Understanding pressures in general practice

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Part of Pressures in general practice

Increasing demands on general practice over the past five years – not just a heavier workload but the increasing complexity and intensity of work – have led to a feeling of crisis. The NHS is finding it difficult to recruit and retain sufficient GPs who want to do full-time, patient-facing work.

Moving care closer to home means that many activities previously undertaken in secondary care are now done in primary care, but funding has not followed the patients. At the same time, more people report difficulty in accessing care and are less satisfied with their experience of using GP services.

This report looks at patient factors, system factors and supply-side issues to see what lies behind this increasing pressure on general practice. It finds that despite GPs being at the heart of the health care system, a lack of nationally available, real-time data has made their changing workload largely invisible to commissioners and policy-makers.

Key findings

  • GP workload has grown hugely, both in volume and complexity. The research sample shows a 15 per cent overall increase in contacts: a 13 per cent increase in face-to-face contacts and a 63 per cent increase in telephone contacts.
  • Population changes account for some of this increase, but changes in medical technology and new ways of treating patients also play a role.
  • Wider system factors have compounded the situation. For example, changes in other services such as community nursing, mental health and care homes are putting additional pressure on general practice. Communication issues with secondary care colleagues have exacerbated GP workload.
  • Increase in workload has not been matched by a transfer in the proportion of funding or staff.
  • The number of GPs has grown more quickly than the population but has not kept pace with groups most likely to use primary care (over 65s and over 85s).
  • GPs are increasingly opting for ‘portfolio careers’ or part-time work. Only 11 per cent of GP trainees surveyed intend to do full-time clinical work five years after qualification.

Policy implications

  • Commissioners and policy-makers must have access to national and local data for secondary use for primary care. They cannot plan effectively or understand the impact of their decisions unless they understand how GP activity is changing.
  • Improvements to the existing system should prioritise structured support for general practice, redesign of commissioning systems to reduce bureaucratic burdens, repairing relationships between primary and secondary care, more use of technology, and better utilisation of community assets to meet patients’ needs.
  • New models of general practice should include new types of delivery, striking a balance between working at scale and making services responsive to local people.
  • The service needs a workforce strategy that supports more sustainable careers for GPs and other team members, while recognising changing career preferences.
  • Policies to change and extend access must be accompanied by commensurate increases in funding and support.

Comments

Susan Sowray

Position
Read coder,
Organisation
GP Practice
Comment date
05 May 2016
Prior to working in a local GP practice I was a medical negligence Solicitor. I am interested in all issues relating to the health service. My son is a trauma and orthopaedic registrar and is convinced that the NHS is undergoing creeping privatisation.

Dr Khan

Position
GP Trainee,
Comment date
05 May 2016
Many thanks for this excellent report, it shows what is really happening in general practice.

stephen gray

Position
gp partner,
Comment date
05 May 2016
why does it take a Kingsfund paper to highlight the issues of working in general practice. we've (jobbing GPs) been saying this stuff for years and little notice being taken by successive governments. Lets hope this paper forces the spotlight on the profession before it is too late and steps are taken to save primary care in UK. I am ever hopeful.

Jane Robinson

Position
retired health visitor and professor of nursing,
Organisation
not applicable/was university of nottingham
Comment date
06 May 2016
I am glad that the report highlights changes in other services, especially community nursing. Like Stephen Gray, all branches of community nursing (jobbing practitioners) have been saying these things for years.
It is about the invisibility to governments and NHS managers of these crucial day to day services that do not normally involve high drama but address the health needs of vast swathes of the population.

Javier Gonzalez

Position
Pharmacist,
Organisation
Me
Comment date
07 May 2016
NHS undergoing privatisation? GP practices are private businesses and I understand have always been.

janet maynard

Position
Pharmacist,
Organisation
independant
Comment date
07 May 2016
I have worked in community pharmacy for over 35 years and the pressure now is worse than it has ever been. We are continually being told we can reduce the pressure on a and E and GPs but who is trying to reduce the pressure on us! can we have some publicity on the stresses and strains on us (eg the surgery asks for at least 48hrs to process a repeat but patients regually expect us to dispense etc them instantly!)

David Dundas

Position
Managing Director,
Organisation
Lion Industries UK Ltd
Comment date
09 May 2016
I am registered with the Westgate practice in Lichfield and I am very concerned about the number of GPs and Nurse Practitioners available to see their patients. It is quite "normal" at this practice for patients to have to wait several weeks to see any of the practice professionals. It is quite clear that this practice has a very high work load. Whilst the easy solution would be to have more clinicians available, I feel that too many patients attend for ailments that could be easily self treated or at least on the advice of a pharmacy or 111 service. If each patient had to pay a nominal fee of say £5 to book a visit, I believe that the work load on GPs would be significantly reduced without any detriment to the nation's health; of course there would have to be exemptions for such a fee as are presently available for prescriptions.

Alan B

Position
Chair - PPG for our Practice,
Comment date
09 May 2016
Secondary use of patient data is a matter of trust; when the NHS takes over two years to honour opt outs and the Royal Free sells data to Google that is readily patient identifiable how can we trust this broken system. The risks far outweigh the benefits of secondary use of patient data.

Mark Rickenbach

Position
GP and Professor Healthcare and Education Innovation,
Organisation
University Winchester
Comment date
09 May 2016
Well done and thank you for helping to highlight the plight of primary care and the key role of primary care in the NHS.
I have never seen such a crisis as this in the my thirty years of NHS work. Surgeries around us are closing or at severe risk thanks to financial and workload pressures. We have had to diversify to survive.
GPs have only seven minutes of face to face time in a ten minute consultation to address multiple issues often leaving a minute or two for each problem. (see http://docrick.co.uk/consultations/seven-min-consultation/ )

Dr Neil Paul

Position
GP,
Organisation
SandbachGPs and the South Cheshire GP Federation
Comment date
11 May 2016
As the lead GP for a wave 2 Prime Ministers Challenge Fund Wave 2 Site we have been using a combination of EMIS Enterprise Searches and Reports and a newly developed piece of software called Apex from a company called Edenbridge Healthcare, that we have been closely involved in testing, to directly access our clinical systems and provide live data on GP activity.

Our real results from 30 practices match the data here. There has been a massive rise in activity over the last 10 years that needs explaining. Attendance rates per person are going up. While some of this is perhaps explainable by an ageing population - I believe that health seeking behaviour has fundamentally changed - whether it’s a combination of "present early in case its cancer", a believe that "medicine can cure all ills", a workplace culture that frowns on time off for illness, or a dumping of work from secondary care to primary care, I'm not sure. But its real.

What Apex is showing us is that our practices are at capacity – that practices are having to switch to telephone based consultations which on the whole are slightly quicker to increase the volume of people they can deal with in a day yet a lot of patient’s satisfaction with telephone calls isn’t as great despite the media hype for skype and the like. Locally what our data is showing is that alternative practitioners are increasingly being used as first point of contact – I’m not suggesting there is anything wrong with this – though some of my colleagues do. Physios, Pharmacists, Counsellors, Third sector travel agents are all being used.

The interesting thing is for this to work – effective triage on first contact needs to be made to direct people to the right service without them needing an appointment. Some IT systems are developing to deliver this, however some patients need to get used to the idea of being asked why they want an appointment so we can offer them the right service – not the one they think they want.

Apex is also allowing our practices to identify their future capacity compared to their predicted demand to identify pressure and pinch points – of course that doesn’t mean they can do anything about them – locums are scarce, job adverts go unfilled. Finally, Apex is hopefully going to allow us to identify the effect of interventions. We are speaking to iPlato around some innovative PROMS work (patient reported outcomes) where instead of being called back for follow up appointments, patients can report their condition via an app saving time and freeing up capacity and Apex should allow us to monitor this.

George Coxon

Position
Various inc care home owner,
Organisation
Various
Comment date
15 May 2016
Really good outline of issues. I'm working my way through the 100 pages and will share.
We, in care home land, hugely value our excellent support to our older folk in 24/7 care living with complex care needs.
We are all feeling anxious about H&SC integration and the squeeze on resources. Lots of GPs retiring in the not too distant future and inadequate succession planning. Only 11% planning to work full time after 5 yrs post qualification is a very scary prospect

Pippa Stables

Position
GP,
Comment date
14 October 2016
while the description of the workload was reasonably typical (i'd have less respiratory infections, more complex such as pain and mental health, MSK etc) but the times given to deal with this were unrealistic, the working day for this volume of patient contacts and paperwork work takes 14 hours or more to complete, not 12. many GPs take work such as emails home or come in at the weekend.

Tim Kent

Position
Primary Care Service Lead, Consultant Psychotherapist,
Organisation
The Tavistock and Portman NHS Foundation Trust
Comment date
16 October 2016
Excellent report, thank you for the detail and data driven headlines.

We have developed an effective primary care service that works with complexity but importantly also supports GPs with case discussion, group supervision and joint consultation. With so much unknown about Medically Unexplained conditions and Somatic disorders we have to work together and pool training and experience with Primary Care MH input so that individual GPs are not left feeling impotent in the face of underlying social and psychological determinants and their ills. Sharing clinical dilemmas helps avoid ‘fundamentalist’ or overly rigid thinking and tactics in the face of such huge anxieties about our system of care and its apparent dismantling. Well done & thanks to all at the Kings Fund.

Amanda Hensman-Crook

Position
Musculoskeletal Practitioner,
Organisation
One Medical Group, Windermere and Bowness Medical Practice
Comment date
27 April 2017
Excellent report. Our practice developed a new role to take on the 20-25% of the workload of MSK patients to create capacity in GPs workload. The MSK Practitioner is an advanced physiotherapist with injecting and prescribing competencies. It also has an impact on secondary care and patients benefit from. A first contact direct access specialised service closely home. This is being replicated in many surgeries across the UK. You can read about it and the outcomes in the RCGPs bright ideas online.

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