Assessing demand and supply in general practice

It seems that hardly a week goes by without a new story in the press about general practice under pressure. Anecdotal evidence is that people are finding it increasingly difficult to get GP appointments. This is backed up, to an extent, by the most recent national patient survey, which suggests that general practice is becoming so pressured it cannot meet demand.

So what is causing this pressure on general practice? How many consultations are carried out each week? Do people have more complicated health issues? Or are people more demanding?

The truth is, there's really no way of knowing at the moment. Despite the seemingly vast amounts of data that individual GP practices collect, there hasn’t been a systematic national data collection that can tell us about the number of consultations, who undertakes them or the nature of those consultations since 2008. The data from 2008, which was from a sample of around 500 practices, is still used today by national bodies to estimate growth in the number of consultations nationally.

For researchers, that’s frustrating. For policy-makers, it’s an increasingly untenable situation. Last week, the National Audit Office published a report on access to general practice and strongly recommended that NHS England improves the data it collects on demand and supply in general practice.

At the Fund we’ve launched a project that will collect up-to-date and detailed evidence about the changes in activity in general practice in the past five years. We’ll be working with ResearchOne, the non-profit research database of TPP, a provider of electronic patient record systems. With them, we’re going to analyse patient appointments from the past five years for about 450 general practices to look at changes in the amount, nature and complexity of the activity that practices are undertaking. In addition, 50 general practices have completed a detailed workload survey that will give us some really rich data to compare and we’re doing in-depth qualitative interviewing with four practices – in Plymouth, Shrewsbury, Sheffield and London – to really get underneath what’s going on in general practice.

We’re three-quarters of the way through our qualitative fieldwork and are just beginning to analyse the data so it’s a bit early to talk about findings, but issues are emerging from our qualitative work that we will explore in more detail and triangulate through our data analysis. I shared some of these at a conference at The King’s Fund last week on pressure points in primary care.

We’re hearing, as you’d expect, about increases in morbidity, particularly multi-morbidity. But we’re also discovering that the success of schemes to use other professionals – such as nurses or pharmacists – to manage minor illnesses and steps to get better at effectively triaging patients – for example, through telephone triage –  is meaning a high proportion of the people that GPs see have particularly complex issues. These require not just complex assessment and management but also significant and time-consuming liaison with other parts of the health system.

Practice staff are telling us about changing expectations around who patients want to see and when. Does this mean that being seen quickly by a GP is an expectation now or is it just that people present their problems as more urgent when they discover they have to wait four to six weeks for a routine appointment? People want to see the doctor of their choice, and the trade-off between access and continuity is one we’re going to explore.

The shift to care closer to home is clearly having a profound impact on GPs. We heard lots of positive messages about this shift – conditions, such as type 1 diabetes, that used to be managed in secondary care are now the responsibility of GPs and this is clearly better for people with long-term conditions. But we also heard from GPs that letters from consultants following an outpatient appointment that previously would have informed GPs about actions being taken in secondary care, now request multiple actions from the GP – such as initiating drugs, ongoing monitoring and follow up.

People are also having shorter stays in hospital, which means that tests ordered in hospital are followed up in primary care and more acutely unwell people are managed in the community. Funding and workforce don’t appear to be transferring from secondary to primary care at the same rate as the work is moving in that direction.

And there are just more things to do in general practice – more drugs with complex monitoring protocols, more immunisations, more checks, more preventive work. This provides better treatment and outcomes for patients, but it takes time.

We’re also seeing changes in the GP workforce. In particular we think we’re seeing some profound changes in working patterns with GPs less likely to be doing full-time clinical work. This isn’t about people managing childcare responsibilities. We’re finding that while GPs may still be working full-time they are doing fewer clinical sessions in general practice and we want to explore why that might be.

We’re looking forward to seeing what our data shows and hope to have a really interesting project to share fully in the spring.

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Comments

#545187 Harry Longman
Chief Executive
GP Access Ltd

"Nobody knows" - this is the shameful answer to the question, what is the demand in general practice?
My blog: http://gpaccess.uk/evidence/gp-demand-its-official-nobody-knows/
We have by the way been collecting this in detail and using clinical system records for ease and precision since 2011!

#545189 Dillon Sykes
Managing Director
productive primary care ltd

Hi Beccy

This looks are really useful project. One I am more than happy to be involved in.

We have been looking at capacity and demand in General Practice since 2009, seeing many patterns and trends from different demand management systems.

Dr Steve Clay our clinical director has been running Doctor First for over 9 years and in doing so has mapped true demand and not just activity.

We have seen this pattern matched across many UK practices and successfully helping CCGs to map this.

If you would like to hear more please get in touch. Otherwise I look forward to your report.

#545192 Nick Mann
GP
Well St Surgery

Another unacknowledged issue: the growth of mandated GP activity under DES/LES/QOF etc has been extraordinary. This has nothing to do with patient demand or complexity. No data exist to quantify this extra work, or to evaluate any benefits to patient outcomes. Constrained funding has not allowed proportionate staff expansion, thus restricting access for patient-driven appts. As core funding has reduced, many Practices must perform these administrative and questionable activities in order to remain solvent. Can you quantify and evaluate mandated activity?

#545194 Alison Crail
Law Reporter

Recently I changed membership group at BUPA. I find that among my terms and conditions is the requirement for a GP to fill out quite a complex form about the history of a condition before authorisation for treatment can be obtained. Often, in my experience, the GP has had little involvement as when someting arises there's no appointment in the relevant timeframe.
What a waste of time asking them to do all this in order to refer a patients sometimes to consultants one has previously seen.

#545197 Dr Kadiyali M S...
Retired GP
NHS

I have answers to all the questions you ask and more information. How and why did I look at this? and why NHS and your King fund is not interested in talking to me?

The answer is simple but very embarrassing for institutions, GMC, Royal Colleges, NHS and BMA.

I am a doctor who was talking about antibiotic resistant bacterial threat to humanity since 1989. In 2000, I started working as a GP to collect information and learn why patients access healthcare.

In 2003, I found an ideal surgery to continue my work so I joined a Pilot GMS nurse/led practice. Here I felt uncomfortable because nurses were allowed to work as GPS, offer emergency care advice and prescribe drugs. The evidence I collected was sufficient to prove this is not safe and is un-ethical. The GMC, BMA and the Royal Colleges must have stopped this un-ethical medical practice but they did not. I have all the information to prove and also have documents to show.

I am a "Whistleblower" who has been ostracised by your institutions and people in power in the NHS. I am still register and licensed to practice. Have 30 years of "Unblemished registration in GMC".

Using the data, I have now created an APP called MAYA, written two books to help protect fellow human and a set of cards. The publishers will be releasing my books very soon.

I am sure you will find the information I share in my book interesting. Please send me an email to call111@hotmail.com and I will share the confiedential information to help you understand why primary care has failed and GP are unable to cope or help bring in changes.

What my teachers said is very true "Your eyes don't see what your mind can't think".

#545198 Kadiyali Srivatsa
Retired P
NHS

I also think its shameful to say the Kings fund does not have the data to understand the working pattern, statistics. How on earth are they acting as expert advisers to politicians, the NHS and claim to be the decision makers. I have published data, shared information with Kings fund and have been very vocal. It looks as if your blog and my evidence is not good enough for these clown to accept because their EGO does not let them listen to doctors who care about NHS and people.

#545199 Jim Kent
Vice-chair
DunsterPPG (West Somerset)

These extra functions that slip under the door have a long history. When I was active as an Emergency Planner, It happened that WRVS were always called upon, usually without consultation, to provide useful pairs of hands for a multitude of jobs in Emergency Centres with the result that they were often multiply-booked. From Nick Mann’s comments, the same thing is happening to GPs.

I am part of the Reference Group for Somerset Pathfinder CCG in the Care.data programme. At present, we are awaiting the result of Dame Fiona Caldicott's deliberations, but in all probability within a year, GPs will be introducing most if not all patients to the process, dealing with a range of documentation and of course the variety of other individual problems that may arise.

In the last six months or so, I have also attended a couple of PPI meetings discussing the 100k Genome project. GPs will again be involved in passing medical records of patients (with cancer or a rare disease) who opted-in to the project, onto a central collecting point. However, it seems very likely to be a different sink to that for Care.data info. Also, although the numbers involved should be much lower (figures I've seen for the South-West suggest about 2 - 3 per 1000 patients in a practice), data may still need to be prepared in a form suited to this project’s analytical requirements..

These two projects are both run by the NHS, but are apparently otherwise unconnected (neither set of organisers were aware of the other when I first explored the details), which to me implies the possibility of two disparate sets of protocols for every practice to be familiar with unless one can bang the appropriate heads together and generate a common process. Even then, there will still be yet more work for over-stretched GPs and practice staff with little or no recognition other than a blanket vote of thanks in some medical journal.

As a biologist, I am perfectly happy with the common concept of long-term experiments using repeated data collection to reveal changes in outcomes and link these to prior treatments. I also know that others are less content, with views of data security that need to be catered for. However, I also have the feeling that nobody has yet carefully ‘walked through’ the entire process for either project to evaluate its costs in time, effort and stress. Time must be taken to consider the fine detail of the data transfer process and pose a range of “What if?” questions.

With the present parlous state of the medical profession (I mean the mismatch between numbers qualifying and prospective retirees – another “unforeseen consequence” just like we elderly) adding further unsupported straws will surely lead to the extinction of camels - aka the NHS as we know it.

#545202 Peter Noone
Cons Occupational Medicine
HSE

Too many 'chiefs and not enough indians'. Lack of autonomy and authority to get on with the job.
Political interference and the 'cult of managerialism' destroying the medical profession and the brightest and the best are voting with their feet by emigrating or not embarking on a medical career with rapidly diminishing terms and conditions, constant intrusive 'harassment' by those that have all the authority but no accountability, loss of discretional effort through loss of perceived value and respect for the job.
Need transformational leadership and Stephen Covey's 'the *8th habit- from effectiveness to greatness' and let the real experts get on with the job.

'Stand back and let the dog see the rabbit'.

#545203 Chris Gunstone
GP
Queens Hospital Burton

I remember when I started work in the 90s disgruntled patients commenting that by the time they got an appointment they had got better! We never succeeded, as a practice, in fulfilling demand over the 23 years I was working... and we tried!
Working in out of hours, it is not uncommon to see anxious parents who have seen a doctor several times in the previous week before seeing me with their child with a viral illness.
Fear of litigation, the loss of the stabilising "grandma" effect, the loss of the concpt of "normal" illness, and the expectation of perfect health all add to increasing demand and reduction in capacity

#545205 Dr Kadiyali Srivatsa
Retired GP
NHS

Chris, you are right, I have worked as a locum GP, OOH triage, primary care emergency clinic and in private GP offering emergency care in central London when I was employed (part-time) as salaried GP in PCT. The reason I did tis was to understand and learn more about demand and see if I can find an alternative method.

The first thing that I identified was the way doctors (Gps) diagnose or name illness. The reason people consult too many doctors is because majority of patients know what is wrong with them and they are looking for doctors to offer the help they need. When their expectations are not not met, they return or consult another doctor.

You won't believe if I say, I have now created a tool that can actually replace primary care physician and can be used by lay man all over the world. The secretary of state, supported by cronies, think they can play with lives of doctors and get away, I am afraid they got it wrong. Doctors like me are determined to make sure fellow human do not suffer and so we will be successful.

My only concern is how are we going to tackle the threat of infections that kill? I am in India and am worried about spreading infection in Chenni after the flood water recedes...if this happens, people all over the world will suffer. We do not have time to continue to organise research, waste time validating or debate about innovations and so I am begging doctors to join hands and support, because its not only patients life but also the life of our children and family that is now under threat.

#545206 Dr Kadiyali Srivatsa
Retired GP
NHS

Please watch my videos in youtube channel "Medifix", visit my website www.call111.com and read my blog. I am very much visible in the internet and working on releasing my apps and book to help people learn all about common illness.

This will help us reduce demand by 60% and help us identify people with infections that threaten staff, patients and us working in the healthcare centres or hospitals.

I will be happy to read your comments, criticism and suggestion. If you do not get involved and think the happy times will continue, please listen to me...the good old days of claiming to be "Doctor sing lives" is dead and gone...start thinking about your family and your life...the bacterias are winning...this is a battle that we may never win.

#545207 John Cosgrove
GP
Midlands Medical Partnership

Very pleased to see The King's Fund collecting data in an attempt to fill the gaping void of evidence in the vital area of GP workload that seems so poorly understood.

As perceived pressures have grown, many GPs have shifted as much work as they can to outside the consultation, without always making time for this work. Nick Mann describes the growth of "mandated GP activity under DES/LES/QOF etc". These are but a few examples of administrative burdens that are imposed on general practice. Increasing numbers of repeat prescriptions and investigations also place significant administrative burden on GPs.

What data will you collect to monitor the work carried out by GPs outside of consultations with patients?

I recall a previous KF publication (with a mischievous title that escapes me now) that acknowledged a particular lack of evidence in this area.

#545208 John Cosgove
GP
Midlands Medical Partnership

PS I should have added supervising and supporting the growing number and range of other clinicians and allied health professionals to my non-exhaustive list of non-patient facing work.

#545209 Peter Brindle
GP and Leader - Commissioning Evidence Informed Care
West of England AHSN

Hi Beccy

Great blog and good news re your new project. So much money is being put into interventions that hope to improve the management of patient flow in GP but remarkably, no hard data on demand. So the impact of these interventions on demand cannot really be evaluated - very important as they can inadvertently increase demand.

Assessing demand via appointments can be rather muddy as appointments is as much a measure of capacity as it is demand.

WEAHSN as just done a project to assess practices (and CCGs) ability to measure real time demand through phone systems and appointments. Currently it is not done but could be without that much effort or investment. This a crucial issue for workforce planning in GP and the rest of the NHS system downstream and we have big plans to do more work in the area.

It would be great to have a chat on the phone sometimes.

#545220 Debbie Carroll
Garden Designer
Debbie Carroll Garden Designs

At last, and the answers may not be what is expected. For 17 years I was with a sole Doctor practice, never waited more than 48 hours for an appointment. When I saw the nurse for a routine visit would be given an overhaul as a matter of course. Sadly he is retiring and we've merged with a practice of 6 doctors, in an area with over 5 large other practices nearby too so no lack of doctors near us. Now I've averaged waits of 3 weeks. Its a battle to get past the fortress of reception, the human factor has gone and I avoid going - surely prevention is better than cure so I'll be iller now when I do go! The sums on this do not add up except that practices are either too big or not that efficient, there is a lot of wasted beurocracy that relationship-centred care would cut through. People make out they are iller just to get seen at all.

#545221 Craig Wakeham
GP
Cerne Abbas Surgery

We need systems thinking (as recommended by the Kings Fund earlier this year in their review of the Five Year Forward View). We need to consider Failure Demand and a 'contract creep'. Add a lack of investment for 10 years, a system that administers, in the worst possible way i.e. NHS England. The 'seen as necessary but adds no value, both in contract monitoring and in 'quality' regulation. Not forgetting an absence of workforce planning. All in all you have a perfect storm!

#545222 Rachael Parkman

As a lay person, I wonder whether the closure of walk-in centres has contributed, at least in the last few years. I used to have two very close by (by public transport) and one slightly further away. Now all have closed and one is now used as an overflow to my GP practice- if you are 'urgent' they will try to find you an appointment. There is a big difference between illnesses that are urgent/emergencies and ones that can wait 3/4 weeks but there are no services to plug that gap so I imagine callers to the surgery are now stressing that it's 'urgent'. I have used telephone consultations and the by phone out of hours service because I'm happy to manage my condition myself, but someone older or with children may not be.

#545228 Cath Denholm
Director of Strategy
NHS Health Scotland

Another source of important data - that I've not seen mentioned in the comments - is how much it is actually costing to deliver the service? Lots of this data tied up in practice accounts which, of course, service planners can't access.

#545635 clare gerada
GP

Its important that the Kings Fund looks at its role in causing some of the demoralisation around GPs. The Fund has been preoccupied with hospitals - and hospital data- collecting and reporting on this and ignoring (even though I and others suggested it was important) what was going on in GP-land. Then there are the reports all of which seem to denigrate us - i think the one that really hurt was 'GP from Cottage industry to industrial revolution' or something like that. GPs have always adapted - far faster than hospitals and we have always been at the forefront of change. We have now been systemically starved of money and blamed for all the ills of the NHS and humiliated by others - telling us we have to change and then how to do it. At last the KF is examining our profession - and hopefully not too little too late. What makes the NHS special - really special is its system of health care with GPs at its front door - providing first contact care (not Kaiser-care). If we lose this we will all be worse off for it
Clare

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