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Evidence and consultations

Debate in the House of Lords: Role of primary and community care in improving patient outcomes and the need for reform

With ongoing GP shortages and backlogs in community health services, this briefing was written ahead of the debate in the House of Lords on the role of primary and community care in improving patient outcomes and the need for reform. While national leaders have made important strides to address these issues, further action is still required.

Key messages

  • General practice is in crisis because of difficulties in recruiting and retaining GPs alongside a growing and increasingly complex workload, making it more difficult for patients to get appointments. There are no quick fixes to this crisis.

  • In 2021/22 there was a shortage of around 4,200 GPs in permanent roles, despite more GPs being in training than ever before. Additionally, GPs are reducing the number of clinical sessions they work, often due to the volume and intensity of the workload, while large numbers are retiring and leaving the profession – with many citing burnout as the reason for doing so. The government’s 2019 manifesto pledge to deliver 6,000 more GPs by 2024/25 will not be met.

  • National leaders have made important strides in addressing these issues through a new GP contract that aims to bring much-needed investment, reform and additional staff. Under the contract, practices will be required to work differently, coming together at scale in primary care networks, with teams of health professionals working closely together to deliver a wider range of services and to extend access for patients.

  • There has been welcome investment in 26,000 additional roles working in primary care networks, including pharmacists, physiotherapists and link workers. However, while primary care networks have swiftly recruited to these roles, effective implementation of these teamworking models is key: primary care networks and individual practices need a clear understanding of the needs of the patient population and how the skills and knowledge of team members map against those needs. They also need a clear and shared vision of how the roles will be integrated within the teams: our research into the implementation of the additional roles in general practice has found that, in many cases, general practices are not ready to implement a multidisciplinary model of care either within or across practices that embraces these roles, leaving some staff isolated and demoralised.

  • Patients are finding it harder to get appointments when they need them. The 2022 GP Patient Survey found that only 56 per cent reported having a good experience of making an appointment, 9 percentage points lower than the 2020 results, and there are also early signs that the pressure on GPs is affecting patients’ experience of their appointment when they get it. Similarly, the British Social Attitudes survey showed satisfaction with GP services fell to 38 per cent in 2021 – the lowest level ever recorded and a 30 percentage point decrease compared to 2019.

  • The mismatch between capacity and demand for general practice predates the Covid-19 pandemic. Over time, demand has increased, while a combination of an increasingly complex caseload, rising thresholds for referral to other parts of the system and an increasing administrative burden have all contributed to growing pressures. Growing pressures have been exacerbated by the Covid-19 pandemic which has increased GP workloads, while rising waiting times for hospital treatment is also having a knock-on effect on general practice.

  • Improving access to general practice will require action from across the health and care system, and it is critical that integrated care systems and their partners, including local government, consider how they will provide support to general practice to improve access in the short term.

  • The Covid-19 pandemic has accelerated new ways of working including a rapid uptake of existing digital tools to deliver patient care, which have enabled greater flexibility of appointment times. While digital tools have benefits for some patients and staff, a proportion of the population in England is digitally excluded or have needs that make digital access less appropriate for them.

  • The complex and piecemeal nature of funding for general practice acts as a barrier to transforming services. There is also a recognition that existing funding formulas do not adequately reflect the additional needs of deprived populations. The distribution of staff across England is also unequal, leaving some areas under-doctored. In addition, it is clear that practices will need to come together at scale to provide certain services, while retaining the benefits of local neighbourhood practices, which can offer continuity to patients.

  • It may be tempting to look at fundamental reform to the GP partnership model. However, while fewer GPs are wanting to take on partnerships, this is often because of the intensity of the workload rather than the model itself. Any further fundamental reform needs to be clear about how it will contribute to overcoming the core underlying lack of capacity in general practice and how it will do so without additional disruption to services.

  • Community pharmacies have an increasing role to play in providing access and support to local populations, and the clinical skills of the pharmacy profession are widely considered to be underused. Pharmacies stepped up to deliver an increasing share of the Covid-19 vaccination programme as the programme progressed and there is an opportunity to continue to unlock the benefits that community pharmacy can bring.

  • While the backlogs in community health services may be less visible than those in hospitals, there are more than 1 million people waiting for services including community paediatrics and physiotherapy services which have not yet recovered after the pandemic. As with other parts of the health and care system, community services are also constrained by workforce pressures, particularly in certain posts such as health visiting and district nursing, as well as by the sustained lack of investment in social care.