While a one-year drop in GP satisfaction is worrying, the long-term trend is even more alarming. Satisfaction has been steadily decreasing for close to a decade from a high of 80 per cent in 2009. Meanwhile, satisfaction levels with other NHS services have not experienced such a steep decline and have tended to fluctuate year on year. And as respondents are more likely to have used GP services rather than the other services covered in the survey, this is likely to be an accurate reflection of their recent experiences.
Satisfaction is usually highest among older respondents (Figure 1). For example, in 2017, satisfaction among those aged 65 or older was much higher (77 per cent) than among those aged 18 to 64 (62 per cent). However, this year satisfaction has fallen in all age groups.
Another way to look at satisfaction data is to calculate net satisfaction: satisfaction minus dissatisfaction. A high-performing service should aim to shift respondents from the dissatisfied category into the satisfied category, and this measure tracks their success in doing that.
Figure 2 shows changes in net satisfaction with general practice along with satisfaction with four other NHS services –inpatient, outpatient, accident and emergency (A&E) and the NHS overall.
It shows that over time there has been a striking change in how the public view general practice compared to other parts of the NHS. From the early 1990s through to the late 2000s net satisfaction with general practice was more than 20 per cent higher than net satisfaction with the other parts of the NHS. For example, in 1999 net satisfaction with general practice was 61 per cent, while net satisfaction with inpatients (the next highest rating) was 41 per cent, outpatients 34 per cent, A&E 28 per cent and the NHS overall just 13 per cent. In market research terms, general practice was definitely the market leader, in line with its international reputation as the jewel in the crown of the NHS.
However, this is no longer the case. Net satisfaction with GP services in 2017 (43 per cent) was lower than net satisfaction with outpatients (52 per cent) and around the same as satisfaction with inpatients (41 per cent).
Why has satisfaction dropped so significantly in recent years? The BSA does not ask respondents about their dissatisfaction with general practice explicitly, but when it asks patients who are dissatisfied with the NHS overall why this is, one of the top reasons is long waiting times for GP and hospital appointments. This suggests that difficulties accessing care are part of the problem. The national GP patient survey provides more insight: key experience measures have been declining since 2012 (the earliest year of comparable data available). These measures include patients finding it harder to get through to the surgery on the phone, harder to see their GP of choice (which affects continuity of care, something that we know is key to keeping patients healthy and out of hospital) and rating their overall experience of the surgery more negatively.
What does this mean for policy-makers? First, the BSA is a gold standard measure of public opinion, so policy-makers should take it seriously. Second, the data sends an unmistakable message that general practice is in decline.
The results are not surprising given the pressures on general practice. These pressures are driven by increases in patient demand, caused by a range of factors including an increasing number of patients with multiple chronic conditions and complex needs, and a growing number of treatments available. The situation is exacerbated by a workforce crisis: more GPs and other primary care staff are needed, but GP numbers at the end of 2017 were lower than in 2015.
While the government is still committed to recruiting 5000 more GPs (with a large proportion coming from overseas), meeting these demands will also require changes to the way we deliver general practice. This is something that The King’s Fund is currently exploring through a project looking at innovative models of general practice in England and elsewhere.
Unless the government and general practices respond to these challenges, public satisfaction levels will continue to slide, and the jewel in the crown of the NHS will struggle to regain its royal status.
I note the comment about the Daily Mail. I have never subscribed to this newspaper until recently because it is the only newspaper to support the campaign by members of the prescribed harmed community, harmed by prescription drugs of dependence, namely benzodiazepines and antidepressants. No doubt GPs think it is an attack on them but drug damaged patients have lobbied hard to get the press even remotely interested. Patients have also been driven to raise petitions with the Scottish and Welsh governments, desperately trying to get some action on the issues of drug dependence and harm. The silence from the medical profession is deafening apart from a few brave doctors willing to speak out in public on our behalf. Patients have also been driven to appear on TV and in the press simply to get their voices heard. None of us enjoys doing this and we go through an immense amount of stress in the process. The online prescribed dependent community grows by the day as more and more patients turn online for help and support whilst the Royal College of Psychiatrists publicly denies there is a problem in mainstream and social media. The Royal College of GPs is strangely silent on the issue. Public Health England has announced a year long review of drug dependence and Southampton University is funded for a 6 year research project on antidepressant withdrawal. For many of us damaged, there has been denial and dishonesty about the cause of the harm done to us. So there is something fundamentally wrong not just with general practice but in the wider NHS. It is of course very frustrating not being able to get a GP appointment, seeing different doctors all the time, having to wait months for referrals etc etc. But the biggest issue for those of us in the prescribed harmed community is the lack of knowledge of drug dependence and withdrawal and the lack of honesty about the harms caused by drugs of dependence and this extends to consultants as well as GPs. A great deal of time and NHS resources are wasted denying rather than addressing the problem. It is quite impossible for patients to get accurate and evidence-based information on antidepressants so that an informed decision can be made about treatment. I think that this is probably the case for many prescribed drugs. The influence of the pharmaceutical industry is immense and the corrupt influences are evident for all to see. So we should not pretend that the crisis in general practice is just about funding and resources. There is something much more fundamentally wrong.
John Appleby has pointed out many times that a huge funding gap has been introduced starting in 2010 and ever worsening. It is naive to think that quality can ever get better with a lower cost service. Who would ever go to a shop imagining that a £10000 Proton would be of the same quality as a £40000 BMW? Yes, Jeremy Hunt has repeatedly told doctors that high quality care can be provided with lower costs and even, incredibly, that focussing on cost reduction can improve quality. We have lower paid doctors and nurses than we did in 2010. Cost cutting is now the by-word for NHS management. When will reporters call it like it is instead of repeating the "more study is required" mantra of those who are unwilling to admit the obvious?
I once offered an appointment or visit within a 20 minute slot . That patient was the focus. This was after my MBA . Since then , as the years and pressure grow, I am wiser. It is not about only pleasing patients. I don't mean giving antibiotics like smarties to a child. My op appointment has been cancelled 5 times in 6 months.
We have to be extra careful , with guidelines, inspectors etc. This is a big change with growing litigation , damaging the virtuous cycle. Nurses will soon be first point of care . The days of 7am. To 12 midnight work has gone . It may save what GPs are left.
I agree entirely with Emily Johnson - the plummet in moral in primary care started several years ago with what appeared to be a media campaign in the Daily Mail and by one of the Conservative government's own policy advisers who is also a journalist for the Times. I am a member of a larger primary care Facebook group and witnessed first hand the effect this had on primary care clinicians.
Primary care is the bedrock of the NHS and is failing. Unfortunately, although this was predictable three years ago, too little has been done too late and I can no longer see a solution - with 10% of GPs having moved to better conditions in Australia, Canada and New Zealand, unfilled training vacancies and no incentives for GPs to continue working past their mid 50s.
Schemes to replace GPs with other professions miss the point of the role of primary care in managing risk and resources.
Really precise analysis here Ruth. Amongst every single one of my GP friends the consensus is that they themselves are deeply dissatisfied with the levels of service, time and attention they can provide patients, and the unavoidable waiting times brought about by high demand and complex co-morbidities/frailty/the surge in those accessing primary care for support with mental health conditions.
As a result GPs are under extraordinary pressure and untenable workplace stress, and the sector is no longer attracting medics to choose general practice as a career (in particular female doctors who traditionally were attracted to general practice due to the relatively more family-friendly working hours). We’re haemorrhaging our existing GPs to overseas practice (one of our own mutual schoolfriends who is a GP has indeed emigrated this year) and simultaneously not attracting overseas medics in return.
I hope that hand-in-hand with discussion around the public’s declining satisfaction in GP services will be more of this well-reasoned, illuminating contextual background as is espoused here in your interesting article Ruth. I fear though that certain sections of the media/political spectrum will use these statistics as sticks with which to further beat the NHS, apportioning blame at the door of the GPs themselves and expecting them to be the authors of a turnaround in satisfaction levels.