Why can't I get a doctor's appointment? Solving the complex issue of GP access

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Part of Primary care networks

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 can be of little surprise that the NHS, and specifically the issue of access to GPs, has featured as one of the key political battlegrounds in the approach to the general election.

Here we run through the proposed solutions and assess their potential effectiveness.

The proposed solutions

More doctors

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.

Digital solutions

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.

In summary

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.

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Comments

John Kapp

Position
director,
Organisation
Social Enterprise Complementary Therapy Company
Comment date
22 November 2019

I have been a patient representative for the last 20 years, and drugs are now overprescribed, and are doing more harm than good with polypharmacy. GPs are now pill pushers for the drug companies, and break their oath, but they are too ashamed to admit this publicly, as they feel betrayed by the fake news. The Health and Social Care Act 2012 also made them join Clinical Commissioning Groups, and take statutory responsibility for £450mpa budget, which they are not trained to take.
The solution is for central government to make councillors on Health and Wellbeing Boards responsible for policy on treatments in the NHS, which should be 'medication to meditation', transferring money from drugs to social prescribing of therapeutic social interventions, such as NICE recommended mindfulness courses, as PRESCRIBE.FITNESS.UK CAmpaign for Social Prescribing Of Talking Therapies, CASPOTT, www.caspott.org.uk.

Clive Durdle

Position
Rtd,
Comment date
23 November 2019

Integrate GPS and hospitals? I am unaware of GPS being directly involved with universities so that we have all our health resources as needed available to all patients. Use health for all processes-,Hesperian, brac, Jamkhed

Andy Lindop

Position
Retired GP,
Organisation
Non
Comment date
26 November 2019

It’s sad you feel like that. If it were true it would be shameful . Trying to deal with mental health issues in 10-15 minutes often feels impossible . Patients sometimes demand a quick fix because they feel desperate The access (and funding )for talking therapy is often not acceptable to desperate patients hence the doctor may feel obliged to offer a medication in the desire to help in some way. It has little if nothing to do with drug companies who now get very little access to frantically busy GPs
The Government have stood by and watched all aspects of the NHS decline If we want to change patients experience we need to get this government out ASAP
Most GPS still abide by the principles of the Hippocratic Oath and where they don’t it’s normally the result of stress and burn out and the resultant empathy fatigue
I was a GP for nearly 30 years and was forced to watch consecutive Governments neglect the NHS especially primary care and they have led us blithely to this crisis and so patients and GP s alike are suffering in the system that has resulted So any anger we feel should be directed at the perpetrators not fellow victims Thanks

Andy f

Position
GP,
Organisation
Dartmouth Medical practice
Comment date
27 November 2019

Conflict of interest?
No need to read further

Tony Hufflett

Position
Director,
Organisation
Datasyrup
Comment date
27 November 2019

A nice overview of the problem, and reminder for me that a ‘more appts’ / ‘more GPs’ solution is naïve without looking at where the appointments go.
Have been lucky enough to study 30-40 practices in detail in the last three years without any pre-set agenda. While all services skew towards certain users more than others, general practice is at a remarkable level of skew.
The pattern is similar in most practices – just 10% of patients take at least 50% of GP appointments. Many of these regular patients visit a GP 20, 30 or 40 times in a year with very low GP continuity – they will see 10 or more different GPs in those visits.
Some practices do improve the cycle, but a minority that I've seen. The predominantly access model is a daily Groundhog Approach. Today’s 8am newly released appointments are rapidly assigned to the first patients who call in or book them. Navigation conversations or continuity are unrealistic in the bearpit of pressure and panic for both patient and receptionists who know that time is ticking… and… boom… all appointments are gone by 9am. Only after does that the screening of requests begin in earnest to get on a duty doctors call list or… please go round again tomorrow, another Groundhog Day.
And the Groundhog approach of course creates the appointment skew - regular users know best how to get in - and poor continuity is baked-in (no time for such a luxury idea).
I agree with the article and am not convinced either than just more, or different channels, or digital solutions, or extended hours with the same workforce are the answer. Or course some patients need more care than others; but surely the leeway for releasing capacity by improving regular patients’ care is by far the largest elephant in the room?
Please tell me where I’m going wrong in my thinking.

Ruth Gateley

Position
Information Analyst,
Organisation
Stockport NHS Foundation Trust
Comment date
04 December 2019

GP practices should go back to having an open surgery for one GP every day. People queueing at A&E with non-urgent problems proves that people would rather be seen the same day even when they have a long wait than try to ring up and get a set time appointment.

Brian Smith

Position
Software sales,
Comment date
05 December 2019

It would be useful to see a utilisation figure showing how many of the notional available full time GP hours are used each nit of time; day, week, month etc.

The number of registered GPs is a known quantity and the number of GP hours worked is also known; correlating one with the other should be reasonably straightforward and possibly helpful?

It may show, for example, that the system needs to disincentivise part-time working by GPs who are either simply not working for some part of the week or working elsewhere?

I feel this is impotent because as dissatisfaction increases more of us will turn to privatised GP services - I did myself when offered the earliest appointment available in 13 days time - which will need staffing leading to an acceleration in the loss of GP hours to the NHS.

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