The NHS was built around the idea that GPs would act as the “gate openers” 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.
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 1 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- 2 patients, and for the past decade, funding for hospitals has been growing around twice as fast as for family doctor services.
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.
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. 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.
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.
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 many more patients now have the option to consult by telephone or via the internet.
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.
https://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-2017-international-comparison-reflects-flaws- 1 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 2 https://www.kingsfund.org.uk/audio-video/key-facts-figures-nhs
The current situation and the failures of the Conservative government
Despite 13 years in power, the Conservative government has failed to invest in General Practice. They have spent more resources on bureaucratic reorganisations rather than investment in front line clinical care. The Lansley reforms and reorganisation introduce by David Cameron and the coalition government wasted nearly £4bn of tax payers money .3
International comparisons show that UK health spending would have been £40 billion higher every year between 2010 and 2019 if it had matched the EU average . Health care capacity in the UK is 4 now lower than in many other countries as seen in the number of hospital beds, doctors and nurses, and medical equipment such as scanners.
Failure to invest more in services in the community has hindered efforts to reduce demand for hospital care and respond to the changing burden of disease. The workforce increase was greater in hospitals than in general practice . Greater investment in secondary care at the expense of 5 primary care is one factor that has contributed to rising demand and the pressures on urgent and emergency care. The recently published plan for recovering urgent and emergency care services sets out proposals for expanding care in the community and people’s homes but misses an 6 opportunity to support patients to manage their own care more effectively and avoid the need for hospital care.
By not taking the road advocated by the Wanless Review , there was insufficient attention to 7 prevention and the wider determinants of health. Analysis shows that improvements in population health stalled or went into reverse during the 2010s at the very time when risk factors such as 8 obesity – for which the UK has the highest rates in Europe – were having an increasing impact . 9 The poor health of the population was reflected in rising demand for care and contributed to the UK having high rates of excess deaths from Covid-19 and other causes . 10
The current crisis in general practice is entirely made by government: failure to ensure adequate numbers of GPs and other staff; a campaign to undermine and devalue general practice and the role it has in society and the NHS; a reduction of real-terms funding ; failure to address the structural inequity in the finding formulae; failure to understand inequality and do anything meaningful to address it. This is a catalogue of very significant and avoidable failures. Morale is now at rock bottom in General Practice, the workload is relentless, demand and expectation is unrealistic and the workforce is in crisis. The work is increasingly stressful as mental health and social care has crumbled leaving GPs holding unmanageable risk. This is compounded by the overwhelmingly negative messaging in the press and political rhetoric which is perceived as deliberate and undermining, colouring interactions with patients negatively especially amongst those who have been hit hard by the pandemic trauma and the cost of living crisis.
https://blogs.lse.ac.uk/politicsandpolicy/hsc-bill-policy-fiasco/ 3
Rebolledo, I. and Charlesworth, A., 2022. How does UK health spending compare across Europe over the past decade?. The Health 4 Foundation.
Tallack, C., Charlesworth, A., Kelly, E., McConkey, R. and Rocks, S., 2020. The bigger picture: Learning from two decades of 5 changing NHS care in England. Health foundation.
6 Department of Health and Social Care and NHS England 2023
https://www.southampton.gov.uk/moderngov/documents/s19272/prevention-appx 1 wanless summary.pdf 7 8 The rise and decline of the NHS 2000-2020 https://www.kingsfund.org.uk/publications/rise-and-decline-nhs-in-england-2000-20 9 https://www.kingsfund.org.uk/publications/vision-population-health
https://commonslibrary.parliament.uk/research-briefings/cbp-7281/ 10
A ten-point GP recovery plan for an incoming Labour administration
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 . 11
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 - especially those who have experience in psychiatry, general medicine, geriatrics, rheumatology) 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 liaise with each other to plan the future care for patients.
6) Put a ceiling on the number of patients that a primary care physician (if they are dealing with more complex patients as part of a multi-disciplinary team) can see in 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 streamlined by combining the various schemes (Investment and Impact Fund, QOF and local schemes (PQRRS). GPs should be incentivised to provide continuity of care for their patients. Reassess the onerous appraisal system so only GPs at higher risk of poorer clinical outcomes are assessed more throughly.
8) Incentivise practices to develop models of care where continuity of care within a GP team is prioritised. Channel more funding into core hours rather than divert to short term access programs.
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.
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.