Is general practice in crisis? big election questions

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Ahead of the general election on 8 June, we examine the big issues around health and care.

What’s the issue?

There are widespread reports that people are finding it more difficult to access their GP. GPs report that they are under growing pressure as a result of an increase in the volume and intensity of their work. At the same time, fewer GPs are choosing to undertake full- time clinical work in general practice, while large numbers are retiring and leaving the profession. This adds up to a profession under enormous pressure and facing a recruitment and retention crisis.

What’s behind this?

Public satisfaction with general practice remains high and people are more satisfied with GPs than with any other NHS service. However, there are signs that patients are becoming less satisfied with their ability to get GP appointments. The GP patient survey shows that satisfaction with their experience of making an appointment has steadily declined from 79 per cent in 2012 to 73 per cent in 2016, while NatCen’s 2016 British Social Attitudes survey found that the proportion of people who thought GP appointment systems were ‘very good’ or ‘satisfactory’ declined from 57 per cent in 2010 to 37 per cent in 2016.

The government’s response has been to focus on improving access, in line with its 2015 manifesto commitment to ensure that everyone can see a GP from 8am to 8pm by 2020. Following pilot schemes in a number of areas, extended access is now being rolled out across England. Latest figures show that nearly a quarter of practices offer ‘full’ access either through their own practice or through the group of practices they are part of. NHS England has brought forward the date for meeting the manifesto commitment to March 2019.

Although there is a lack of national data about activity in general practice, it is clear that pressure on GPs has increased. Last year, The King’s Fund undertook the most comprehensive analysis to date of demand and activity in general practice. This found that GP workload had grown both in volume and complexity, with our sample showing a 15 per cent increase in the number of consultations between 2010/11 and 2014/15. There are many reasons for this, including the growing number of patients with complex conditions; new services and clinical advances; and changing relationships with other parts of the health and care system. Over the same period the proportion of NHS funding spent on general practice declined by 0.4 per cent.

The wider impact of financial pressures on the NHS and social care is also affecting the work of GPs. The last Budget included funding for GP triage in accident and emergency departments, in the hope that this would improve waiting times in A&E. While there is evidence from some high-performing hospitals that this can have an impact, it will be a challenge to find enough GPs to staff these services. The recent relaxation of the 18-week referral-to -treatment waiting times standard for elective treatment is also likely to impact GP workload, as people waiting longer for operations may need more input from their GP while they wait.

The pressure is having an impact on the recruitment and retention of GPs. Despite a government pledge to increase the number of doctors working in general practice by 5,000 by 2020/21, the number of full-time equivalent (FTE) GPs fell by 0.3 per cent in 2016. Around 17 per cent of the GP workforce (5,700 FTE) is over the age of 55 and while more GP trainees are being recruited this is not yet having an impact on overall numbers. In our research, we found that, as a result of the pressure they are under, many GPs are increasingly unwilling to work full time in patient-facing roles, and prefer to work in salaried or locum roles rather than as partners.

We also surveyed more than 300 GPs in training, and found that less than a third (31 per cent) intended to work full-time in general practice one year after qualification, with many suggesting they intend to have ‘portfolio careers’ combining clinical work with other activities – such as teaching medical students or working in urgent care centres -, particularly later in their career. The most commonly cited reason for not wishing to pursue full-time clinical work in general practice was ‘intensity of the working day’.

In recognition of the growing pressures in general practice, NHS England published the General practice forward view in 2016 which committed additional funding and outlined measures to help with recruiting and retaining GPs. NHS England is also encouraging GPs to come together in larger groups, whether through mergers, federations or other models, so that they are better able to deliver services.

The King’s Fund view

The workload in general practice has grown significantly in recent years but this has not been matched by growth in funding or workforce. This has left the profession facing a crisis. NHS England has recognised this by publishing the General practice forward view and primary care is one of four national service improvement priorities identified in the Next steps on the NHS five year forward view.

National level data is now essential to understand changes in demand and activity in general practice and direct resources accordingly. There is considerable scope for GP practices to improve efficiency and effectiveness, for example by coming together at scale, using data more effectively to understand patient demand, and implementing new ways of working such as telephone triage. However, with workload continuing to grow, GPs will continue to be over-stretched, especially as the pledge to recruit 5,000 more GPs by 2020/21 looks very challenging.