Public satisfaction with general practice is lower now than it has ever been, while the number of people reporting difficulties in booking appointments continues to grow. Given this, it was of little surprise that the NHS, and specifically the issue of access to GPs, featured as one of the key political battlegrounds in the 2019 general election.
Here we run through the proposed solutions and assess their potential effectiveness.
The proposed solutions
England has fewer GPs per 100,000 population than other UK and EU countries. Current efforts to train more GPs are proving successful; in 2019 a total of 3,538 GP training places were accepted, the highest in the history of the NHS. Despite this, the number of full-time equivalent GPs has decreased as there are more GPs leaving the profession or reducing their hours. The reasons cited by GPs for retiring early or reducing their working hours are broad and varied, though they often focus on their unsustainable workload and pension issues.
Increasing international recruitment has been put forward as a short-term solution, but this too presents challenges. Despite the efforts of NHS England to recruit 2,000 overseas doctors into GP practices by 2020, by September this year the international GP recruitment programme had brought in just 140 doctors.
The ambitions to train more GPs are right, but they will only be effective if the growing number of GPs leaving the profession can be reduced. There are already efforts to improve retention, including financial and educational support for doctors who are thinking about leaving the profession and improved access to mental health support. Improving doctors’ working lives by addressing their workload is likely to improve retention. This will mean not just increasing the overall workforce but also implementing effective team-based models of care and redesigning processes and workflow, supported by expert service improvement support and investment in technology and buildings. Addressing the pension issue is also key and will require action from HM Treasury and the Department of Health and Social Care.
Working in teams
Future models of general practice will use the diverse skills of a range of professionals, not just doctors but also physiotherapists, nurses, mental health professionals, clinical pharmacists, link workers and physician associates to name a few.
Evidence tells us that team-based care – where a range of professionals work together to provide proactive, person-centred care – can support improved access, more efficient co-ordination and improved continuity, if implemented effectively.
The NHS long term plan committed to expanding the number of other professionals working in general practice, and that commitment is supported by significant investment in the new GP contract framework. However, this is not a panacea, particularly given an overall shortage of nurses. There also needs to be significant investment in the bricks and mortar of general practice; the current GP estate is simply not extensive enough or sufficiently well maintained to house the diversity or scale of workforce that is required.
There are many digital solutions that can support access and capacity in general practice, for example, telephone triage models; digital first models where patients mainly see their GP by video link; and e-consultations. The evidence suggests that the way in which these solutions are implemented is as important as the intervention itself and that they may improve patient experience without reducing GP workload. There is also evidence that some digital models are attractive to younger patients but may not be appropriate for patients with chronic or complex conditions.
Alternative routes to primary care
There have been various attempts to create new and alternative routes into primary care. These tend to focus on unplanned care and include access hubs, which offer out-of-hours appointments for people across a catchment area; minor illness schemes in community pharmacy; urgent care centres; walk-in centres; and placing GPs in A&E departments. Evidence suggests that these services, particularly hub models, can sometimes create new demand rather than diverting existing demand.
Extended opening hours
In 2013 the Prime Minister’s Challenge Fund was introduced to support extending access to general practice beyond normal working hours, and this is now part of the funding for primary care networks. Early evaluation of these schemes found they did reduce the number of people going to A&E for minor issues but did not have much impact on the number of people admitted to hospital as emergencies or the number of people using GP out-of-hours services across the pilot schemes.
Waiting time targets
In 2000 the Labour government introduced a target that patients should be offered an appointment within two working days and invested in on-the-ground support for practices to help them make changes.
The evaluation found that that not only did most practices not meet the target, the overemphasis on rapid access interfered with providing access to appropriate care and even though access times improved, overall patient satisfaction went down.
Access is only one aspect of general practice; other aspects such as continuity or co-ordination of care might be more important to keep people healthier at home for longer and to reduce the need for admission to hospital. Focusing on access at the expense of other key aspects of care can have unintended consequences: experienced GPs may find themselves diverted to delivering rapid access clinics giving them less time to spend on longer appointments or multidisciplinary team meetings for complex patients.
Past attempts to address access to general practice have had variable success, and public satisfaction with general practice continues to decline. There is no single solution– improving access is complex. Increasing the numbers of staff in primary care is critical, and that will mean both recruiting new staff and retaining existing staff. Equally important is investment in technology to support models of digital care and to improve our understanding and investment in estates and in organisational development support to implement effective team-based models of care.