RESOLVING THE CRISIS IN GENERAL PRACTICE
A ten point plan to revive general practice
This paper sets out a plan for reviving general practice - outlining 10 key interventions which have been developed based on an analysis of what is going wrong in general practice (see page 2-6).
1) Update telephony systems in general practice and ensure that all practices will be able to offer a choice of telephone/video consultations and face to face appointments. Calls to a practice which require clinical assessment, (which can be web based requests for device/ appointments) should be triaged by clinicians with patients being given the choice of face to face or telephone consultations depending what is most appropriate based on clinical need. Practices will need to rearrange their appointments system to accommodate theses changes and they should be supported with management advice on how to do this. Launch a public education campaign so that patients know about the new ways of consulting GPs and the different clinical roles that most practices offer for help with patients needs. This will allow patients to access support from practice based mental health workers, pharmacists, physiotherapists, social prescribers, physician associates, practices nurses and nurse practitioners.1
2) Ensure that GP practices continue being funded so that they can employ the additional staff that are now essential for the delivery of care in modern practices. This is a recognition that not all patients need to see a GP every time. Many health care problems can be dealt with by practice based mental health workers, pharmacists, physiotherapists, social prescribers, physician associates, practices nurses and nurse practitioners. Support practices so that they have the resources to clinically supervise these additional roles where necessary and encourage practices to develop systems to integrate these roles into team based delivery of primary care services.
3) Improve the links between hospital consultants and GPs so that GPs can seek advice on the phone about their patients within 7 days. This will require a restructure of hospital outpatient departments and will reduce the need for referrals to hospital for clinical advice and management. The resources that can be saved from restructuring outpatients can be reinvested in Primary Care.
4) Enable specialist and associate specialist doctors (SAS doctors) to retrain as general practitioners. The current training programme for GPs is 3 years after completion of foundation training. For SAS doctors who are already highly experienced and who are working in the NHS, a shortened program of training (1 year) delivered in general practice by working closely with GPs as trainers/mentors will provide the increase in workforce numbers of doctors that are needed.
5) Increase the links between NHS 111, paramedics and A&E departments and primary care. It should be possible to create systems where clinicians in NHS 111, paramedics who visit patients at home and patients who attend A&E and where there is an identified need for further assessment and management in primary care, can be booked in for advice and further treatment by primary care clinicians.
6) Put a ceiling on the number of patients that a primary care physician can see in a day (24 patients a day) and make 15 minute appointments a standard in general practice. 7) Reduce the unnecessary bureaucracy in primary care. The Quality and Outcomes Framework should be abolished and GPs should be incentivised to provide continuity of care for their patients.
8) Increase funding for primary care to provide extended hours opening with practices working co-operatively to deliver this service. With the additional workforce it should be possible to increase the hours of opening for primary care. Ensure that all practices can provide basic investigative services such as phlebotomy, dressings and minor surgery.
9) Encourage new models of delivery of primary care - for example social enterprises and community interest companies where GPs and mental health workers, pharmacists, physiotherapists, social prescribers, physician associates, practices nurses and nurse practitioners work collaboratively as teams to develop and deliver primary care services
1 See a you tube vide produced by the School of Primary Care in Manchester https://www.youtube.com/watch?v=-wEvQtgpkAE Page 1
10) Incentivise Health Education England (now incorporated int NHS England) and Medical Schools to encourage future medical students to choose general practice as a career. In the short term provide financial incentives such as ‘golden hellos’ to encourage newly qualified nurses, pharmacists, GPs and mental health workers to work in primary care and community services.
Although this paper is focused primarily on an analysis of what is going wrong in General Practice and recommendations to address some of these problems, it should be pointed out there are problems more widely than those just faced by general practice within primary care. There are problems with NHS dentistry and with NHS community services (covering health visiting, district nursing and community mental health services). The latter are not addressed in this paper even though some of the problems in these services directly impact on general practice.
General Practice in the UK
The NHS was built around the idea that GPs would act as the “gateopeners” to the NHS. They are the first port of call for people with a range of symptoms related to cancer and dementia, for those experiencing issues with their mental health and for a whole range of other problems, including monitoring for ongoing diseases. GPs are expert generalists and are trained to identify and treat patients with serious problems, sometimes referring patients for care from specialists. However, they manage the great majority of patients without referral or admission to hospital. They are also responsible for providing many population based preventative services such as immunisations and cancer screening and provide the majority of care for patients with multi-morbidity (people who have more than one illness). GPs also have access to a range of diagnostic services and work closely with community based services such as health visitors, district nurses and community psychiatric nurses. The cornerstone of the GP service is the dedicated practice list with a registered population. This allows the GP practice to develop an ongoing therapeutic relationship with the majority of its patients. Research shows that this continuity of care is associated with better health outcomes, higher patient satisfaction, lower mortality and fewer unplanned hospital admissions.2
What does the GP service cost
Primary care (which includes pharmacy, dentistry and optometry) deals with 90% of the patient contacts in the NHS for 8.5% (approximately £8 billion a year) of the total NHS budget. Its share of the NHS budget has fallen from 11% in 2006 to under 8.5% now. GPs provide over 300 million patient consultations a year compared to 23 million emergency department visits. It is general practice that makes the NHS one of the most cost effective health services in the world. On 3 average GPs get paid approximately £175 per patient per annum for looking after their patients. The average cost of a GP appointment is £39. For comparison purposes, the average cost of a visit to the A&E department is £359, to an urgent care centre is £77, the cost of an out-patient appointment is £260, the cost of an ambulance visit to your home and taking you to the A&E department is £300. We spend less on general practice nationally than we spend on hospital out- 4
Pereira Gray DJ, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors- a matter of life and death? A 2 systematic review of continuity of care and mortality. BMJ Open. 2018;8:e021161.
Barker I, Steventon A, Deeny SR. Association between continuity of care in general practice and hospital admissions for ambulatory sensitive conditions: cross-sectional study of routinely collected, person level data. BMJ. 2017;356:j84. Bazemore A, Petterson S, Peterson LE, Bruno R, Chung Y, Phillips RL. Higher general practitioner continuity is associated with lower costs and hospitalizations. Ann Fam Med. 2018;16:492–7.
https://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-2017-international-comparison-reflects-flaws- 3 and#:~:text=Key findings: The U.S. ranked,, Australia, and the Netherlands.
https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly#rank
4 https://www.kingsfund.org.uk/audio-video/key-facts-figures-nhs
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patients, and for the past decade, funding for hospitals has been growing around twice as fast as for family doctor services.
When General Practice fails the NHS fails
Part of the problem that we are currently facing in the NHS - whether it is long ambulance and A&E waits, out-patient waiting lists and delays in cancer referrals, is because GP practice is failing to do what it should be doing- seeing patients in a timely and appropriate manner when they are unwell. Because people have difficulty getting a GP appointment they present themselves to the A&E department, often enduring long waits and often getting some stop-gap treatment without dealing with the underlying problem which resulted in patients seeking care from A&E in the first instance. Sometimes patients feel so desperately unwell that they ring for an ambulance - often when they try and fail to contact their own GP or when their GP, already working under huge pressure in the surgery can’t find the resources or time to arrange a home visit and tells the patient to call an ambulance. The extra demand on the ambulance services is curtailing their ability to deal with urgent and serious calls with the result that many patients are dying because the ambulance cannot get to them on time. Sometimes when patients can’t get through to their surgery for an appointment, they are told to ring NHS 111. This service is primarily staffed by call handlers working to clinical algorithms and they can’t always make an appropriate decision. The outcome is often for patients to be told to go to the A&E department or for an ambulance to be called. This puts further pressure on the A&E department and the ambulance service. In many areas of England, the ambulance service (and the associated NHS 111 service) is now the first port of call for patients unable to contact their own GP.
There is a huge waiting list for out-patient appointments - currently 7.3 million people are on an NHS waiting list in England, with nearly 3 million people waiting over 18 weeks and nearly 400,000 waiting over a year. People waiting for definitive treatment because they need ongoing care for the condition invariably expect more input from their GPs which adds to their workload pressures. We also know that nearly 60% of follow up appointments to secondary care are unnecessary and could be managed better in general practice if the resources were available. Dealing with this problem could free up capacity in secondary care and help reduce waiting times for new out-patient appointments. Many of the problems in many parts of the NHS can be traced to problems with General Practice. When General Practice fails, the NHS fails.
The causes of the crisis in General Practice
Workforce
What is the root cause of the problem in General Practice? The first and most pressing problem is the lack of GPs. Despite a series of pledges and concerted action by government to increase GP numbers through increasing the number of doctors training to become GPs, there are currently 456 fewer full time equivalent GPs compared to 2015. Initiatives to increase GP numbers through training UK graduates, international recruitment and schemes to encourage GPs to re-join the workforce are more than offset by increasing patient demand, increase in GPs retiring because of burnout and dissatisfaction and by existing GPs cutting their hours because they are overworked, dissatisfied and also suffering from burnout. If staffing trends observed today were to continue, England would face a shortfall of 7,000 FTE GPs in 2023/24 increasing to 11,4500- FTE GPs by 2028/29.There are now just 0.44 fully qualified GPs per 1,000 patients in England – down from 0.52 in 2015. For the GPs that remain, this means increasing numbers of patients to take care of. The average number of patients each GP is responsible for has increased by around 310 – or 16% – since 2015, and now stands at 2,248.5
Changes in populations
https://www.rcgp.org.uk/getmedia/0bb5dc8f-1afe-485b-a29c-772a62fbe2dc/RCGPs-Submission-to-Comprehensive-Spending- 5 Review.pdf
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The shortfall in GP numbers is further compounded by an increase in the size of the population and the fact that people are now consulting GPs more often. The number of people with multiple long term health conditions is increasing and people are living for longer in ill health. An ageing population will drive a rising tide of chronic illness. Eighty five years olds on average will have 25 GP consultations per year compared to 12 for 50 year olds.
New ways of working
Rising demand for general practice pre-dates the COVID-19 pandemic. However, the system of payment for general practice – weighted capitation – means that the service is not paid more for this increased activity. This has had implications for investment in general practice - particularly in IT infrastructure and digital technologies which have become increasingly important.
The Covid-19 pandemic transformed the ways that GPs now consult with their patients. Social distancing measures during the pandemic meant that GPs were encouraged to consult by telephone and this was supplemented with other digital technologies such as video consultations and text messaging. Prior to the pandemic nearly 80% of consultations were carried out face to face but some practices (less than 10%) were already using telephones and online access to manage their workload.
There is evidence from practices using telephone and online consulting prior to the pandemic that patients could have better access - with most being able to offer patients same day access for appointments. There is also evidence that these practices were able reduce A&E and urgent care 6 centre attendance by their patients. Paradoxically these new ways of working also increased continuity of care for a large number of patients.The experience from these practices also suggested that it was not only a change in the mode of consulting that had an impact but the other system wide changes that accompanied this - for example training reception staff to better direct calls, retraining practice nurses so that they could prescribe and deal with minor illnesses, the increased employment of nurse practitioners as part of the GP team and the employment of additional staff such as mental health workers and physiotherapists. GPs also had to be retrained so that they could consult using techniques that supplemented their face to face consultations skills. The employment of new staff with differing roles within the primary care team also required the creation of new models of clinical supervision for these staff, ongoing training and monitoring and changes in many aspects of practice organisation. Typically these changes took at least 3 years to be implemented and bedded down.7
Post-pandemic many GP practices moved to this way of consulting without introducing the system wide changes that were essential to this new way of working. Most practices had outdated telephone systems and poor IT infrastructure. Reception staff continued to work in traditional ways and most practices did not employ the range of staff that makes working in this way possible. There was also very little public education in explaining to patients what the new way of working meant and why it was important. The end result has been a perfect storm whereby GPs have struggled to cope with the new ways of working and the public has found it increasingly difficult to make appointments with their GPs.
Because of the centrality of general practice within the NHS, this is having huge ramifications. GPs who can’t manage requests for appointments refer the public towards NHS 111 and the ambulance service. NHS 111 works in a silo and the way it is structured as a call handling service means that nearly 10% of calls are transferred with a request for an ambulance. A higher proportion are directed to the A&E department. Increased pressures on the ambulance service 8 means delays for patients and serious consequences for some (sometimes resulting in deaths). Poorer access to GPs means that patients frequently turn up to the A&E department seeking primary care. Overcrowding in A&E departments indirectly impacts on the ambulance service
https://www.health.org.uk/news-and-comment/news/analysis-finds-10-of-patient-care-requests-indicate-a-preference-for-face-to- 6 face-gp-consultation
General practice: new technology isn’t necessarily better 7
BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k2829 (Published 02 July 2018)
8 https://www.health.org.uk/blogs/nhs-111-understanding-the-impact-on-urgent-and-emergency-care
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through long waits because there are not enough A&E staff to cope with the demands of these walk in patients. Often patients are admitted to hospital unnecessarily when their medical condition could be better treated at home, causing overcrowding in hospitals which are often running at full capacity. Delays in discharging these patients also impacts on long waits for the ambulance service exemplified by long handover times. And also, because of health inequalities, many of these problems are exacerbated in more deprived areas, impacting on people who are most vulnerable. When general practice fails, the NHS fails.
In summary, a combination of too few GPs, changes in population demographics, GPs facing unprecedented levels of stress with increasing workload and a failure to fully embrace the changes in practice organisation required to cope with the new ways of working has caused the current crisis.
What can be done
1. Address the workforce crisis
The workforce crisis in general practice cannot be solved overnight - typically it takes between 5-6 years to train a doctor to become a general practitioner post-qualification. However there are some levers which the NHS can use. More needs to be done to encourage medical students and newly qualified doctors to consider training in general practice. Medical schools need to be encouraged to develop curricula which provide more exposure and training in general practice. They can be incentivised to encourage their graduates to become general practitioners. Financial incentives can be provided to encourage newly qualified doctors to choose general practice (especially in deprived areas) as a career option.9 Regulations can be relaxed to encourage Staff and Associated Specialist (SAS) doctors to work general practice, enabling them to become fully independent GPs after a suitable period of additional training. There is evidence in England that Health Education England (HEE) has succeeded in encouraging more doctors to enter GP training using a combination of overseas recruitment, restricting the creation of specialist roles and training in hospital grades and improving pathways for part-time training and incentives to encourage doctors who have left the GP workforce to return.
2. Increase investment in digital technology (telephony and integration with hospital and community care)
The funding formula for general practice needs to be changed so that funding is directed more equitably - especially to practices based in deprived areas. Investment needs to be made to the IT infrastructure - for example linking in general practice to full fibre broadband so they can take advantage of internet based telephony systems to fully utilise web based consulting, including video consulting, remote working and better integration with hospital based systems. Better links between hospital consultants and GPs could reduce the demand on out-patient services and reduce waiting times for patients who have urgent and life-threatening medical conditions. More work needs to be done on integrating NHS 111 with primary care so that demand for appointments can be channelled more appropriately.
3. Encourage the integration of additional roles into the GP workforce and training opportunities for practice staff
The government has increased funding for practices to employ additional staff through the Additional Roles Reimbursement Scheme (ARRS). This is an important development and has allowed GPs to employ clinical pharmacists, social prescribing link workers, nurse practitioners, physician associates, paramedics, physiotherapists, mental health practitioners, occupational therapists and dieticians. Current estimates suggest that only 40% of the funding has been utilised by general practices because of problems associated with clinical governance - for example ensuring that adequate supervisory arrangements are in place for these staff. As things currently stand, many general practices do not have the organisational capabilities to integrate these new members of staff into their working practices. GPs should therefore be given the organisational support to integrate these new roles into general practice. It may be that the
https://www.england.nhs.uk/gp/the-best-place-to-work/starting-your-career/recruitment/ 9
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current model of general practitioners as independent contractors with the NHS is not suitable for these new arrangements and consideration should be given to encouraging new models of working such as social enterprises, community interest companies and models like the John Lewis Partnernship model (where every employee has a stake in the company). Where possible practices should be incentivised to reduce their use of locums - providing alternative working organisational models should offer more opportunities fro GPs who don’t want to take on the burdens of a traditional partnership. Funding should also be made available to up-skill Reception staff, provide practices with organisational support to develop new appointment systems to take account of the range of appointment types (face to face, telephone, internet and video) and to support additional training of GPs in telephone and video consulting.
General Practice can be an attractive option for GPs who want to work part-time with a better work life balance. New models of care will give the opportunity for all staff working in primary care to work flexibly with GPs and other clinical practice staff not being overburdened with unnecessary administrative work load which are a feature of current GP working arrangements.
4. Re-establish the norm of Continuity of Care in General Practice
Continuity off care should be encouraged and should become the norm - the plethora of organisations that have been developed over the past 20 years have fragmented primary care. Urgent care centres, Walk-in clinics, NHS 111 and primary care centres based in A&E departments have all created confusion for the public in terms of where they can get their care. Although initially developed to offer choice to the public they have proved costly and because they are staffed primarily by more junior clinicians - for example nurse practitioners and in the case of NHS 111 call handlers who rely on clinical algorithms to give advice to patients. Nearly 10% of NHS 111 calls end up with an ambulance being dispatched. A similar proportion probably get advised to visit the A&E or a walk in centre if the call is made out-of- hours. The desire to separate acute problems from those requiring continuing care is a false economy. Many continuing care problems can present with acute exacerbations and these patients will get better care from their general practitioners. Even patients with self limiting acute problems will get more appropriate care from their general practitioner - and seeing patients acutely helps develop the long term relationship based care that is central to general practice. Although there is always a trade-off between access and continuity, the balance has shifted too far towards access at the expense of continuity. Leaving GPs dealing with multiple complex cases one after another contributes to clinical burnout and ultimately compromises patient safety. Modern IT systems and a range of consulting options (video, web-based and telephone consulting) should allow the practice to once again become the first port of call for all the patients problems. Minor illness nurses, nurse practitioners, physician associates, mental health workers and pharmacists are all now part of the primary care team and working together with GPs can provide enhanced care with continuity for the patient. Even out of hours care can be better provided by general practice with co-operative models between GPs enabling the sharing of out of hours care by GPs who have access to patient records through secure laptop connections. Such models worked well during the Covid pandemic. Obviously the funding model will need to change but the only way to reduce the burden on the ambulance service and the A&E departments is to shift the care substantially back to primary care and GP practices with the associated funding.
These are complex solutions to a complex problem that have been allowed to develop over many years. It will take time to get right but good models of care where primary care has embraced the new technologies, providing continuity of care for all their patients - both those with acute and ongoing chronic problems are present throughout the UK. That care is being delivered through practice based teams with a range of health professionals working together with GPs. The examples do exist - the only question is whether there is the political will to enable this to happen by marshalling the resources back towards primary care and general practice.
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