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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.