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GP Recruitment and Retention

Volume 638: debated on Wednesday 28 March 2018

[Mrs Madeleine Moon in the Chair]

I beg to move,

That this House has considered recruitment and retention of GPs.

It is a pleasure to serve under your chairmanship, Mrs Moon—for the first time, I believe. I am grateful for the opportunity to hold this debate on an issue of critical importance to all our constituents.

General practitioners are the cornerstone of the health service in this country. The work they do on a daily basis is vital to the nation’s wellbeing. As the first point of contact for people with physical or mental health problems, they have a unique duty of care within the NHS. From newborn babies to our elderly citizens, the continuity of care that they provide from cradle to grave puts them at the heart of communities up and down the country, and the lifelong relationship they build with their patients as a result is unique. We in this House must do our best to protect and promote that relationship in any way we can. That is one reason why I am holding today’s debate.

I also sought this debate out of increasing concern for the state of general practice in my constituency and the wider north-east. Since entering the House in 2010 I have noticed a marked increase in the number of constituents getting in touch to raise concerns about the amount of time it has taken them to see their family doctor. It was on the back of those concerns that I began to survey my constituents on waiting times at their local GP practice. That survey is ongoing, but the results that have come in over the last year are concerning. When asked how long they had to wait for an appointment to see their GP regarding a routine matter, over 30% of those who responded to my survey said it took more than two weeks, and 15% said it took even longer. Waiting times for urgent care were equally concerning, with over 30% waiting more than 24 hours for an appointment. The growing difficulty in accessing GP services is clearly having a knock-on effect on the rest of the health service in my area.

Due to staff shortages in a local GP surgery, one of my constituents in the Colne Valley was referred to our local hospital for a blood test. They had a 30-minute drive each way and a two-hour wait for the test to take place. Does my hon. Friend agree that that is a warning sign that general practice is struggling to cope with extra pressures and less money?

I am sure the experience of my hon. Friend’s constituent is happening up and down the country. We want to ensure that people can access quality healthcare close to home. It is neither cost-effective nor in the best interest of patients to have to travel further to hospital for things that could be dealt with more readily within a GP’s practice.

More and more local people are telling me that they have to attend accident and emergency to get the treatment they need, because they cannot get an appointment with their GP or their local practice is closed when they need it. We saw record numbers at Sunderland Royal Hospital A&E this winter, when the entire NHS was stretched to breaking point. It is extremely worrying in that context that so many people are turning to emergency services simply to access the care that family doctors might ordinarily provide.

The hon. Lady has made a brilliant start to her speech. I did a similar survey to the one she describes in my own constituency, and I found that access to GPs was almost instantaneous provided that people did not specify the GP they wanted to see. My own practice consists of a number of GPs. I think the results are patchy around the country. Is this not a time to look at the old partnership structure of GPs, to avoid the situation where a young doctor has to find £100,000 or £200,000 in order to go into practice?

The hon. Gentleman raises a fair point about patchiness, and I hope the Minister will be able to respond to it in his summing-up. There are big regional variations, and differences even within cities and towns, and we need to try to even out access to general practice. He raises an important point about routes into the profession and the barriers that they sometimes place in the way of those seeking to work in general practice, and I hope the Minister will say a bit more about what the Department will seek to do to take away some of those barriers.

In my constituency, just yesterday, a practice in Hightown that had been earmarked for closure was saved at the eleventh hour thanks to a vigorous campaign by residents, the local authority and the parish council. Does the experience of Hightown, which is no doubt repeated elsewhere, not show that the damage done by the reorganisation of the NHS from 2010 onwards has caused real problems in GP services up and down the country, and that the Government need to get their act together and address the shortage of GPs for communities in all our constituencies?

I am happy to hear that my hon. Friend was successful in his campaign, but we are seeing closures and mergers of practices across the country, and we need a much broader solution. It should not fall only to local campaign groups or local NHS managers to try to put right some of the broader systemic problems in our health service.

My hon. Friend is making a powerful speech about not just patchiness but the consistent pattern we see across the country. It is not simply down to people being too picky about who their GP is. In Scotland we have seen the number of GP practices fall from 1,029 when the Scottish National party came into power in 2007 to just 956. We have seen the number of GPs increase by only 1% in Scotland, but the size of GP practice lists has increased by 7%. The root cause is one of supply and demand; we are not getting enough GPs to come into the sector when more and more are retiring all the time.

I agree with my hon. Friend and I am sure his constituency, in common with mine, has significant problems with industrial illness and long-standing health problems, which means that we do not need just the national average number of GPs, or just enough to get by. To deal with the health need we face in the local population, we need a much better service to ensure that we drive down some of the health inequalities that most seriously affect communities such as mine and, I am sure, his.

More generally, constituents are also worried that changes to the GP workforce at their local practice are producing a less effective service. Many are concerned by rates of retirement, especially among family doctors with whom they have built up a close relationship over many years. They also believe that the overall decline in the number of family-run practices resulting from retirements is damaging the continuity of care they expect from their local practice.

On the securing of timely appointments, constituents who work full time are frustrated by restrictive booking systems and a lack of availability in the evenings and at weekends. Others complain that constraints in the system mean that the 10-minute consultation period is so strictly enforced that multiple appointments are necessary just to outline the problems that they face. Their frustration grows if they cannot see the same doctor on each occasion and have to repeat the same problems time and again.

There is a general sense among my constituents, and indeed in the comments posted on the House of Commons Facebook page ahead of this debate, that the pressures on general practice will only increase as more new homes are built in communities where public services are already under pressure.

Does the hon. Lady agree that the pressures have been compounded by the ageing population, by retirements and by an increase in expectations? Does she welcome the new hospital schools announced this week?

I will touch on all the points the hon. Lady raises as I continue through my contribution.

I am clear that addressing the housing crisis in our country should be an absolute priority for the Government, but I argue that building thousands of new homes without ensuring that the necessary infrastructure is in place to meet increased demand on health, transport and education services would be a recipe for disaster. Poorly planned housing developments that do not take account of local need will only undermine public confidence in supporting a housing revolution in this country.

It is not just our constituents who are concerned about the deteriorating state of general practice in the north-east. Just over 18 months ago I was contacted by the Sunderland local medical committee about the findings of a confidential survey of local GPs and practice managers, which showed that almost half of those surveyed had seen a large increase in their workload and a further 31% reported an increase to unsustainable levels. Although two thirds of practices had attempted to recruit new family doctors, many had found recruitment difficult, and a majority reported that patient care had been adversely affected by the failure to recruit and retain GPs, the increasing workload that imposed on existing GPs and the significant reduction in core funding allocated to their practices. As a result, 60% of Sunderland GPs and practice managers said that their practice was viable only for between one and three years, with many local doctors considering early retirement or a career change.

That survey highlighted the profound problems at the heart of general practice in Sunderland, further evidence of which was laid bare in statistics I requested from the Department of Health later in 2016. Those figures showed not only a shocking 25% reduction in the number of full-time equivalent GPs in the NHS Sunderland clinical commissioning group area between 2013 and 2015 but also an accelerating rate of decline from one year to the next. The way in which full-time equivalent GP numbers were measured changed in 2015, but the new methodology shows a continued decline of 9% in the Sunderland CCG area between September 2015 and December 2017.

I am sorry to say that the most recent figures for other parts of the north-east make for even more painful reading. In the Hartlepool and Stockton-on-Tees CCG area there was a 15% drop in numbers over the last two years. In the South Tees CCG area it was 14.9%. In the Darlington CCG area it was 13%, and in the Durham Dales, Easington and Sedgefield CCG area it was also 13%. I could go on, but it is obvious that the exodus of family doctors from the profession is having a serious impact on the number of hours being made available for general practice in our region.

As a result, the demand on family doctors who continue to soldier on is intensifying. Not one practice in my area has a lower ratio of patients to full-time equivalent GPs than the England average of 1,738:1. In fact, each and every practice is consistently and significantly above that. The situation will be similar, if not worse, in other parts of the north-east.

Coupled with the plummeting number of full-time equivalent GPs is the similarly concerning decline in the number of GP practices in the area, from 53 in 2013 to just 40 today. I accept that there are merits to the argument that consolidating practices makes them more sustainable in the long term by creating larger patient lists. However, it is really important to remember that practice closures can leave behind big holes in communities.

In Scotland we face a shortage of 1,000 GPs by 2021. Torry medical practice in my constituency has really struggled to fill vacancies and decided to end its contract with the NHS at the end of July. The practice is vital to the area, and thousands of my constituents rely on its services. Does the hon. Lady agree that the Scottish Government should seriously consider ways in which they can attract more medical students to Scotland?

Attracting medical students to areas of the country with the greatest need is important. That is something I have been seeking to do, and I am sure the hon. Gentleman will continue to make that case as well.

I am absolutely delighted that Edge Hill University in my constituency has just been granted a medical school. Does my hon. Friend, or indeed the Minister, have any view on how to retain the doctors who will train there and ensure that they can practise in the area? Lancashire has seen the largest fall in the number of GPs of any county since 2015—it is nearly 10% down. We need solutions to make areas attractive in order to retain the medical students who train there.

My hon. Friend is entirely right. I will say a bit more about Sunderland’s successful bid for a medical school—a number of parts of the country have benefited from those new schools. She will no doubt accept that this is part of a much longer-term solution to resolving the crisis we face. Meanwhile, we need action from Ministers to deal with some of the short-term pressures on local services.

The most vulnerable patients, who already find it difficult to get to their local practice, will undoubtedly be further inconvenienced if that practice moves further away. The creation of larger super-practices also risks breaking the critical link between family doctors and the patients they serve. In any case, the national and local strategic push for larger practices appears to be having little impact on GP numbers, as I have sought to make abundantly clear.

I do not believe that we can go on like this. We should rightly celebrate that people are living longer, which is in part a testament to the world-class care that the NHS provides, but we need to acknowledge that an ageing population with increasingly complex long-term care needs is likely to put further pressure on GP services in years to come. The British Medical Association is clear that general practice in England is under unprecedented pressure to deliver more support to patients with fewer resources. As the problems grow increasingly severe, GPs are being forced to test their resilience beyond reasonable limits and to confront issues from a multitude of directions.

I am deeply concerned that eight out of 10 GPs feel unable to deliver safe care; that seven in 10 feel that patient access to services has decreased of late; and that six in 10 have reported a rise in their stress levels. There is a workload limit beyond which we cannot reasonably expect family doctors to go. Given that more than half are now considering the temporary suspension of new patient registrations to ease the burden, it seems that we are close to that point.

If we are to address the crisis in general practice, we must first consider the factors that drive it. The Sunderland CCG practice area is grappling with several problems that I am sure will be familiar to GPs in other parts of the country. I have mentioned the long-term challenge of coping with an ageing population that has longer and more complex care needs, but that is coupled with rising public expectations of what their local general practice should be able to deliver. Let me be clear: demands for flexibility in terms of evening and weekend opening hours are not unreasonable at a time when so many people work during the week. After all, public services must be responsive to how people live their lives. That said, it is inevitable that offering round-the-clock access to GP practices will increase the pressure on existing workloads unless more family doctors come into the system.

Unfortunately, the opposite is happening in my area, where there are significant issues with recruitment not only of GPs, but of nurses and other healthcare professionals. Meanwhile, existing GPs and practice managers are dealing with additional work moving from hospitals into the community without associated funding. Added to that is the increased pressure on budgets resulting from rising estate costs from NHS Property Services, and the fact that the percentage of the NHS budget allocated to general practice has not kept pace with the rest of the health service. Finally, the cost of medical indemnity for GPs has risen significantly in recent years, pushing up the cost of insurance and making some work, especially unscheduled care, prohibitively expensive for GPs.

We therefore have a perfect storm of pressures on general practice that is driving experienced family doctors from the profession, with a third of GPs in the Sunderland CCG area considering retirement in the next five years. The dramatic fall in the number of GP partners over the last year should also come as no shock given the increasing responsibilities of running a practice where income is falling but workload is rising. In that context, it is easy to understand why more and more experienced GPs are opting for locum work instead, which allows them to work set hours with a set fee to a very specific set of tasks.

However, the cost to the NHS of this shift in culture cannot be measured only in financial terms, although that is certainly a major concern. As I mentioned earlier, the closure of a local practice is often devastating for a local community and can leave the most vulnerable patients with less access to the long-term care they need.

The crisis in GP retention therefore needs to be urgently addressed, and I ask the Minister to explain what the Government are doing to stem the flow of GPs quitting the workforce or rejecting partnerships. The GP retention scheme has proved a popular way to help family doctors who are considering leaving the profession to remain in work for a reduced number of sessions, but the Government simply must do more to ease their workload if they are serious about their commitment to attract and retain at least an extra 5,000 GPs in England.

On the other side of the coin is recruitment. Given the challenges for retention I have outlined, improving recruitment is critical if the general practice forward view target of increasing the number of GPs by 5,000 by 2020 is to be met. The BMA has warned that that target looks increasingly unachievable without a significant increase in the number of doctors through the expanded international GP recruitment programme.

Sunderland CCG is part of the NHS Cumbria and North East submission to that programme, and at least four local practices have expressed an interest in hosting a minimum of 10 GPs. In addition, the CCG is running other schemes to attract more family doctors, such as the GP career start scheme, the golden hello scheme and the GP bursary, yet whatever additions those can make to the workforce will clearly be insufficient to address the long-term drop in the number of hours made available for general practice in our area, with the number of full-time equivalent GPs falling from 201 in 2013 to just 139 in December last year. I know that the methodology for measuring that number has changed, but it is evident, whatever way the figures are measured, that there are simply not enough new doctors coming on stream to plug the ever-widening gap in service need in Sunderland.

I hope the Minister will take responsibility for this situation, and that he will agree that this is a national crisis, rather than an issue to be dealt with by local NHS managers. He will be aware that, in addition to the GP shortages we have discussed, the most recent figures show more than 100,000 NHS posts currently lying vacant—this is before we have even left the European Union.

What assessment has he made of the impact of Brexit on EU workers in the NHS, and does he agree that the Government’s increasingly hostile attitude towards migrants from both inside and outside the EU risks exacerbating the jobs crisis within the NHS at a critical moment? Rather than creating a hostile environment, should the Government not celebrate those who have come to our country to keep our NHS going, and who have made such a fantastic contribution to our health service since its inception?

I hope the Minister will at least acknowledge the problems that the north-east faces in recruiting new medical students into general practice. We in the House have a duty to confront those challenges and to support creative efforts to help the NHS to attract more students into the profession in the areas of greatest need. That is why I was so delighted by the news last week that the University of Sunderland was successful in its bid to set up a new medical school. My hon. Friend the Member for Sunderland Central (Julie Elliott) and I supported the bid, because the school will focus specifically on addressing workforce need in general practice and psychiatry in the north-east. It will deliver an additional 150 graduates into general practice between 2024 and 2028. All the experience is that GPs tend to stay in the longer term in the areas where they train, so the creation of a dedicated medical school in Sunderland is an important development for the city and the wider area.

The bid should also be praised for seeking to widen access to medical schools by ensuring that those with the talent and motivation to succeed are encouraged to apply regardless of background or social connections. The new medical school will champion general practice as a career path for researchers, offering them opportunities to explore their chosen field of interest after their training is complete. It will focus on reflection, responsibility, leadership and motivation when recruiting students to the programme in order to identify those who are most passionate about building a career in general practice. The creation of an institute for primary care practice and a general practice society should also help to foster communities of practice that will last for many years to come.

I have every confidence that the new medical school will play an important role in addressing health inequalities across the north-east in the long term, while improving social mobility in the region. I therefore wish it every success and hope that other medical schools will replicate its innovative approach to attracting talented students from less advantaged backgrounds into medicine and, specifically, general practice. I want to take this opportunity to thank all those who were involved in putting together the bid, especially Professor Scott Wilkes and Vice-Chancellor Shirley Atkinson. Without their determination, dedication and leadership, the bid would never have succeeded. They deserve a great deal of credit.

We can all agree that training new family doctors in this country is the most sensible and sustainable way to improve recruitment and retention in general practice in the long term, but that will do nothing to address the immediate crisis facing the GP workforce. I have already discussed some of the programmes that have been put in place to meet the target of 5,000 new GPs by 2020, and I agree with the BMA that it is encouraging that the number of GPs entering training has risen for the third year in a row. However, as I mentioned, those gains are being offset by the fact that many existing GPs are choosing to work less or retire completely because of rising workload pressures. Furthermore, the BMA is clear that the overall intake for GP training places still falls far short of the Health Education England target.

Nowhere is the problem more apparent than in the north-east, where the fill rate for GP specialty training vacancies last year was just 77%. That is by far the worst rate in England and it is nothing new. Two years ago, for example, the north-east fill rate was a shocking 62%, which at the time was the lowest in the whole country. There is a real problem in relation to general practice in the region that has some of the most acute health inequalities in the country. Sunderland, South Tyneside and Hartlepool are ranked in the top 20 of 326 local authorities for bad or very bad health, and Sunderland has some of the worst health metrics in the UK for diabetes, hypertension, respiratory disease and many other health conditions. Setting aside for a second the increased demands that the forecasted ageing population will place on primary care provision, we can see that there is an urgent need for more family doctors to deliver health improvements today.

I raised this issue with senior NHS leaders during a recent session of the Public Accounts Committee, but I want to put it to the Minister again. Will he tell the House what exactly the Government are doing to ensure that the regional imbalances in GP recruitment are addressed, and how does he intend to ensure that the right people are trained in the right places? That is a crucial aspect of the challenges facing general practice in my area, and put simply, we need to know that Ministers and the Department have got a handle on it. Furthermore, will the Minister tell us whether his Department is looking at ways to open up access to medicine more broadly—not just supplementing existing provision, but looking at creating new and different ways of getting people into medicine in the way the University of Sunderland is seeking to do? Those are critical questions and they deserve concrete answers. I am sure the Minister will not disappoint.

On that note, I will draw my remarks to a close. I am sure that all hon. Members in the Chamber will agree that the challenges for general practice are significant and require a range of approaches, none of which will be quick fixes. To meet those challenges, the Government need to take a long, hard look at the things that they can do in the short, medium and long term to help to reverse the growing crisis in GP recruitment and retention. We cannot do otherwise, because this is simply too important to our constituents and to the future sustainability of our precious NHS.

Order. Before calling Jim Shannon, I advise hon. Members that I intend to start calling the Front Benchers at 3.28 pm, so I expect you to divide the time accordingly. I call Jim Shannon.

Thank you, Mrs Moon. I did not expect to be called quite this early, but I am very pleased to speak at any time in this Chamber, as everyone will know.

I thank the hon. Member for Houghton and Sunderland South (Bridget Phillipson) for setting the scene and giving us the chance to participate in the debate. Its title is “GP Recruitment and Retention”, and I am very pleased to speak on this topic. The title does not refer to a particular area, which gives me the opportunity to talk from a Northern Ireland angle—although as most hon. Members will know, that would not prevent me from speaking from a Northern Ireland angle anyway.

During the debate on the Northern Ireland Budget (Anticipation and Adjustments) Bill just last week, I raised the issue of GPs, out-of-hours services and so on. I highlighted the fact that we need to improve the accessibility of GPs and enhance the capability of GP out-of-hours services to help with the immense pressure that our accident and emergency departments are under. The fact is that we are an ageing population, which increases demand on GP services, and at present we seem unable to meet the demand.

The Minister and I seem to meet in this Chamber on many occasions, and also in many Adjournment debates in the main Chamber. He is obviously a very popular Minister, but he also has a remit that includes many of the issues in which I and other hon. Members have an interest.

In Northern Ireland, this issue has certainly been a big concern. GP practices have been moving away from the old surgery system to a new system in the hope of triaging demands on doctors and surgeries. Health is a devolved matter, but I want to give a Northern Ireland perspective to this debate. Thankfully, the Department of Health’s permanent secretary in Northern Ireland has released funding for a scheme that was approved by the outgoing Minister of Health but not implemented before the untimely demise of Stormont, which is now in limbo-land. It saw the investment of an extra £3.9 million, following investment earlier in the year of £1.9 million for elective care and £3.91 million to continue the roll-out of nearly 300 practice-based pharmacists. I know that the Minister is deeply interested in this subject, not just because he is the Minister responsible for it but because he has a genuine and sincere personal interest. I hope that details from Northern Ireland might be of some help in considering what is done here on the mainland and in other parts of the United Kingdom.

The permanent secretary said at the time:

“Given the current difficult financial position, investing nearly £10m more in GP services, the largest additional investment in recent years, reflects the Department’s commitment to the continued development of sustainable and accessible primary care services…The Department is also introducing changes to…eligibility to the sickness leave scheme for GPs.”

That is another thing we have looked at in Northern Ireland, and perhaps the Minister will comment on it. The permanent secretary continued:

“It is estimated that these changes will save GPs more than £2.5m per year in sickness leave insurance premiums.”

The thrust of the debate so far, and undoubtedly of the speeches to come, is about how we can retain GPs. The hon. Member for Houghton and Sunderland South clearly made that point, and I too think that that is what we need to try to do.

The move to which I have referred was made in a very uncertain political climate back home in Northern Ireland. Few other decisions to implement schemes have been taken by any Department’s permanent secretary. We are slowly moving towards what will perhaps be a hybrid system of government in Northern Ireland, whereby we can ensure that the health schemes move forward.

I have spoken to former GPs, who have illustrated to me how much the system has changed and how happy they are to retire. Some have begun to do a few hours in GP out-of-hours services, which takes a bit of pressure off the ordinary GPs, but it is important that we have a system that sustains itself, and the pressure and stress that services are under has seen most GPs walk away from that system. We are trying to stop GPs walking away—that was the point that the hon. Lady made in introducing the debate, I fully support it. The simple fact is that our doctors cannot cope and we need to help them find a new way forward.

In 2016, 36% of the 15,430 people who died in Northern Ireland were aged under 75, compared with 50% 30 years previously. The resident population of Northern Ireland rose by 10,500 people to reach 1.862 million in the year to June 2016. Every GP surgery knows that the people on their books who need the most attention are the grey vote and the young families. Our GPs are great, and we support them greatly. We understand their position—we know the pressures that they are under and we have the deepest respect for them.

One of my local surgeries has heavily invested from its own budget in a machine that can determine whether chest infections are bacterial through the practice nurse taking blood and analysing it on-site. That innovation stops the surgery sending people for analysis in hospital and facilitates the provision of better care in the GP surgery. It allows antibiotics to be prescribed and means less pressure on the hospital. Such a machine would help every surgery. Sometimes we have to look at a different way of doing things. If we can do them better, let us do that. We should be making funding for such innovations available, for the benefit of all of us across the whole United Kingdom of Great Britain and Northern Ireland.

Due to the stringent nature of benefits assessments, many practices in my area now refuse to give support letters for benefits. That is another pressure on GP surgeries all the time. I am constantly contacting GPs on behalf of my constituents, saying that they need a letter about their health condition to support their application for disability living allowance—personal independence payment, as it is now—and employment and support allowance. The GP says, “Let them write to us; we will reply,” and they do, but they usually send a list of the constituent’s appointments with the GP, which is not what PIP is about.

I am adhering to your timescale, Mrs Moon—I have worked it out, so I know what time I will have to stop.

A retired doctor I am very friendly with suggested to me—I know the Minister is sympathetic to this idea—that we have a bursary scheme whereby if a medical student will commit to doing five years or more at a surgery, they will have some or all of their student debt written off. That would encourage people to get into GP surgeries and make a difference for five years or so. I am given to understand that the Department are looking into schemes like that, and I hope so. I am interested to hear the Minister’s response to that idea, because I think that might provide encouragement for some of the young student doctors who wish to go on to general practice. If we provide that incentive through a bursary, I think it will be a massive step forward in addressing the issues, as the Department proposes to do by reducing the pressure on GPs and increasing their number.

Have any discussions taken place with the regional devolved Administrations so that they can respond? The Scottish National party spokesperson, the hon. Member for Central Ayrshire (Dr Whitford), has vast knowledge of medical issues, and I know that her contribution to this debate will make clear what has been done in Scotland. Yes, it is a devolved matter, but the NHS is nationwide and this scourge in our surgeries is in every area. A focused, co-ordinated approach is the best one to take, and I ask that the Department focuses on this vastly important issue. We need good GPs, and we need to support GPs. If we do not do that, there will be a domino effect on our hospitals and all other NHS institutions. We need to encourage our first line of defence, which is GPs, and ensure that defence is sure and certain. At the moment, the fact of the matter is that it is struggling.

I am delighted to serve under your chairmanship, Mrs Moon. I congratulate my hon. Friend the Member for Houghton and Sunderland South (Bridget Phillipson) on leading the debate. I will be short, because I wish to make three key points and I do not need long to do that.

First, we have a recruitment and retention problem in Stroud, like in many other parts of the country. That became apparent to me only when I was re-elected, when I talked to various of my GP friends who were keen to retire and were not necessarily finding replacements easily. It is clear that at the moment there are huge gaps in the service. However, it is not necessarily that they are not being filled, because as my hon. Friend said, locum work is very popular. That is the main point I want to make. Because locum work is so popular, we have to look at the reasons why the traditional model is not working. Even for people who become doctors, it is not necessarily a lifelong career, so for all sorts of reasons buying into a practice now is not an attractive proposition. I ask the Minister to look at what ideas are coming forward, as it is clear that the traditional practice model, where a GP buys into the assets of the practice as well as becoming a doctor there, is now of a bygone age. That particularly matters because trying to get a lead practitioner is onerous, because they are often the only full-time doctor in their practice, which puts additional responsibilities on them. I hope that we can have some flexibility in how we attract people in, otherwise there is only one direction things will go.

Secondly, the number of people who start on the route to becoming a GP but do not end up as a GP in practice is disappointing. There is something wrong both in doctoring in general, and particularly in general practice, with the number of people who fall by the wayside. Again, as I have intimated, that is because there are attractive alternative career structures. There are ways in which people can be a GP part-time as well as doing other things, which may be commendable for someone’s work-life balance but does not fill the gap. I hope the Minister will look at what is happening to recruitment patterns. We need to recognise that eight or nine years is a huge investment, so if someone does not become a GP in some form or other at the end of it, it is a wasted investment. I hope the Minister will be able to say something about how we can ensure that people follow through on their training potential.

Thirdly, as my hon. Friend the Member for Houghton and Sunderland South mentioned, we need to recruit a number of doctors from overseas at least in the short run. Having talked to consultants and the Royal College of General Practitioners, I know that there is a problem at the moment—at least in perception, if not in reality—of people not wanting to doctor in this country when they would traditionally have wanted to do so. We need to overcome that problem urgently, because we need those people in place, otherwise, there will be an even greater shortfall.

My last point—it is not to do with GPs, but I think it is crucial—is about the pressure on other people within primary practice. I get calls continually from health visitors, practice nurses and physiotherapists saying how difficult things are, and that must have an impact on general practice. If we could ease some of the pressure on those people, we could only help those who want to be in general practice and be at the front end of our NHS.

It is a pleasure to serve under your chairmanship, Mrs Moon. I congratulate my hon. Friend the Member for Houghton and Sunderland South (Bridget Phillipson) on making such a powerful opening speech. I want to talk about primary care in Plymouth, because I am worried that the crisis we have is at risk of getting much worse in the coming months, as GPs are considering whether to hand back their contracts in the next couple of days.

A lot has been done in Plymouth to integrate our healthcare system and our social care system. Sometimes our distance from London has meant that we have managed to avoid the headlines, but not the hard work. There has been a huge effort of innovation and integration in the west country, merging social care, mental health provision and our acute hospital trust together. Enormous thanks and credit should go to the hard-working staff who have pioneered that, along with the city council and other providers.

There is, however, a problem with primary care in particular. That is exacerbated by other parts of the system that do not seem to work, as my hon. Friend the Member for Stroud (Dr Drew) said, but there does seem to be a real crisis in primary care that needs to be addressed. I welcome the news given by Simon Stevens on his visit to Plymouth last week that we will get an additional 12 GP training places for our university, but there is a real crisis today. I am looking for actions from the Minister to assist us in combating that crisis today.

Nurse and GP vacancies persist in Plymouth’s primary care sector, and waiting lists continue to be high. It is important to say that this is not because the superb staff in our NHS are not working their socks off, because they really are. However, there is persistent underfunding of not only general practice but the wider sector. NHS England estimates that one in seven GP posts in Plymouth have not been filled, which is an alarming statistic. I have heard of one GP surgery in the heart of the city that has been advertising a GP vacancy for a year and has had no applications so far.

I have similar issues in Melksham in my constituency. Is the hon. Gentleman aware of the targeted enhanced recruitment scheme, which offers £20,000 to attract trainees in areas that have failed to fill places for a number of years? That is available in Swindon, in Wiltshire, but also in Plymouth.

The problem is that the schemes that currently exist are not having the effect that we need them to in Plymouth, because we have a crisis today.

I want to talk about the concern that a lot of GPs have expressed to me. My remarks will be about what GPs have told me, rather than my analysis of what I believe GPs are saying, because I think it is important that their voice is heard in this debate. Will the Minister meet those GPs so that they can raise their concerns in person? There are a number of GPs who have solutions or suggestions about what can be done.

At the moment each GP in Plymouth has about 2,364 patients. As we heard earlier, the average is about 1,700, so there is a greater demand on the GPs we have in Plymouth. One GP told me last night:

“I’ve just walked in the door after a day where I saw my first patient at 0825 and left my last patient’s home at 8.15pm. Because the district nursing service is currently unreliable (through no fault of their own), I will go back to the latter at 0800 tomorrow as the patient is housebound and needs blood tests.”

He went on to say:

“A large part of the pressures on...GP’s is the fact that other community services have had such drastic cutbacks.”

He said:

“I feel very...lucky to have a secure well-paid fascinating and rewarding job but it is all a little overwhelming and I constantly worry that just one major problem will mean things become very, very unsafe.”

I will continue, if I may. Apologies.

Another GP, Dr Williams, said that the system is failing and it feels as though it might be intentional. GPs have heard NHS England say that it is watching Plymouth as a place where primary care could fall over, a sentiment that several GPs have expressed to me in private. They believe that Plymouth’s city-wide system is facing bigger concerns in primary care than elsewhere. A meeting with the Minister is vital, so that he can reassure those GPs that the Department of Health and NHS England are on top of this.

Another inner-city GP said:

“I became a GP to help people with physical and emotional health difficulties and this is a job I have really enjoyed for a number of years. During this time patient needs and demand on general practice has increased significantly but unfortunately funding has not kept pace...We only get...£115 per patient per year to provide the totality of patient care so it’s no surprise we are struggling when some patients consult us at least once a week.”

The general medical services contract includes between £73 and £117 per patient, but as we have seen in Plymouth where GP surgeries have fallen over and emergency providers have been brought in, there can be as much as £347 per patient under emergency access contracts. There seems to be a huge financial gap there that could be moderated by supporting GPs—not by giving them more money themselves, but by providing support and assistance so that they can hire more GPs, and by supporting the other professions that make for a successful GP practice.

Worryingly, the doctor I referred to said:

“I no longer enjoy being an NHS GP because I cannot keep pace with demand and I know our patients are getting frustrated with restricted access to their GP. Patients are complaining, and rightly so, but those complaints just compound my loss of joy from the job because I’m working harder than ever to try and provide the service patients want but the majority of feedback we get is negative.”

That has been echoed by a number of GPs in Plymouth, who really want to inject the joy and passion back into their role. They entered the profession not because it was easy—it was hard and difficult—but because their efforts would make a huge difference to their communities.

I will continue, if I may.

I am genuinely worried that Plymouth’s primary care crisis is going to get worse in the coming days. We know that there are GPs who are considering whether to renew or to hand back their GP contract—a decision that will be made in the next couple of days. That is deeply worrying not only for them, but potentially for patients.

My GP surgery in Plymouth closed recently, so I know what it is like to lose my GP. At the moment I am especially concerned about people who do not reregister with a new GP, effectively becoming an unregistered cohort of people in the city who then can rely only on acute A&E services. Our staff at Derriford A&E do an absolutely fantastic job, but they cannot keep going if there is a continuing crisis.

The Plymouth Herald reports that a third of GP surgeries are at risk of closure as vacancies in primary care escalate. Will the Minister meet Plymouth GPs so that they can raise concerns directly with him? There is an opportunity to avoid the crisis getting any worse through proactive measures. I do not want to see the crisis getting worse and then more emergency access having to be put in place as GPs who have worked beyond the point of exhaustion hand back their contracts. That decision can be justified because of the pressure on them and their families, but we can avert that situation if we take action today. I hope the Minister will address that in his remarks.

It is a pleasure to speak under your chairmanship, Mrs Moon. I compliment the hon. Member for Houghton and Sunderland South (Bridget Phillipson) on a real tour de force around the issues before us today. Like the hon. Member for Strangford (Jim Shannon), I will dwell on an aspect of the issue that affects a constituency that is part of a devolved Administration. I hope that what I am about to say will be helpful at the UK level and possibly at the Scottish Government level.

I come from the basic premise that no matter where someone lives they have an equality of right to decent health services. I represent the second biggest constituency in the UK, and there is a particular challenge in the north of Scotland in terms of access to GPs and other medical services. In that context, within the past few days a big issue has developed—it has been fairly well reported in one of Scotland’s main newspapers. In the Caithness part of my constituency, in the top right- hand corner of Scotland, GP provision and access to other health professionals is not what it should be, notwithstanding the best efforts of the professionals that we do have. In no way do I want anything I say to denigrate their efforts because they work exceedingly hard, but the issue is a big concern for my constituents, and they raise it with me repeatedly.

Out of fairness to the Scottish National party represented here, the matter is devolved, but I hope that what I suggest will be helpful. A group called the Caithness Health Action Team has been formed and it outlines the problem on its Facebook page probably more succinctly and better than I can during the brief time available to me. I give credit to the fact that the group is campaigning in a constructive way to try to help matters.

NHS Highland has recently admitted that the recruitment and retention of GPs and similar professionals in other branches of medicine is proving a real challenge in that remote area. It really prompts the question of whether we say there is nothing we can do about it. Do we have to walk away and accept that some parts of the UK or Scotland will not have equality of provision, or do we say we will roll up our sleeves and tackle it? In my book, the answer is the latter.

Before I return to recruitment specifically, one of the most irritating things, or perhaps encouraging things, is that when we recruit a health professional in somewhere like my part of the world—although I daresay it is also true of Plymouth—after a while they begin to love it. There is every chance they might settle and their children be educated locally, and that is good for the community. That is a prize worth remembering.

I want to mention two specific points. Several Members have already mentioned a kind of bursary, a cash incentive to encourage someone to do GP training. We all know how expensive medicine is, how student debt can be built up and the length of time it takes to qualify. This is just a suggestion and it might not be possible within UK recruitment law—I am prepared to be corrected—but I am keenly aware that the armed forces can offer a bursary to go to college or university to be trained, but part of the deal is that when the person graduates the armed forces can send them to where they are needed most. I have a daughter who is serving in the armed forces and she knew right from the start that that was part of the deal. Whether that can be done within UK law, I do not know, but it might be worth looking at. A given health authority could help someone through their five years of GP training, but then have the right to say that for the next two or three years they will be placed in Plymouth, Wick or wherever in the UK. I think a cross-border UK-wide solution is best in that respect.

My second point is an old one. I remember that when I was a kid the nurse got a house. There were doctors’ houses, and that made a difference in recruiting people. As far as I am aware, the nurses’ houses have all gone and no longer exist, but it was part of the local authority’s responsibility to allocate such housing.

The answer in the Scottish context is for NHS Highland and probably the Scottish Government to take a co-ordinated and targeted approach to a specific problem in a specific part of the highlands. I think the willingness is probably there, to give credit where it is due. As and when a solution is found as to how we get people into the area, that experience could be useful to UK Government Ministers as well. There is everything to be learnt from each other. Should the Minister or the UK Government find a way to deal with these problems before the Scottish Government do—

As a constituency MP, the hon. Gentleman has no doubt had the same correspondence that I have had from Scottish students who have been denied access to Scottish medical school. I do not know whether he shares my concern that the current cap by the Scottish Government on Scottish domiciled student places means that only 51% of current medical places at university are filled by Scots.

That is a relevant point, and I share that experience. I do not want to go into the specifics, but within the past two days I have encountered the case of a sixth-year pupil at a school in my constituency who, because of the curriculum limitations in the sixth year, will be unable to pursue the tertiary education in the medical field that she would like to. It is a worry, but I shall take that up with the director of education.

The matter we are debating is a big issue in my constituency. It is particularly acute because of the distances involved, and it is at the forefront of my constituents’ concerns. I accept that it is devolved, but I feel duty-bound to air the matter in this place.

It is a pleasure to serve under your chairmanship for the first time, Mrs Moon.

I declare an interest, in that my other half is a GP. He is German and has been here in our service for 32 years. That highlights a particular problem that we shall face in the next few years because of Brexit. As the hon. Member for Houghton and Sunderland South (Bridget Phillipson) mentioned, GPs are not just gatekeepers, but are the core and heart of general practice, which is where most interactions occur. They specialise in teamwork and continuity. They may know their patients for years and over generations. All UK health services face three key problems. We all face tight budgets and increasing demand because of an ageing population, and the workforce is bringing those things to a head in relatively short order.

There is a drive in Scotland and England to rebalance the proportion of funding that goes towards primary care, to approximately 11% of the budget. With the climbing complexity of cancer care, emergency care, A&E and targets, more money has been moving into secondary and, indeed, tertiary care. The demand is still there. Having worked as a breast cancer surgeon for more than 30 years I can tell the House that we also face shortage and increased demand, so there is no easy solution—but if primary care fails, the entire system fails.

In Scotland the new GP contract was designed by working with the British Medical Association, and at the moment it is in phase 1, which is trying to stabilise the system. Two thirds of practices will have a significant increase in income, and the others will be protected so that no one experiences a fall. Phase 2, which will start next year, is an attempt to consider something a bit more radical. It touches on issues that have been raised by some Members, to do with changing the shape of primary care, and the system. The income of GPs varies hugely. Some practices are immensely profit-making and have a good income. In other areas the GP, despite perhaps working longer hours, may earn £20,000 or £30,000 a year less. That means that the area in question becomes relentlessly harder to recruit to. Consideration is being given to whether there should be a range of income, perhaps similar to what consultants have—an NHS salary.

That is obviously a huge change from the situation at the moment—the independent contractor status. Older GPs who have lived with independent contractor status certainly do not want it to go. They welcome the independence and the ability to design and run their practice as they see fit. However, it is important to recognise that the younger generation feel utterly differently. As has been mentioned, they are not interested in buying into a practice or even, necessarily, in being partners. They are not attracted to the businessman side of being a GP. Therefore we need contracts that do not destroy independent contractor status for those who already have it, or those who want it, but that enable people to work in practices where perhaps the building is provided by the health board, and where they are salaried and can create a more predictable work-life balance.

One of the small-print issues that is arising in England is the fact that no new general medical services contracts have been awarded since 2013; everything has been done on the basis of alternative provider contracts, which means that they are only for five years. It might be attractive to a big multinational to take on a franchise and hope that it gets the contract again; but there is no possibility that a family doctor would be interested in setting up or taking on a practice for a mere five years.

I am greatly interested in what the hon. Lady is saying, which is very constructive, good stuff. Would she, at this stage in her planning, factor in the extreme rural issue that I mentioned, in any way?

If the hon. Gentleman will bear with me, I shall come to that naturally later.

The issue of indemnity has been touched on. I am not sure whether it is realised how extreme the position is. GPs in England are paying three to four times the indemnity that GPs in Scotland are paying. The range in Scotland would be £1,500 to £2,300 on a range of half a dozen to 14 sessions, but in England that would be £5,500 to £9,500. That is a considerable chunk of money to ask of someone, and it is very significant when it comes to taking on the extra weekend surgeries of seven-day working, or out-of-hours work.

That is an acute point. Does the hon. Lady share my consternation, particularly with respect to out-of-hours work, that in the past few years the premiums have been rising stratospherically? I think they went up by close to 10% last year.

I absolutely agree. As I have said, it is not particularly an issue in Scotland, but it is very much one in England. I know that it is being looked at under the new contract. Hon. Members may remember the Prime Minister’s challenge fund: extra surgeries at the weekend are better paid and do not involve the same indemnity issues as going to do a stint at the local out-of-hours. Unconsidered consequences of that kind must be looked at.

There is obviously increasing demand. We talk negatively about the ageing population, but living longer is a good thing, and I would like to recommend it. I spent 30 years trying to achieve it. In Scotland the number of GPs increased by 9% between 2005 and 2015, but the number of patients over 65 increased by 18%. Obviously, much innovation across the UK is to do with trying to reduce workload. Scotland was first to get rid of the quality and outcomes framework, which had encouraged significant quality improvements but grew into a huge bureaucratic machine. We are working on developing the multi- disciplinary team, with physios, access to counsellors, and pharmacists. That is happening in England as well. One innovation in England is known as “time for care” and concerns extra training at the frontline—reception—to encourage triage of patients to the right member of the team. However, my attention has been caught by the development of a new app that allows patients to book appointments directly; that would remove the option for triage. It is important for innovations to be joined up.

We need to innovate and to use all community resources. Scotland has for 10 years had community pharmacies providing minor ailment services. Our optometrists are allowed to make direct referrals to hospital for cataracts, and now they treat 90% of all acute eye problems. Those are things that may at the moment be referred to general practice simply to ask for a letter to be passed on. That is a waste.

There has, obviously, been a climb in the number of practice vacancies, including in Scotland. Our whole-time equivalent has fallen, in the past three years, by 1.9%—in England the figure is 2.8%. There has been a 50% increase in the number of GPs taking early retirement, at the age of about 57. Some of that is because of the change in pension tax rules. The problem of having too big a pension is a nice one to have; however, if people who invested 40 years ago in very expensive added years are finding suddenly, as they approach retirement age, that that means they are accruing no further pension, we have a problem.

Brexit is definitely a threat. In Scotland, 3.5% of the health and social care workforce—and 5.8% of doctors—are from the EU. In London the figure is 14%. We know that 14% of EU doctors in Scotland, and 19% in England, are already in the process of leaving and, as has been said, that is simply because they feel unwelcome. As we have seen with the difficulty of getting tier 2 visas over the past four months, recruiting from outside the EU is a real issue. Businesses in London can increase someone’s salary to get past the limitations, but the NHS is not able to be so flexible.

Does the hon. Lady agree that we also need to tackle social injustices to ensure that the most disadvantaged in our society have the confidence and know-how to pursue a medical career? Does she welcome Government programmes to tackle that?

I absolutely welcome them. Similarly, in Scotland the new graduate medical programme will take on people who have done other degrees, and that is particularly aimed at encouraging those people to go into general practice and rural practice.

May I gently ask the hon. Lady whether Scotland has a bursary scheme? Both I and the hon. Member for Caithness, Sutherland and Easter Ross (Jamie Stone) referred to that, as we feel that such a scheme might help.

Obviously, in Scotland we do not have tuition fees, so that is a considerable difference in student debt, particularly for a five-year medical course. We do not, as yet, have a system of bonding or tying students down. The worry is that that would create a feeling of being trapped, and that as soon as the bond finishes, the person runs away. I am sure that all Governments in the UK are thinking about such things, but it is about working out whether such a scheme is beneficial or negative in the long term. We do have a GP bursary scheme for those entering a traineeship, so that when someone moves from a hospital where they work on-call, and becomes a GP trainee, the drop in salary is compensated.

As the hon. Member for Caithness, Sutherland and Easter Ross (Jamie Stone) said, in Scotland we have a particular issue with the provision of rural services. We have a much higher ratio of GP per head of population, with 91 GPs per 100,000 people, as opposed to 71 in England, 73 in Wales and 70 in Northern Ireland. What often gets forgotten when people look at the weirdly angled weather map, is that although Scotland is one third of Great Britain’s landmass, it has 8.3% of the population. Anything that involves providing services across an enormous area is a challenge. We also have 70 inhabited islands that require services. Our recruitment and retention fund is putting additional money into this issue. The Scottish Rural Medicine Collaborative involves 10 health board areas, and relocation money—the golden hello for trainees or indeed any GP moving into practice—has been increased from £2,000 to £5,000. Any GP moving into rural practice will have a golden hello of £10,000, and trainees will have £20,000. That has been rolled out from the 44 island practices to all 160 rural and remote practices.

One key issue driving this problem, which perhaps is not often recognised, is the change from full-time to part-time working. Headcount for GPs is up by 5% in Scotland, but down by 4% from 2013. The change seems to have been in the last five years—indeed, there is a real culture change as the next generation comes in. When my husband became a GP, he was the first part-timer in his practice. They interviewed all the women before him, because it seemed so weird to have a man who wanted to work part time—that is because I was always in the hospital. Now, out of eight GPs, only two are full time. The number of patients in the practice has not changed, but instead of six actual GPs, there are eight. Therefore, the average GP is working considerably less. In England, the change in headcount of those looking to work full time meant that numbers went from 39,000 to 27,000. That shows the dramatic difference between the full-time equivalent and headcount, and it means that the average GP is working about 70% of what a full-time GP worked. The problem for any Government is that they then need to train 30% more GPs to cover that.

The key, however, is satisfaction. At the deep end, the 100 most deprived GP practices in Scotland face the inverse care law: people do not demand, and therefore service is not delivered. Govan health centre is running the SHIP project—social care and health integrated partnerships, and that innovation is now being picked up elsewhere. It means that GPs have extra time, and a significant multidisciplinary team, but in those areas, 31% of patients will have four or more conditions.

We have an even deeper problem, however, which is the attitude to general practice. Other specialisms look down their nose at it, and therefore a student may not be encouraged to enter general practice. Students are not getting enough exposure to general practice, either as students or in their foundation years. We also have a particular problem with the two foundation years since “Modernising Medical Careers” came in. We pour all our young doctors into a hopper—a computer—and they get divvied out. They will struggle to be with their family or where they were living before. In 2011, 29% of young doctors left after the two foundation years. Last year it was 50%. They do not feel part of the team or have a sense of continuity—things that are utterly crucial to general practice. Therefore, although we may be putting in more money and coming up with schemes, we must also reform the foundation years so that we do not have an entire lost generation.

It is a pleasure to serve under your chairmanship, Mrs Moon, and I thank my hon. Friend the Member for Houghton and Sunderland South (Bridget Phillipson) for securing this important debate and for the strong case she made.

To set the debate in context, the NHS has the equivalent of 28,960 full-time GPs, which is 1,300 fewer than two years ago, despite the fact that the Government promised in the NHS Five Year Forward View to deliver an additional 5,000 GPs by 2020. The situation is getting worse as fewer medical students decide to enter general practice, while at the same time more GPs are opting for early retirement. The average age of retirement among GPs is 59, and given that 20% of all GPs are approaching that age, it is no exaggeration to say that there is a ticking retirement time bomb. The situation is set to get a whole lot worse as the number of GP vacancies continues to rise.

In 2011, the number of GP vacancies stood at 2.1%, but by the end of 2017 that had risen to a worrying 12.2%. NHS Digital data showed that, between 17 March and September 2017, the number of full-time equivalent GPs decreased by 166. Over the same period, the number of GP partners fell by 638. I spoke to one young GP and former practice partner who gave his reason for leaving. They said

“no one wants to be the last man or woman left standing.”

When GP recruitment was raised during Health questions in December, the Secretary of State said:

“One of the best things about the NHS is that people have a GP who knows them and their family.”—[Official Report, 19 December 2017; Vol. 633, c. 894.]

I agree, but increasingly that is not the experience for many people. For the elderly, the mentally ill and the chronically ill, that lack of continuity is troublesome. I have elderly constituents with complex needs who rarely see the same GP twice, and because no single GP really knows the whole person, they are constantly bounced back and forth between the surgery and A&E. Too often, that leads to hospital admissions that could have been avoided.

In many areas across the country, patients report that they have experienced difficulty getting to see any GP—that point has been made forcefully by a number of Members today. Indeed, it is not just patients who say that: 71% of doctors surveyed feel that patient access to services has decreased. I have spoken with GPs across the country—including some with 30 years’ experience or more—who declare that there is a crisis in general practice, the like of which they have never seen. The traditional service is struggling to cope with the ever-increasing demand from an ageing population, and GPs face unprecedented workloads. In addition, the harsh economic environment has negatively impacted on the wellbeing of many of the poorest people. Depression and stress-related illnesses have increased, further adding to the demand for GP services. Inadequate mental health resources mean that GPs are often unsupported, with patients in need of specialist support. Cuts in adult social care budgets have meant that many old people are left at home without the support they need and with no one to turn to except their local GP.

In the face of all those pressures, it is no wonder that doctors are choosing early retirement. The more who leave, the greater the pressure on those who have been left behind. The downward spiral of retention is particularly evident in the most deprived parts of the country, where the challenge of recruitment is reaching nightmare proportions. I spoke to one GP in such a community. He said that he had had only one week’s leave in three years because he had been unable to recruit either a partner or a salaried GP to help. Other GPs have told me that they feel like they have their finger in a hole in a dam holding back a tsunami of demand.

It is clear that this situation is unsustainable. The BMA says:

“With an insufficient workforce, a funding plan that is no longer sustainable, a growth in population and a sea-change in the level of complex cases being presented, urgent steps need to be taken to save general practice.”

It tells me that eight out of 10 GPs feel unable to deliver safe care. For the benefit of patients and the long-term future of the general practice that we all know and love—the service that was the envy of the world—the Government must heed these severe warnings from the professionals.

The Government have taken little action to date. When I raised this with the Secretary of State in December, he said that we must

“encourage more medical school graduates to go into general practice as a specialty”.—[Official Report, 19 December 2017; Vol. 633, c. 895.]

I agree, but progress is poor. The recently announced new medical schools are welcome, but they will not in themselves make the profession more attractive. If the Government are serious about delivering 5,000 additional GPs, they must demonstrate that they truly value the service. At a time when morale in the profession is low, the Government must stop adding to the pressures by demanding seven-day access, which is not a priority for patients.

The offer of an additional £2.4 billion is welcome but does not go far enough. The Government must increase the proportion of NHS funding that goes into general practice. They must put general practice at the heart of a primary workforce strategy. Instead of having ill-equipped private companies foisted on to surgeries, GPs should be offered comprehensive support with everything from surgery premises to professional indemnity. If the sector is properly resourced and supported, it will be a more attractive proposition for medical graduates. Such measures would not only attract new graduates into the profession, but help to retain existing practitioners. The current GP retention scheme for doctors who are approaching retirement and considering leaving the profession for personal reasons is helping, but reducing the daily workload would do more to stem the tide of retirement.

Finally, the service cannot be viewed in isolation. There is no doubt that properly funded adult social care, and public health and mental health services, would alleviate pressure. I also make the case for greater utilisation of community pharmacies, which are not to be confused with the welcome addition of pharmacies in GP practices. They would help in so many ways. A nationwide roll-out of minor ailment services would be a good first step that would help enormously, leaving GPs time to see patients with more serious medical needs.

GPs across the country, the excellent Royal College of General Practitioners and the BMA will be listening. I take this opportunity to pay tribute to our GPs for their exceptional dedication. I want GPs across the land to know that the Opposition appreciate the work they do, which so often goes above and beyond the call of duty. They want the Minister to go beyond warm words and wish lists and to outline a detailed, properly funded plan to save general practice. I hope the Minister will not let the professionals and our constituents—the patients—down.

It is a pleasure to see you on your throne this afternoon, Mrs Moon.

I have a lot of time and respect for my shadow, the hon. Member for Burnley (Julie Cooper), but what a counsel of despair that was. As the sun comes out after a day of rain in London, let me see if I can bring some sunshine to our proceedings.

I congratulate the hon. Member for Houghton and Sunderland South (Bridget Phillipson) on securing the debate. She spoke passionately, as always, about her constituents and her area. The hon. Member for Strangford (Jim Shannon) said that we are often in here together and share many of the same subjects. That is true but, to be fair, he is in here even more than I am.

I note the Prime Minister’s announcement yesterday that she intends to bring forward a long-term plan for the NHS with the Secretary of State, Ministers and our partners. That will build on our record of extra funding for the national health service in England year on year since 2010, to deliver a NHS that is fit for the future. I agree with the shadow Minister that this is about the wider NHS, and that we cannot see primary care in isolation. We are able to do what we have done for the past eight years because of the state of the economy, which we have got into a better place. When the economy fails, the NHS catches a cold or much worse, which is important.

I will not give way at the moment.

As everybody has said, we recognise the importance of general practice as the heart not only of our NHS, but in many ways of the country. It is as much about prevention before people get into the NHS as it is a gateway to it. That point was made well by the hon. Member for Central Ayrshire (Dr Whitford), who spoke for the SNP. As others have kindly said, I am absolutely committed to ensuring that the NHS has the resources, workforce and Government backing to make it fit for the future.

As the hon. Lady said, it is a great success that we are living longer, but an ageing population and more people living with long-term conditions, or so-called comorbidities, means that general practice will become more important than ever in keeping well and living independently for longer. On Friday, I spent a morning sitting and observing—lucky patients—a general practitioner in Hampshire, not in but near my constituency. I watched him do his morning surgery. It was a brilliant thing to do as the Minister with responsibility for primary care, but I would recommend it to any Member who has that relationship with GPs in their area. By sitting and watching, it is possible to see what comes through the door and the pleasures of general practice, which is not dissimilar to the surgeries we hold as MPs.

The number of people over the ages of 60 and 85 is set to increase by about 25% between 2016 and 2030, and the number of people living with long-term conditions is increasing. In 2017, almost 40% of over-60s had at least one long-term condition. I am sure we can all think of people in our families who are in that position—I certainly can. We recognise that that places general practitioners in England under more pressure than ever before, and are taking comprehensive action to ensure that general practice can meet the demand.

The NHS set out its own plan for general practice in the general practice forward view. We have backed that with additional investment of £2.4 billion a year by 2020-21, from £9.6 billion in 2015-16 to more than £12 billion by 2020-21. That is a 14% increase in real terms. That is not made up—those are genuine figures, on the record. As has been said, we have also announced our ambition to grow the medical workforce to create an extra 5,000 doctors in general practice by 2020, as part of a wider increase to the total workforce in general practice of 10,000. We recognise that that is an ambitious target—it is double the growth rate of previous years—but it shows our commitment to growing a strong and sustainable general practice for the future.

This debate is about recruitment and retention, so let me break those down. NHS England, which we work with—it is approaching its fifth birthday—and Health Education England are working together with the profession to increase the GP workforce. That includes measures to boost recruitment, address the reasons why GPs are leaving the profession and encourage GPs to return to practice. We recognise that GPs are under more pressure than ever, but we want them to remain within the NHS and are supporting them to do so.

The hon. Member for Stroud (Dr Drew) made the point about recruiting and then following through. As I said at oral questions last week, there are things we can do, but there are things the profession can do too. If doctors in general practice are a counsel of despair, it is little wonder that people do not want to follow them. There are some good, positive voices in general practice, ably led by Helen Stokes-Lampard, who leads the Royal College of General Practitioners. She is a brilliant example of the cup being half full. That kind of positivity is very important—it is a partnership.

I am grateful to the Minister, because I am conscious of the time. He spoke about the support that can be given with regards to recruitment and retention. In my area, the cost of housing is part of the conundrum that we have to solve for everybody, but particularly for key workers. Does he agree that excellent, well-run district councils such as West Oxfordshire—ones that think creatively, outside the box, and help to provide affordable housing in a new way that is targeted at key workers—can be part of the solution to the recruitment and retention challenge?

They can certainly be part of the attractiveness of coming to an area. My council in Winchester is one of the few authorities that is building new council houses—all power to it. My hon. Friend makes his point well, as always.

Increasing training in general practice is important. It is a top Government priority, which is why HEE has made 3,250 places in GP speciality training available every year since 2016. As a result, the number of doctors entering training has increased year on year. In 2017, a record 3,157 new starters were recruited to GP training posts.

The hon. Member for Houghton and Sunderland South spoke very well in introducing the debate, but hon. Members may not be aware that she asked me my first question as a Minister at Health questions in July. She said:

“Does the Minister accept that new medical school places should be created in areas such as Sunderland, where there is the greatest need to recruit and retain general practitioners?”—[Official Report, 4 July 2017; Vol. 626, c. 1008.]

All I can say is that we were listening. I did not say yes at the Dispatch Box, but we looked at the under-doctored areas and at the areas where it is hardest to recruit, which is why Sunderland’s bid was successful. I am glad she welcomed that.

The hon. Lady also welcomed the University of Sunderland putting that in place. As she said, the medical school will encourage general practice as a speciality after students have completed the two years of foundation training. It is envisioned that 50 new students will enrol in 2019 and 100 students in 2020. Experience tells us—this will be encouraging to the hon. Member for West Lancashire (Rosie Cooper), who is no longer in her place—that GPs tend to stay longer in the area where they train, so it is an exciting development for general practice in Sunderland. Once someone has gone there, why would they leave?

As we have heard, the Government have introduced the targeted enhanced recruitment scheme, which funds a £20,000 salary supplement for GP trainees who commit to work for three years in areas of the country where GP training places have been unfilled for a number of years. The hon. Member for West Lancashire is back in her place now—she missed her mention, but I am sure she will catch up on it. The scheme was launched as a one-year pilot in 2016. It was extended for a further year in 2017 and again in 2018. It is a positive innovation.

I am whipping through my brief because of the time. There are a lot of points to try to respond to, and if I do not respond to them all, I will write to hon. Members. A number of hon. Members asked about international recruitment. In August 2017, NHS England announced plans to accelerate its international recruitment to 2,000 GPs in the next three years.

A small number of pilot areas started recruitment last year. The next stage of the recruitment programme is on track to start at the end of the financial year as planned. The aim is to recruit 600 doctors by the end of March 2019 and the remainder by the end of March 2020. As the hon. Member for Houghton and Sunderland South said, that is part of the north-east and Cumbria submission to the national scheme, which runs from this year to source qualified GPs from abroad to work in England. She welcomed that, as do we.

On retention, in addition to our significant efforts to train and recruit more GPs, we want experienced GPs to stay in the NHS and are supporting them to do so. The GP retention scheme, which the hon. Lady mentioned, is a package of financial and educational support to help doctors who might otherwise leave the profession to remain in clinical general practice. It was launched to support GPs who cannot work more than four sessions per week and who cannot secure a suitable substantive post. In September, 218 GP retainers were working in general practice, which is a 40% increase on two years previously.

The induction and refresher scheme provides a safe, supported and direct route for qualified GPs to join or return to NHS general practice in England. By December, it had received 600 registrations. Of those, 368 GPs have completed or are progressing though the scheme back into general practice.

Several hon. Members rightly mentioned pensions. We need experienced GPs to stay. Pensions are an issue for them, alongside workload and indemnity. They are ultimately a matter for the Treasury—it would be a foolish junior Health Minister who wrote Budgets in Westminster Hall—but my hon. Friend the Member for South West Bedfordshire (Andrew Selous) recently made the point in Prime Minister’s questions—the Prime Minister assured him that the Chancellor was listening. He will also listen to hon. Members who have raised it today. We certainly need to address it. As the hon. Member for Central Ayrshire said, to have a full pension pot is a nice problem in some ways, but I take her caveat on board.

We recognise that indemnity is one of the challenges to people staying in the profession. It is a great source of concern to GPs and to me. We want to put in place a more stable and affordable system of indemnity for general practice. At the Royal College of General Practitioners conference in Liverpool in October, the Secretary of State announced that we would develop a state-backed indemnity scheme for general practice in England. We are working with GP representatives and those conversations are going very well. We expect to announce further details of the scheme in May, with the scheme going live in April next year.

Several hon. Members rightly mentioned the partnership model. The Secretary of State and I believe in the partnership model and that it has a role to play in the future of general practice, but times have changed, as the hon. Member for Stroud said in his first point. The Secretary of State announced at the RCGP earlier this year that we are setting up a review with the BMA and the RCGP to consider how it can be reinvigorated and sustained for the future. We hope to announce further details soon. I encourage hon. Members to engage with it.

I get excited about multidisciplinary teams and the wider workforce in primary care, because they are so important. They allow experienced GPs to deal with people with long-term conditions and comorbidities. Pharmacists working in general practice through the pharmacy integration fund, who will number 2,000 by 2020, are very important, as is community pharmacy. The hon. Member for Burnley is passionate about that, as am I. They are part of one NHS and are funded through public funds, so they should absolutely be part of sustainability and transformation partnership discussions. I discussed that with the Royal Pharmaceutical Society at the Department yesterday. The wider workforce is critical to us.

General practice is and always has been the heart of the NHS. GPs play a crucial role in our communities in terms of treatment and prevention. The hon. Member for Plymouth, Sutton and Devonport (Luke Pollard) said that the majority of feedback that we get is negative—he mentioned the feedback from some of his GPs—but that is not what the GP patient survey says. In answer to his question, he should bring those GPs in. I would very much like to see them and I may even make them a cup of tea. He should contact me and I will do that.

I thank hon. Members for their contributions. A tremendous amount is going on, and we face a tremendous challenge, but good things are happening across the country and I am out and about visiting all the time. We have to take that best practice and not just share it, but implement it across the NHS in England to address many of our primary care challenges.

I am grateful to all hon. Members who contributed to the debate. We have heard that the future of general practice faces a significant challenge the length and breadth of the country.

On the Minister’s point about funding, since 2010, the rate of increase in NHS spending has slowed considerably. It is well below the real-terms average increase of the 3.7% that the NHS has received since its inception in 1948.

For all that the Minister referred to the Prime Minister’s comments about a long-term and sustainable funding model for the NHS, we are nearly eight years on. We need that model, but we also need something to undo at least some of the damage that has taken place in that time.

On a more positive note, given the success that we achieved in the University of Sunderland bid, I hope the Minister will look carefully at regional variation in the fill rate for training places. We need to take more action to address it.

The scale of the challenge that we face with general practice is clear. It falls to the Minister and to NHS England to take action so that all our constituents, no matter where they live, get the access to world-class healthcare they need.

On a point of order, Mrs Moon. I have a factual correction to make. The hon. Member for Aberdeen South (Ross Thomson) stated that only 51% of students at Scottish universities were from Scotland. In fact, it is 70%.

I am sure that information will have been gratefully received.

Question put and agreed to.


That this House has considered recruitment and retention of GPs.