing the way we prescribe. https://www.healthiernorthwestlondon.nhs.uk/news/2017/06/12/choosing-wisely-changing-way-we-prescribe
2. Iacobucci G. Doctors call for national rules on OTC prescribing. BMJ 2017;356:j1442
3. Phizackerley D. National approach to OTC prescribing is needed. BMJ 2017;357:j1849.
4. NHS England. Items which should not be routinely prescribed in primary care: a consultation on guidance for CCGs. https://www.engage.england.nhs.uk/consultation/items-routinely-prescribed/
5. Department of Health. Availability of gluten-free foods on NHS prescription. https://www.gov.uk/government/consultations/availability-of-gluten-free-foods-on-nhs-prescription
6. Kurien M, Sleet S, Sanders DS, Cave J. Should gluten-free foods be available on prescription? BMJ 2017;356:i6810.
7. Iacobucci G. NHS to stop funding homeopathy and some drugs in targeted savings drive BMJ 2017;358:j3560.
8. British Medical Association. BMA responds to NHS England action plan on wasteful drug use. https://www.bma.org.uk/news/media-centre/press-releases/2017/july/bma-responds-to-nhs-england-action-plan-on-wasteful-drug-use
9. Majeed A. Shortage of general practitioners in the NHS. BMJ 2017;358:j3191.
10. Gleed G. Commentary: We’re under financial strain without prescriptions for gluten-free food. BMJ 2017;356:j119.
11. Toynbee P. Feet first, our NHS is limping towards privatization. The Guardian, 16 August 2016. https://www.theguardian.com/commentisfree/2016/aug/16/feet-nhs-limping-towards-privatisation-podiatry-diabetic-amputations
12. Iacobucci G. GPs urge BMA to explore copayments for some services. BMJ 2017;357:j2503.

Interview with the British Medical Journal

The BMJ published an interview with me earlier this year for their ‘Observations‘ section.

What was your earliest ambition?
As a boy I was keen to be a pilot. My poor eyesight put an end to that ambition.

Who has been your biggest inspiration?
Two of my former consultants, James Stuart and Keith Cartwright, who mentored me early in my career, helped me write my first scientific papers, and started me on my academic career path.

What was the worst mistake in your career?
Early in my career I admitted a man who had undergone some changes in behaviour after a minor head injury. I did not consider ordering a CT scan immediately, but fortunately my senior registrar did, and a diagnosis of a subdural haematoma was made. The patient underwent surgery that evening and had a good outcome.

What was your best career move?
Moving to London in the 1990s to take up my first academic post. Although I was unsure about moving to such a large city, having always lived in much smaller towns, working in London opened up many professional and academic opportunities to me.

Who has been the best and the worst health secretary in your lifetime?
William Waldegrave and Frank Dobson both tried their best for the NHS. Those who followed them, from Alan Milburn onwards, have been far less successful.

Who is the person you would most like to thank, and why?My wife, for supporting me in my personal and professional life.

To whom would you most like to apologise?
The patients in my medical practice. As an academic GP I see them only one day a week. Because of this, many of my patients think I work only part time and have a very easy life. I can assure them that I do work full time.

If you were given £1m what would you spend it on?
Education is the key to development, so I would use the money to support university scholarships in a low income country.

Where are or were you happiest?
I am happiest when on holiday with my family in Pembrokeshire, which I visit regularly.

What single unheralded change has made the most difference in your field in your lifetime?
The development of the internet and the rapid and easy access to medical information it has made possible for patients, clinicians, and academics.

What book should every doctor read?
The Citadel by A J Cronin. Though it was published in 1937, its core messages are still relevant to doctors. For a non-medical book I would recommend The Conquest of New Spain by Bernal Diaz del Castillo, a fascinating contemporary account of the overthrow of the Aztec empire by the Spanish and their local allies.

What poem, song, or passage of prose would you like mourners at your funeral to hear?“Do not go gentle into that good night” by Dylan Thomas.

What is your guiltiest pleasure?
Chocolate. But don’t tell my patients.

What television programmes do you like?
When I have time I enjoy watching scientific, historical, and current affairs programmes.

What is your most treasured possession?
My family and friends. All the material objects I own can be replaced.

What, if anything, are you doing to reduce your carbon footprint?
I am taking far fewer overseas trips and hence flying a lot less now than in the past. I have also switched my house to LED lights.

What personal ambition do you still have?
General practice and the rest of the NHS are going through a very difficult period. I would like to see my general practice continue to provide high quality, accessible care to the people of Clapham.

Summarise your personality in three words
Honest, conscientious, logical.

What is your pet hate?
Politicians who do not base policy on evidence. Many of the problems we now face in the NHS are because of this.

What would be on the menu for your last supper?
A salmon starter, followed by roast chicken with vegetables, and finished off with bread and butter pudding.

Do you have any regrets about becoming a doctor and an academic?
No. I am very grateful that I have had the opportunity to be an academic doctor. Being an academic and a clinician opened a tremendous career path for me.

If you weren’t in your present position what would you be doing instead?
If I weren’t a doctor I would have probably pursued a career in a field such as information technology or accountancy.

The divergence of minimum unit pricing policy across the UK

A paper published in the Journal of the Royal Society of Medicine discusses the implementation of a minimum unit pricing policy across the UK. Above recommended levels of intake, alcohol use is associated with harm including hypertension, haemorrhagic stroke, liver disease, mental health disorders and cancers, as well as accidents, injuries and assaults. The 2015 UK Global Burden of Disease study indicates that 2.9% of disability-adjusted life years and 1.9% of mortality are attributable to alcohol use, and the 2013 Health Survey for England found that 23% of men and 16% of women in England drink at levels associated with risk to health. Despite the ongoing discussion about minimum unit pricing policy across the UK, and although it is difficult to predict what it would take for the Westminster Government to revert to a minimum unit pricing policy, any minimum unit pricing policy that does come to be implemented in Scotland or England and Wales will only be implemented because the relevant evidence exists.

Read the full article in the Journal of the Royal Society of Medicine.

Key priority areas for developing a patient safety improvement strategy in Libya

A paper published in the journal BMJ Open describes a protocol for a study examining patient safety in Libya. Patient safety is a global public health problem. Estimates and size of the problem of patient safety in low-income and developing countries are scarce. A systems approach is needed for ensuring that patients are protected from harm while receiving care. The primary objective of this study will be to use a consensus-based approach to identify the key priority areas for patient safety improvement in Libya as a developing country.using a modified Delphi approach.

A three-phase modified Delphi study will be conducted using an anonymous web-based questionnaires. 15 international experts in the field of patient safety will be recruited to prioritise areas of patient safety that are vital to developing countries such as Libya. The participants will be given the opportunity to rank a list of elements on five criteria. The participants will also be asked to list five barriers that they believe hinder the implementation of patient safety systems. Descriptive statistics will be used to evaluate consensus agreement, including percentage agreement and coefficient of variation. Kendall’s coefficient of concordance will be used to evaluate consensus across all participants.

DOI http://dx.doi.org/10.1136/bmjopen-2016-014770

Prioritizing medication safety in the care of people with cancer

A recent study from Imperial College London published in the Journal of Global Health examined clinicians’ views on main problems and solutions in medication safety in the care of people with cancer. The top ranked problems focused on patients’ poor understanding of treatments due to language or education difficulties, clinicians’ insufficient attention to patients’ psychological distress, and inadequate information sharing among health care providers. The top ranked solutions were provision of guidance to patients and their carers on what to do when unwell, pre–chemotherapy work–up for all patients, and better staff training.

The School of Public Health joins the UK’s effort to tackle global health challenges

The School of Public Health at Imperial College London has been awarded funding as part of a UK drive to tackle global health challenges. The work is funded by Research Councils UK as part of the Global Challenges Research Fund (GCRF), a £1.5 billion fund launched by the UK government in 2015. The fund aims to support cutting-edge research which addresses the global issues faced by developing countries in areas including agriculture, medicine, well-being and infrastructure.

The GCRF funding will also enable Imperial Professors Azeem Majeed, Toby Prevost and Mala Rao to investigate low cost technologies for screening for diabetic eye disease, a leading cause of blindness in India, in partnership with clinicians from Moorfield’s Eye Hospital in London. Professor Mala Rao, who is leading Imperial’s contribution to the project, said: “This award offers a very exciting opportunity for us to work together to transform the lives of people with diabetes and diabetic eye disease in particular, not only in India but worldwide, and to reduce the costs of diabetic eye screening in the NHS. We are thankful for this amazing chance to make a difference.” The project lead is Professor Sobha Sivaprasad from Moorfield’s Hospital in London.

Advice on the management of the transgender patient in primary care

A recent article in the journal BJGP Open provides advice on the management of transgender patients in primary care. With referrals to gender identity clinics rising rapidly, general practitioners (GPs) and primary care physicians are more likely to meet patients who are transgender (whose gender identity, or internal sense of gender, does not match their gender assigned at birth) or diagnosed with gender dysphoria (the severe psychological distress that is experienced by an individual as a result of the conflict between their gender identity and gender assigned at birth).1 Teaching on transgender medicine is lacking in both undergraduate and postgraduate curricula, leading to a perceived lack of expertise in this area. Furthermore, General Medical Council (GMC) guidelines on the GP’s role in prescribing are vague, resulting in some controversy. As waiting times for appointments at specialist clinics are often at least 18 months, GPs and primary care physicians will increasingly be involved in the initiation of the transition process: this is the process by which an individual changes their phenotypic appearance of gender to match their gender identity through medications and/or surgery.

Some of the actions advised:

  • Ensure the patient’s electronic record is updated with the correct pronoun and patient’s desired name.
  • Outline potential treatment options to include psychological therapy, speech and language therapy, hormones, and surgery.
  • Discuss with the patient a direct referral to a specialist gender identity clinic, advising that wait times are often lengthy.
  • Explain that initiating medications is usually done by the specialist gender identity team or under their advice, then discuss medication side-effects and risks.
  • If the individual is distressed or experiencing mental ill health, discuss a referral to the community mental health team.
  • If the patient is self-medicating, consider specialist advice from an endocrinologist.
  • Discuss smoking cessation if the patient is a smoker, or weight loss if they are overweight.
  • Provide the individual with advice on websites or support groups for transgender people.

The full article can be read in BJGP Open.

DOI: https://doi.org/10.3399/bjgpopen17X101001

Perspectives on the management of polypharmacy

A paper published in the journal BMC Family Practice discusses the management of polypharmacy (the concurrent use of multiple medications by one individual). Because of ageing populations, the growth in the number of people with multi-morbidity and greater compliance with disease-specific guidelines, polypharmacy is becoming increasingly common.

Although the correct drug treatment in patients with complex medical problems can improve clinical outcomes, quality of life and life expectancy, polypharmacy is also associated with an increased risk of adverse drug events, some severe enough to result in hospital admission and even death. Hence, having systems in place to ensure that medications are started only when there is a suitable indication, ensuring patients are fully aware of the benefits and complications that may arise from their treatment, and reviewing patients regularly to ensure their medication regime remains appropriate, are essential.

The development and rapid uptake of electronic patient records – particularly in primary care settings where the majority of prescribing takes place – makes monitoring of patients more straightforward than in the past; and allows identification of sub-groups of patients at particularly high risk of adverse drug events and complications. It also facilitates ‘deprescribing’ the process by which medications are reviewed and stopped if not clinically beneficial.

In recent years, we have also seen the development of smartphone ‘apps’ to improve communication between patients and healthcare professionals, improve people’s understanding of their conditions and their treatment, and maintain a record of changes made to patient’s medication. In the longer term, developments such as the introduction of artificial intelligence and clinical decision support systems also have the potential to improve prescribing and minimise the risks from polypharmacy. Finally, there is considerable scope to improve the quality of prescribing and reduce risks from poly-pharmacy using non-medical groups such as pharmacists, specialist nurses and physician assistants.

https://doi.org/10.1186/s12875-017-0642-0

What will Brexit mean for the NHS?

On the 29 March 2017, the Prime Minister of the UK Theresa May formally notified the European Union (EU) Council President, Donald Tusk, of the UK’s intention to leave the EU. Theresa May’s letter to Donald Tusk triggered a two-year process during which the UK will have to negotiate both the terms of its exit from EU and the arrangements that will replace those we have had for over 40 years with the other member states of the EU. The consequences of the United Kingdom’s departure from the EU (commonly referred to as ‘Brexit’) will be wide-ranging and will affect all areas of UK’s society, including the National Health Service (NHS).

For the NHS, Brexit comes at a time when it faces many other major challenges. These include severe financial pressures, rising workload, increased waiting times for both primary care and specialist services, and shortages of health professionals in many key areas (such as in general practice and in emergency departments), and rising rates of obesity and type 2 diabetes. The NHS also faces challenges from societal changes, such as population growth; and an aging population, which is leading to an increase in the number of older people with complex medical problems. Hence, Brexit has come at a difficult time for the NHS and will add further to the many issues the NHS needs to address in the next few years.

The most immediate challenges from Brexit will come in areas such as the recruitment and retention of doctors and other health professionals; and in negotiating new arrangements for accessing healthcare both for EU nationals living in or visiting the UK; and for UK nationals living in or visiting the EU. There are also numerous EU laws that affect the NHS and public health in the UK. For now, these EU laws will be incorporated into UK law via the ‘Great Repeal Bill’, which will end the primacy of EU law in the UK. Over time, parliament will decide which parts of EU law to keep, change or remove from UK law, a process that will take many years.

Further complications in dealing with Brexit arise from the devolved nature of the NHS in the UK, which means that the UK does not have a single NHS but rather, it has different versions in each of the four nations of the UK. Some issues arising from Brexit that will affect the NHS will be dealt with by the UK Parliament (such as freedom of movement); and some issues (such as how health services are organised) will be dealt with by the devolved administrations in Wales, Scotland and Northern Ireland.

For many decades, the NHS has faced shortages in its clinical workforce and has relied heavily on overseas trained doctors, nurses and other health professionals to fill these gaps. This reliance on overseas-trained staff will not end in the foreseeable future. For example, although the Secretary of State for Health, Jeremy Hunt, has announced that the government will support the creation of an additional 1,500 medical student places in England’s medical schools, it will be over 10 years before these students complete their medical degrees and their subsequent post-graduate medical training. Hence, these additional doctors will not address the immediate needs of the NHS and we will continue to rely on the nationals of other countries to staff the NHS for many years to come.

Furthermore, although the UK has been able to recruit health professionals from other countries in the past, we may find that this will become more difficult in the future. The changes in the political environment in the UK, for example increased antagonism towards immigration, may discourage health professionals from other countries from moving to the UK; as will the fall in the value of pound against currencies such as the Euro, which makes the UK less attractive to work in financially.

Like our own NHS, health systems in other countries in the EU and elsewhere in the world also face their own challenges; and other countries will be keen to retain their health professionals to help address the health needs of their own populations. There is a global shortage of health professionals and they will be in demand in many countries. The UK may therefore find itself a less attractive destination for health professionals in the future. Moreover, as we saw with the junior doctor contract dispute in England, when the NHS tries to impose unpopular employment policies on its staff, this can lead to an exodus of health professionals out of the NHS. We may therefore find other countries trying to recruit health professionals from the UK to address their own staffing needs, thereby further exacerbating staff shortages in the NHS.

The recruitment of overseas-trained staff by the NHS has been facilitated by EU legislation on the mutual recognition of the training of health professionals. This means that health professionals trained in one EU country can work in another EU country without undergoing a period of additional training. Moving forwards, it is unclear that this cross-EU recognition of training will continue in the UK. There are some in the UK who see clinical training here as superior to that in other EU countries and view Brexit as an opportunity to implement tougher employment checks on EU trained health professionals. This too may discourage health professionals from elsewhere in the world moving to the UK. We will therefore need to take urgent action to ensure that the NHS can continue to recruit sufficient professional staff to meet the health needs of our population.

The UK government will also have to address the issue of access to healthcare, both for EU nationals living in or visiting the UK and UK nationals living in or visiting other EU countries. Currently, all these individuals are entitled to either free or low cost healthcare. It is unclear what will happen to these arrangements for accessing healthcare in the future, until further progress is made in our negotiations with the EU. Access to healthcare is particularly important for the elderly, retired UK nationals living overseas, in countries such as Spain, who will have a high need for health care. Furthermore, as the NHS has never been very effective in reclaiming the fees owed to it by overseas visitors to the UK, the UK may find itself substantially worse off financially when new arrangements for cross-national funding healthcare are put in place.

There are also many other areas that affect the NHS that will need to be addressed. These include, for example, our involvement in future Europe-wide public health initiatives. These cover many areas including food regulations, road safety, air pollution, tobacco control, and chemical hazards; and are important when dealing with cross-national issues that do not stop at a country’s boundaries (e.g. air pollution). Although such initiatives have had important positive effects on health in the UK, there is strong resistance from some pro-Brexit politicians about participating in such programmes, as they often view them as unnecessary interference in the UK’s internal affairs. There are also risks to health-related research and development in our universities, the pharmaceutical industry, and the wider life sciences sector. This will include the ability of UK researchers to lead multi-national EU-funded research programmes, which is another area that is at risk post-Brexit.

At a time when the NHS is already facing major problems, Brexit will impose a further layer of complexity on the challenges the NHS must address in the next few years. Thus far, the negotiations with the EU over Brexit have been dominated by issues such as the size of the financial settlement the UK will have to make when it leaves the EU. However, it is very clear that Brexit will have wide-ranging impacts on the NHS and it therefore essential that the NHS engages with government to ameliorate these risks and ensure they are dealt with before the we leave the EU. This will include gaining support for the continued recruitment of health professionals from elsewhere in the world; addressing issues around access to healthcare; and the continued participation in EU-wide public health and research programmes that benefit the health of the UK population.

This blog was first published in Public Sector Focus in March/April 2017.

Shortage of general practitioners in the NHS

In an article published in the British Medical Journal, I discuss the implications of the current shortage of NHS general practitioners. Ensuring that countries have sufficient primary care doctors is a key challenge for health planners globally because of the important role that primary care plays in supporting cost-effective health systems that promote equity in health outcomes. For example, the USA is predicted to need 7,800 to 32,000 additional primary care physicians by 2025.[1] We also know that the National Health Service (NHS) in the United Kingdom is short of general practitioners.[2] What we do not know is the size of the shortage; and how many additional general practitioners the NHS needs to provide comprehensive primary care services.

In its plan for general practice published in 2016, NHS England set a target of 5,000 additional general practitioners by 2020.[3] However, no data was presented to show that this was a sufficient number to meet the needs of primary care in England. Research presented at the Royal College of General Practitioners 2016 Annual Conference concluded that NHS England had substantially under-estimated the current shortage of general practitioners and how many new general practitioners would be needed to address future health needs in primary care. According to this analysis, in 2016 the NHS in England was already around 6,500 general practitioners below the ideal number, rising to 12,100 short by 2020.[4] Given that recruitment to general practice training schemes in England remains below target, shortages of general practitioners will continue in the foreseeable future. What can the NHS do to provide comprehensive primary care services in this era of permanent shortages of general practitioners?

One key issue in workforce planning is the lack of accurate and timely data on workload in primary care; and the lack of accurate information on the number of general practitioners working in the NHS.[5] The NHS does not routinely collect or publish information of the workload of general practices (in stark contrast to hospital activity, where workload statistics are published regularly). Information on the number of general practitioners working in the NHS is also limited and does not fully take into account what proportion of their time general practitioners spend on direct clinical care as opposed to time spent on administrative tasks; or time spent in management roles either inside or outside their general practices. Improving the statistics of the number of general practitioners working in the NHS and their workload would be a useful start. However, it will not by itself address the shortage of general practitioners. That requires more radical solutions than the NHS is currently considering.

The most important step will be to link primary care funding to workload through the implementation of workload-based funding for general practices. Since the NHS was established in 1948, capitation-based payments have been the core method of finding NHS general practice.[6] However, capitation increasingly looks like a 20th century model of funding and one that is not fit for the 20th century. With activity-based funding, general practices would be paid for the work that they do. Any new work would only taken on by general practices if the funding for the work met the full costs of providing the service. Activity-based funding would also allow more rational decisions to be made about the transfer of work from secondary care to general practice; rather than the current situation in which work is often transferred from hospitals to general practices because there is little or no additional cost for the NHS in doing this.

One disadvantage for the NHS of activity-based finding is that this would be considerably more costly than the current method of funding. The government would then have a stark choice: fund NHS general practice entirely from taxation; part-fund it from taxation and allow general practices to charge patients to make up the difference; or scale back the services that general practices offer to fit in with the public funding that was available.[7] All these options are problematic but this an issue on which the government urgently needs to take a decision as the current situation not tenable.

The NHS can also examine the use of non-medical practitioners and to what extent work done by general practitioners can be carried out by groups such as nurses, physician assistants, healthcare assistants, pharmacists and physiotherapists. For example, programmes that allow patients to see physiotherapists directly without requiring a referral from a general practitioner can help reduce demands on general practices and provide an alternative, cost-effective care pathway for patients with musculoskeletal problems.[8] The NHS also needs to make more services fully accessible by patients without requiring a referral from a general practitioner – for example, exercise and weight reduction programmes, antenatal services, podiatry, termination of pregnancy services, and services for drugs and alcohol misuse.[9]

Another action that can be taken to improve the supply of general practitioners is reducing the administrative burden on them.[10] This requires a detailed review of all non-clinical tasks undertaken by general practitioners with the aim of removing as many as possible to free up more time for clinical work. An increasing administrative burden on physicians is a global phenomenon and something that increases stress among doctors. Hence, reducing the administrative burden on general practitioners, as well as releasing time that can be spent on clinical tasks, can also improve their morale and reduce their stress levels.

The NHS also needs to encourage doctors to return to clinical practice after career breaks. This is particularly important for women doctors who may have had career breaks for family reasons. Doctors are expensive to train and for the NHS not to have implemented effective initiatives to encourage their return to clinical work after career breaks is a waste of the public investment in their training. Other sectors – such as universities – have active programmes to encourage women to support women in returning to work and the NHS can learn from them. Key barriers to return to work include the very high indemnity payments that doctors now have to pay (particularly for out-of-hours work) and the poor child care support offered by the NHS to doctors with families. Finally, given that shortages of general practitioners will continue in the foreseeable future, they should be treated by the NHS as a scarce resource and be deployed in a manner that makes full use of their skills and training; with caps on the amount of work they are expected to carry out. In parallel, measures must be taken to remove barriers to recruitment and retention, while we put the systems in place to measure, track, and ultimately fix this threat to the sustainability of the health service.

References
1. Dall T, Chakrabarti R, Iacobucci W, Hansari A, West T. The Complexities of Physician Supply and Demand: Projections from 2015 to 2030. Association of American Medical Colleges. Washington, DC, USA, 2017.
2. Majeed A. Primary care: a fading jewel in the NHS crown. London Journal of Primary Care; 2015: 7: 89-91. http://www.tandfonline.com/doi/full/10.1080/17571472.2015.1082343.
3. Department of Health. General Practice Forward View. https://www.england.nhs.uk/gp/gpfv/
4. Hayhoe B, Majeed A, Hamlyn M, Sinha M. Primary care workforce crisis: how many more GPs do we need? RCGP Annual Conference, Harrogate, 2016.
5. King’s Fund. Understanding the pressures in general practice. London, 2016. http://www.kingsfund.org.uk/publications/pressures-in-general-practice
6. Rhys G, Beerstecher HJ, Morgan CL. Primary care capitation payments in the UK. An observational study. BMC Health Serv Res. 2010;10:156.
7. Iacobucci G. GPs urge BMA to explore copayments for some services. BMJ 2017;357:j2503.
8. Salisbury C, Montgomery AA, Hollinghurst S, Hopper C, Bishop A, Franchini A, Kaur S, Coast J, Hall J, Grove S, Foster NE. Effectiveness of PhysioDirect telephone assessment and advice services for patients with musculoskeletal problems: pragmatic randomised controlled trial. BMJ. 2013 Jan 29;346:f43.
9. Greenfield G, Foley K, Majeed A. Rethinking primary care’s gatekeeper role. BMJ: British Medical Journal (Online). 2016 Sep 23;354.
10. Erickson SM, Rockwern B, Koltov M, McLean RM, for the Medical Practice and Quality Committee of the American College of Physicians. Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians. Ann Intern Med. 2017;166:659-661. doi: 10.7326/M16-2697

doi: https://doi.org/10.1136/bmj.j3191