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General practice is in crisis – that much is clear. But, despite the increasingly loud voices of GPs, the crisis has – up to now – been all but invisible to national policy-makers.
While the pressures facing acute hospitals are obvious through almost real-time data on activity and performance, by contrast there is almost no nationally collected activity data – and certainly none available in real time – for general practice (or for community and mental health services). It’s unthinkable that information about activity in A&E would only be available through retrospective research studies examining data that is more than a year out of date – yet that is exactly the case for general practice.
Currently, there is no routine public reporting of GP activity data and no standardised national dataset. The only data available is extracted for secondary analysis from the research databases developed in collaboration with the three main providers of GP clinical information systems (TPP, EMIS and In Practice Systems). National bodies have been using an extrapolation of data published in 2009 from QResearch (taken from practices using EMIS clinical information systems) to estimate growth in the number of GP consultations nationally. A recent National Institute for Health Research-funded study, published in The Lancet, used data extracted from the Clinical Practice Research Datalink (CPRD), and the Nuffield Trust has also analysed data from CPRD.
Over the past nine months we have been working on a project designed to address the data deficit in general practice and have now published our comprehensive analysis of the extent and causes of the pressures in general practice. We used a combination of quantitative and qualitative research to create a detailed picture. We’ve analysed 30 million patient contacts taking place over five years from 177 practices using data from ResearchOne, a research database drawn from TPP’s SystmOne; carried out a workload survey of 43 practices for week in October 2015; conducted detailed interviews in four diverse practices; and surveyed more than 300 GP trainees.
All this means that we have been able to assess how much activity in general practice has increased since 2010 and what the nature of that activity is. Our analysis found that the number of consultations taking place in general practice grew by more than 15 per cent between 2010/11 and 2014/15. By far the biggest growth in activity was in contacts with people aged over 85 who have increasing numbers of chronic conditions. We also explored other factors that are having an impact on general practice, such as: people presenting with increasingly complex needs; changes in acute, community nursing and mental health services; and the introduction of new services and treatments. We also looked at ‘supply-side’ issues such as changing work patterns, methods of funding and commissioning.
However, while we were able to identify some interesting trends and assess some areas of activity, the main quantitative part of our analysis was challenging. All the clinical information systems used in general practice are designed for practices to use in their everyday work and not for the purpose of data analysis. Unlike secondary care, there are no national standards for data entry about activity, which means that when researchers look at the data they need to make lots of assumptions about how practices code their data and, because of widespread differences in approach, some data just isn’t useable. For example, information about the average length of appointments is notoriously difficult to assess. When we looked at our data, a typical contact appeared to be unrealistically long. Having spoken to staff who used the system, we discovered that they often left the appointment record open until any administrative tasks had been completed, even if this was some time after the consultation had actually ended, thus giving a misleading record of consultation length. So we couldn’t draw any conclusions about changes in consultation length over the study period and have not included this area in our report.
Our report provides a comprehensive analysis of changes in activity between 2010 and 2015, but without an ongoing understanding of changes in activity and demand or supply, neither national policy-makers nor local commissioners can be sure whether general practice has the capacity to allow people to access care when they need it. NHS England now urgently needs to consider how it can get a comprehensive and ongoing picture of the workload and capacity of general practice so that the challenges facing general practice can be robustly addressed.