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.


Alex Prian

Comment date
17 August 2018

What about the rest of us who have to work on minimum wage jobs and have our mental health affected? GP's should stick up for us too and I blame primarily Psychiatry and Psychology which are total frauds and forms of social control to uphold and justify the unequal capitalist mode of production. Did you know psychiatrists use to label black slaves with "drapetomania" because they wanted to flee captivity in the 19th century. Today if you can't handle the stress of working for the minimum wage, being constantly tested or bullied at school or any other social problem then you get labelled with a mental illness and drugged to the eyeballs to keep you quiet while the other slaves work for nothing, or immigrants do the job.

This is why people are labelled with a mental illness, their personality is incompatible with our heartless exploitative capitalist environment and rather than change the environment to meet your needs YOU have to change. Because people with mental illness can't change psychiatrists need to do research in to why and how you can change in the future but all they need to do is accept that our environment is the cause of peoples misery and change the environment.

Well if it's that simple why don't they change the social environment? Because our environment is based on inequality, someone become rich and someone becomes poor, the minimum wage goes up then so do your bills and food so you're always stuck in poverty. If they give people with Autism and ADHD a job in the community and help it goes against the principles of our capitalist environment which isn't about help and caring for each other. Then there's another problem, if they give a job and help to people with Autism what about all the people who have depression because of their low paid jobs, people in prison with mental illness who need help and everyone else. The capitalist system would collapse so it's imperative that people with mental illness are dependent on mental health services which creates jobs for psychiatrists, psychologists, therapists and neuroscience research teams. They uphold and justify the capitalist mode of production which is why after 200 years of psychiatric research suicide is on the increase and they can't even diagnose properly like real medicine does.

At the moment the whole premise behind psychiatry is that if you're mentally ill its due to a biological problem like a brain disease which is a lie. This means society can carry on screwing people over and making them ill because if it's a brain problem then nothing needs to change and those who do thrive in this environment will continue to do so. Most of the illnesses in the DSM are voted into existence by the American Psychiatric Association, none are discovered in the laboratory. In fact most mental illnesses are diagnosed through an interview. Can you imagine a normal doctor giving someone insulin, chemotherapy, drugs to treat cancer etc on the basis of an interview? If I'm going to have chemotherapy or be put on a life long drug treatment plan then I want a test to prove it especially when psychiatric drugs can causes liver, kidney damage and other health problems.

But isn't capitalism the best social environment? Well for some people it might be like a business man but because different environments effect different people differently it doesn't work for everyone. Also we're told at school to think about ourselves, get good grades, go to Uni and get a good job but we don't look over our shoulder to see how these stresses affect other people. We're not told that it's an unequal exploitative, capitalist system where employers mainly care about money and will screw you over. In Business Studies we are taught about the differences between sole trader, partnerships and limited companies when discussing business but we are conveniently kept in the dark about the dark side of business.

What do you mean? Take the slave trade for example, slavery expanded to satisfy European consumers and enrich merchants and bankers. in the 1700's the British were the main consumers of these goods. ports like Liverpool and Bristol became rich during the slave trade and lots of people depended on it including boat builders, sail makers, rope makers, carpenters, sailors and shopkeepers who sold the products. Slavery was seen as normal and even shopkeepers with savings to invest would finance slave voyages and the economy would boom. Sir Francis Baring founder of Barings Bank was one of the many bankers in the city of London who made fortunes out of the investments in the slave voyages without seeing any of the suffering inflicted on the Africans. Lloyds of London ( the insurer) has its roots in the slave trade. It was founded by Edward Lloyd in the 17th century in Tower Street and became a major insurer of slave ships during the Atlantic slave trade. it was originally called Lloyds Coffee House.
A bronze statue on a pedestal of Portland stone was unveiled in Bristol city centre (in 1895) showing a deep thinking Edward Colton leaning on a stick, its inscription reads "Erected by the citizens of Bristol as a memorial of one of the most virtuous and wise sons of their city". Not mentioned are the thousands of slave victims that Colston and his family trampled over to obtain much of their wealth.

Ok but slavery ended now business is a good thing? No business exists to make money and screw you over that's why there's always been a conflict between employer and employee, like in 1823 The Master & Servants Act was a law which required obedience and loyalty from the workers to their contracted employer, with punishment enforced by jail or hard labour. It was used against workers organizing for better working conditions until the Trade Union Act of 1871 was implemented and secured the legal status of Trade Unions. Even today workers go on strike asking for better pay and conditions because their employers are taking advantage of them. Also think about all the cheap clothes and products we can buy, somebody somewhere must be getting screwed over. In April 2013 an eight storey building the Rana Plaza collapsed in Savar in Bangladesh, over 900 people died. The building contained clothing factories for companies like Benetton, Primark and Monsoon. The workers were worried about the state of the building because cracks appeared in the walls but they were forced to return to work and threatened with loss of pay if they didn't. It doesn't end there there's also corruption.

What do you mean about corruption? Well business exists to make money and that's all they care about. Take Libor for example (the global benchmark for interest rates) was manipulated during the financial crisis of 2007 so Banks could carry on doing business. Also in 2012 an investigation by the US authorities found that HSBC the UK Bank was failing to stop criminals using the banking system. Mexican drug traffickers like the Sinaloa Narco Cartel laundered hundreds of millions of dollars with the bank. The New York Times reported that Federal Authorities would not prosecute HSBC in case a criminal prosecution would topple the entire capitalist system.

If you're a GP please look up "psychiatry fraud" on You Tube and do some of your own research on internet, please help blow the whistle because it's not only GPs mental health which is affected but your patients too

Amanda Hensman-Crook

Musculoskeletal Practitioner,
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.

Tim Kent

Primary Care Service Lead, Consultant Psychotherapist,
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.

Pippa Stables

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.

George Coxon

Various inc care home owner,
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

Dr Neil Paul

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.

Mark Rickenbach

GP and Professor Healthcare and Education Innovation,
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/ )

Alan B

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.

David Dundas

Managing Director,
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.

janet maynard

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!)

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