In November 2016 we published our report, Primary Care Today and Tomorrow; Adapting to survive, which highlighted the growing number of challenges facing primary care, including the fact that funding has fallen well below the funding of hospitals despite expectations that more care should be delivered in primary care. It evaluated the impact of rising demand in the face of an increasingly challenged workforce. It also acknowledged that a plethora of policy initiatives had been launched to tackle many of the identified problems, including the General Practice Forward View (GPFYFW). We concluded that the future of primary care, and in particular general practice, was at a tipping point, and that immediate action was needed to ensure it had a sustainable future. Some ten months later, the media headlines continue to highlight concerns over general practice, so I thought I would use this week’s blog to look at the developments to date.
Our research for the above report was unequivocal that primary care is, and remains, critical to the future overall sustainability of the NHS, and that general practices need to remain the first port of call for their local patient population. Furthermore, its multiple roles, as care coordinators, coaches and providers of treatment, advice, and support for their local populations, is highly cost-effective. However, we concluded that if we are to realise the ambition for general practice to be the responsible and caring pivot in the healthcare system, the planned reforms needed to be implemented as intended and the increased resources allocated as promised, with a sense of urgency.
Some 16 months since the GPFYFV and nine months since our report, concerns are being raised that too little is being done, and what is happening, is happening too slowly. For example, research carried out by the University of Warwick, surveying 178 GP trainees in the West Midlands, who were within three months of receiving their certificate of completion of training, found that perceptions of work-life balance and low morale during training was leading many prospective GPs away from the NHS. The research revealed that only two-thirds of trainee GPs are planning to go on to work in general practice in the NHS; and, of the GPs who said they would stay in the NHS, around two-thirds (62.8 per cent) proposed working as a locum or a salaried GP rather than entering a GP partnership. Furthermore, more than half (56.4 per cent) also said that the current political and media commentary around general practice was having a negative influence on their career intentions. Their conclusion was that trainees are being put off from a career in general practice because they are seeing first-hand the intense resource and workload pressures.1
Separately, doctors have called on the government to introduce a “black alert” for GPs so that clinicians can alert authorities when surgeries are running over maximum safe capacity.2 Indeed, our research into changes in workload found that the workload has increased year on year by between 10 and 15 per cent (or 10.51 per cent increase between 2007-08 to 2013-14 to more than 15 per cent between 2010-11 to 2014-15) - depending on the number and size of practices, location of practices, software used to log consultations, and staff and criteria included within the underlying analysis.
For many patients, their ability to see a GP or practice nurse at times of need is something that is highly valued. Moreover, while the 2017 patient survey shows continued satisfaction with their GP practice (84.8 per cent rate their practice as good, 42.9 per cent very good and 41.9 per cent fairly good), an increasing percentage of patients couldn’t get an appointment on the day they wanted (an increase from 11.4 in 2016 to 11.9 per cent in 2017) with increasing numbers now waiting longer than a week for an appointment.3 The Royal College of GPs (RCGP) analysis of this survey data found that in 21 Clinical Commissioning Group (CCGs), serving around 5.6 million people, more than a quarter of patients were waiting at least a week for an appointment with their doctor or practice nurse. The RCGP suggested that if current trends continue, the number of consultations where patients waited a week or more to see a GP will rise by more than 20 million over the next five years, from 80 million occasions in 2016-17, up to 102 million by 2021-22.4
Overall however, the NHS England GP Patient survey 2017, remains very positive, with more than nine in 10 (91.9 per cent) saying that they were confident in their doctors and trusted them to deliver quality care.5 However, the survey also raised some concern in terms of accessibility of surgeries. Indeed, only two-thirds (68 per cent) of patients said it was easy to get through to their GP surgery on the phone, a decrease of 1.9 percentage points since 2016; 18.3 per cent stated that they were unable to get in touch with their GP in the last six months due to the surgery being closed; only two-thirds (68 per cent) of patients said it was easy to get through to their GP surgery on the phone, a decrease of 1.9 percentage points since 2016.
Importantly, the uptake of opportunities to utilise technology to improve accessibility have only marginally improved. For example, patients using on-line ordering of repeat prescriptions increased from only 10.4 per cent in 2016 to 11.8 per cent in 2017; only 8.9 per cent used on-line appointment booking services (up from 6.8 per cent in 2015) and 1.6 per cent of patients had accessed their own records on-line (up from 0.5 per cent in 2015). These results, suggest that there is significant scope for surgeries to improve their patients understanding of alternative routes of accessing services.
Moreover, the latest figures from NHS Digital show that NHS England has failed to increase the GP workforce in line with the targets in the GP FYFV. Estimates for March 2017 found that there was a total GP headcount of 40,039 GPs in England (excluding locums), a decrease of 46 compared to December 2016, and 658 compared to when the GPFV established the target to increase GPs by 5,000 by 2020. However, Full Time Equivalent GPs did increase marginally to 33,423 FTE GPs (excluding locums), an increase of 36 (0.1 per cent) from 33,387 at 31 December 2016; this is still some way off the target of achieving the ambition in the GP FYFV.6
While the above update is somewhat depressing in terms of progress on this much needed transformation, I thought I would put the spotlight on what a typical consultation for a GP can look and feel like to suggest that perhaps we need to look at the challenges from the bottom up rather than top down.
A typical GP consultation
On average, GP’s have between 10 and 12 minutes time slots allocated per patient, for those patients attending the practice (time will also be set aside for some phone consultations and home visits where required). In this 10-12 minute time slot, the doctor is expected to go to the waiting room to locate and invite the patient into a consultation room; introduce themselves; and try to ascertain why the patient’s there (there is often more than one reason, which may only be revealed as the discussion progresses). If the patient is new to the doctor there will be a need to obtain details of the person’s health history, which for an increasing number of the more regular attendees, the very young, the elderly or those with long term conditions, is often quite complicated. They are then likely to need to perform a physical examination (which may be delayed slightly due to need to physically help the patient or get a chaperone, and, in some cases, a translator). Then, clothes need to be replaced, hands washed (again); blood tests or swabs may need to be taken or as a minimum organised (these need forms and sticky labels). Concurrently, the information generated needs to be entered onto the patients’ record, via the computer, checks done as to the types and timing of previous prescriptions and any allergies added? All the while the clock is ticking.
Finally the GP discusses their diagnosis and treatment options, ideally as part of a two way dialogue with the patient. At the same time, the computer may alert the GP that the patient’s blood pressure needs to be rechecked; in both arms, with the patient relaxed! There may also be expectations, from on high, that the GP will use each point of contact as an opportunity to identify and discuss obesity, alcohol consumption, domestic violence, physical activity, cyberbullying, and sexual problems — or whatever the latest awareness campaign is concerned with. For those patients with long term conditions, polypharmacy is common, as are medicine queries and uncertainties; not to mention the requirement for medicines to be routinely reviewed and choices discussed. Just as you’re nearing the end of the consultation, and the patient feels more relaxed and confident, the GP catches their eye, or there’s a pause or change in tone, and the patient now feels able to discuss what it is she or he really wants to talk about.
Can anyone really believe that all of this can be done safely and well in 10 minutes? Work flow estimates suggest that acceptably safe practice would take double that, and excellent practice would probably need more again to ensure that everything’s in place for proper, shared decision making.
So while the GP FYFV could well be the lifeline general practice and patients need, it certainly needs to be delivered, in full, and as a matter of urgency. Moreover, I would also suggest that there needs to be a rethink about what is a safe number and length of consultations for patients who need to be seen physically by the GP. Indeed, the availability of individual and population health data, technology enabled triage systems, and developments in AI, mean it should become relatively easy to move away from ‘one size fits all’ appointments.
Correction: The original posting for this blog omitted a reference to the source of the synopsis - 'A typical GP consultation' - which was derived from an article 'Why GPs are always running late' by Margaret McCartney, a GP partner in Glasgow and was first published in the BMJ. https://doi.org/10.1136/bmj.j3955 (published 29 August 2017): BMJ 2017;358:j3955.
5 https://www.england.nhs.uk/statistics/2017/07/06/gp-patient-survey-2017/ and http://www.nationalhealthexecutive.com/News/rcgp-points-to-huge-problem-as-over-200-gps-closed-or-merged-last-year/176897