What we think
General practice is in crisis because of difficulties in recruiting and retaining GPs alongside a growing and increasingly complex workload. This is impacting on patients, who are finding it harder to get appointments when they need them.
National leaders have made important strides forward 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.
The development of primary care networks alongside commitments from the government to increase the size of the primary care workforce and the number of appointments available is welcome and offers the potential to improve patient care by improving access to a range of services. However, the scale and complexity of implementation should not be underestimated. It will take time to embed new staff roles and to develop the leadership needed to enable joint working among multi-professional teams. Efforts to retain and recruit more GPs will need to continue alongside the introduction of new roles if commitments to increase the number of GPs are to be successful. Outdated primary care buildings and IT infrastructure will also provide significant challenges.
However, the emerging long-term health effects of the Covid-19 pandemic mean that GPs are now facing greater workloads, including treating ‘long-Covid’ patients, and supporting those whose health has deteriorated due to a lack of routine care during the first phase of the pandemic and the impact of delays in accessing secondary care services.
The Covid-19 pandemic has also necessitated new ways of working including a rapid uptake of existing digital tools to deliver patient care. Digital primary care provides many benefits for patients and staff, including greater flexibility of appointment times, easier access for some and improved staff morale. However, for some groups digital technology is inaccessible for a range of reasons like affordability and personal preference. Looking ahead, the task for national bodies and local leaders is to learn lessons from recent months and make lasting changes to policy and practice to create an environment that is more supportive of digital health innovations that improve patient care.
Effective primary care, including general practice, is the bedrock of a high-quality and cost-effective health system. But general practice is under strain as it struggles to deal with a rising workload that is becoming more complex and intense. While there is no national activity data that allows us to accurately quantify the change in activity, our research indicates that this has risen significantly due to a combination of rising demand, growing complexity, higher expectations, increased administrative burden and rising thresholds for referral to other parts of the system.
While more GPs are being trained than ever before, issues around retention mean overall numbers have not been increasing in recent years. Fewer GPs are choosing to work full time in patient-facing general practice (eight or more half-day clinical sessions per week), often due to the volume and intensity of the workload. To help increase capacity in primary care, The NHS Long Term Plan commits to bring in 20,000 more primary care professionals, such as pharmacists, physiotherapists and link workers, to the general practice workforce by 2023/23. Then in 2019, the government pledged an additional 6,000 primary care professionals, on top of those already committed to in The NHS Long Term Plan, as well as 6,000 more GPs in an effort to increase the number of appointments available in general practice by 50 million per year by 2024/25.
These pressures are affecting patients’ experience of general practice. Although patient satisfaction with the care they receive remains high, the GP Patient Survey and British Social Attitudes survey both show declining satisfaction in recent years, driven by problems accessing appointments.
Real-terms financial investment in general practice has been increasing since 2013/14 after some years of decline, and The NHS Long Term Plan promises further investment in exchange for GPs providing some additional services.
In recent years, national policy has focused on improving access, with GPs required to offer extended hours and weekend appointments. A growing number of practices have been adopting new access routes such as video consultations, email consultations and telephone triage and this has accelerated during the Covid-19 pandemic, with almost all practices now offering some form of remote consultation. While these approaches can help patients to get appointments when they want them, they require careful implementation and significant changes to the way GPs manage their work. New forms of access must also be designed in a way that does not increase health inequalities and can work effectively with other local health and care services.
Following the introduction of the new GP contract, which channels new money directly to general practice, GPs have come together in primary care networks covering populations of around 50,000 (NHS England 2019a). Networks receive additional funds to support the introduction of new clinical roles into general practice teams including pharmacists, physiotherapists, paramedics and community link workers.
NHS England has significant ambitions for primary care networks, expecting them to be a key vehicle for delivering many of the commitments in The NHS Long Term Plan. They will be required eventually to deliver a set of seven national service specifications by introducing new roles into general practice, working in multidisciplinary teams with community and social care services and proactively managing the health of their local population. Critically, they will also need to shore up core general practice provision to ensure access to high-quality, sustainable primary care.