Written evidence submitted by Professor Richard Baker OBE MD FRCGP, FRCP (FGP0088)

 

I am a GP researcher, having been a general practitioner first in Cheltenham followed by Leicester City, and an academic at Bristol and then Leicester Universities. Head of Department at Leicester, 2003-2010. Now retired, I continue to undertake some academic activities. I have conducted research into patient experience of general practice, interventions to improve the quality of care, development of guidelines (with NICE), continuity of care and the outcomes of primary health care. On occasions, I have undertaken investigations of patterns of mortality at the request of senior NHS staff. The effect of primary health care in influencing population mortality is often taken for granted but the importance of this effect and the mechanisms that explain it are not well understood. The evidence that follows is based on my particular interest in primary health care and mortality.

This submission concentrates on three of the questions of the Call for Evidence by the Health and Social Care Committee. I am familiar with the evidence relating to these aspects of general practice, having conducted research on these issues, some of this work having been funded by the National Institute for Health Research (NIHR).

The impact will vary from patient to patient and will also depend on the alternative methods of access. Some patients may be delighted to discover a convenient method they had been previously unfamiliar with. The recently introduced email service is an example; the use of mobile telephones to transmit photographs of skin lesions is another that enables some face-to-face consultations to be avoided. In recent months I have experienced both these methods of access as a patient and appreciated them both.

 

Difficulties can arise for patients in understanding the options for access and how to obtain each one, and in the process of negotiating which method they can use – a process usually referred to as triage. The patient needs to know which methods are available, and in my personal experience this is not always clear on general practice websites and is not routinely explained to patients when they telephone the surgery. Triage can add a layer of difficulty. The receptionist needs sufficient information to select which method of access is appropriate; patients may be reluctant to disclose personal information to an unknown non-clinician. I can attest to this problem, which can be made worse by the policy of not permitting appointments to be booked ahead. The requirement to ring back each morning, repeat the story you don’t want to share over again with a different receptionist, until a vacant routine appointment is found, can be a deterrent to seeking medical help.

 

Some patient groups will find negotiating for alternative methods of access difficult. Those who are sight or hearing impaired, people with serious mental illness, people with limited ability in English, the homeless and other marginalised groups are likely to experience difficulty in seeking access and in making headway through triage.

 

An important impact of difficulty in access is the effect on health. Access is not simply important for convenience, satisfaction of patient experience – it is important for health as well. Evidence of this impact can be found in associations between access, levels of chronic disease in the practice population, and hospital use and population mortality.

 

      In a study of 146 general practices in two English counties, practices that had higher levels of chronic disease (as measured by QOF registers) tended to have worse access as reported by patients in the general practice patient survey.[1] As the number of patients recorded with chronic disease increased, the capacity of practices to meet patients’ requests for appointments declined – practices were busy managing chronic disease.

 

      A study that included 8,079 general practices in England investigated the relationship between numbers of doctors per unit of population, the numbers of patients with hypertension whose condition had been detected, and patient reports of access (being able to get an appointment fairly quickly). As the numbers of patients with hypertension increased, access declined, but those practices with a higher number of doctors per unit of population were able to detect more cases of hypertension and at the same time maintain access.[2]

 

      Hypertension is under-diagnosed although the percentage of affected people who have had their condition detected has been increasing in recent years. Population mortality from coronary heart disease is lower when general practices have detected more people with hypertension.[3] Detection leads on to treatment and the risk of death from heart attacks or strokes is reduced. This study included all 152 primary care trusts in England that were then in place.

 

      Patients’ perceptions of access to their general practice can lead to increased use of emergency departments. In one study, using data on attendances at emergency departments in 2006/2007 and 2007/2008, greater deprivation, shorter distance from the central emergency department, lower practice list size, white ethnicity and lower satisfaction with practice telephone access were associated with higher emergency-department attendance rates.[4] This finding is supported by evidence from qualitative interviews of patients attending an emergency department. Patients’ concern about their problem, the expertise available at the emergency department, and perceptions about access to alternative services including general practice influenced decision on use the emergency department.[5]

 

      Patients’ reports of access to general practice have also been associated with mortality. In a study using data on mortality under the age of 75 years (premature mortality) over the years 2006 to 2010, associations with features of 7,858 general practices in England were investigated. After accounting for characteristics of practice populations, including deprivation, ethnic groups, smoking and morbidity as indicated by the proportion of people with diabetes, a higher proportion of patients being able to get an appointment at the practice within 48 hours (a measure of access) was associated with lower premature mortality.[6] A 1% increase in the proportion of people reporting being able to get an appointment within in 48 hours was associated with a reduction of between 31 and 172 premature deaths in England.

 

 

 

 

The proportion of patients who experience continuity in general practice has steadily declined in recent years.[8] Continuity in primary medical care has been shown to be associated with not only lower emergency hospital admission rates7,[9] but also, in our recent systematic review, with mortality,[10] an effect likely to be explained by the reduction in mix-ups in care created by dis-continuities[11] and the opportunity continuity presents for trusting patient-professional relationships to develop.[12] Trust is important for giving patients the confidence to follow the advice the health professional gives them, a process often referred to as adherence. Vaccine hesitancy, a problem we have become familiar with in recent months, is a specific example of adherence and the important role of trust. It follows that continuity should not be seen as an end in itself but instead as a means for relationships of trust to develop – so-called therapeutic relationships.

 

The allocation of a named GP to a patient does not ensure the development of a therapeutic relationship. It may be no more than an administrative device that has no effect on the practice appointment system. However, depending on how practices operationalise the named GP policy, it could allow the named GP to become the preferred GP and the preferred GP to become the usual GP (‘my doctor’), if appointment systems are operated to bring patient and preferred GP together (whether face-to-face, by telephone or by video).

 

For the named GP to become ‘my doctor’ an element of choice will be needed when a relationship cannot be established between the patient and the GP. Both the patient and the GP should have the ability to suggest the named GP should be changed. Procedures to allow the development of therapeutic relationships in general practice should not be regarded as a luxury but as a process that contributes to improving health and reducing mortality.

 

It is important to mention some reservations. Continuity should not be imposed. People with chronic conditions or worrying problems tend to prefer to see a familiar GP[13] but some patients do not want continuity, and often, when a problem is urgent but not especially worrying, many patients place speedy access before continuity.[14] Continuity may also have adverse effects. For example, it may sometimes be related to delay in suspecting cancer,[15] although this effect is small and the overall effect of continuity is to lower population mortality. Continuity, then, must be used intelligently, offered when it is desired (which is most often for people with chronic problems) but replaced with referral to another GP should the patient prefer this or in cases of diagnostic uncertainty.

 

 

  1. Capacity

The most important challenge facing general practice in the next five years is the lack of capacity. A shortage of GPs and other staff is not only a matter of access and convenience, it is also a matter of health. Claims about the effect of the number of general practitioners per unit of population have usually relied on evidence from US studies but extrapolation of the findings to other countries requires some caution. The health system in the USA is very different to the systems in place in almost all other high-income countries; it is also much more costly.

 

Evidence is now available about the effect of numbers of GPs on population mortality in England.6 In this study of almost all general practices in England that accounted for population characteristics (age, deprivation, smoking, ethnicity) and practice characteristics (access, continuity, aspects of clinical care), we found that lower premature mortality (under aged 75 years) was associated with higher numbers of GPs per unit of population. Using mortality data for the period 2006-2010, an increase in GP supply of 0.16% was estimated to be associated with 1078 fewer deaths per year. Since 2010 the demand for health care has increased in line with growth in population size and multimorbidity but the capacity of general practice has changed very little, and further research is needed to investigate the consequences for population mortality. The impact of lack of capacity on population mortality may have increased. The impact on mortality of the supply of health professionals other than doctors, for example, nurses, or physician assistants, is not known.

 

The challenge of ensuring capacity according to need is linked to the problem of creating a funding formula for general practice. Getting the right numbers of staff to the parts of the country where they can be of greatest benefit requires a funding formula designed for the purpose. The current funding formula does not adequately account for the disease burden in practice populations[16] nor for the level of deprivation.[17] Workforce planning and funding strategies to achieve effective distribution of staff need to be closely integrated. Explicit policy objectives are also needed. The cost of preventing the death of a deprived person is almost certainly higher than the cost of preventing the death of a privileged person but the details of these costs are not known, and judgement is needed in weighting funding according to levels of deprivation.

 

  1. The health needs of different generations

It is inevitable that health services will be heavily preoccupied with the care of older people. The numbers of older people are increasing, they acquire multiple chronic conditions as they age, and they place increasing burdens on both general practices and hospitals. GPs will need to continue to manage as many people with multimorbidity as possible in the community to protect specialist services. This will be a necessary and unavoidable feature of general practice for the foreseeable future.

 

This inevitable preoccupation of general practice with the chronic conditions of older age groups must not be at the expense of children and young people. The Royal College of Paediatrics and Child Health reports that in recent years declines in infant mortality have stalled, and that mortality among adolescents has increased.[18] We now better understand how chronic disease and premature mortality often have their origins in early life. The underlying biology has been summarised in the idea of early life programming, the experiences of children before and after birth leading to biological changes that affect health in later life.[19] The effects of adverse childhood experiences on mortality later in life has been identified,[20],[21] and the life course theory of health inequalities clarifies how social, psychological and economic disadvantage accumulate to shorten lives.[22] General practice can play a part, along with other agencies, in reducing these adverse outcomes. This begins with pre-conception care of women in before pregnancy, and continues with general health care during and after pregnancy, and getting to know and support families. We used to refer to general practitioners and family doctors; perhaps it is time this idea was re-formulated for the 21st century.

 

 


[1]. Anwar SM, Walker N, Mainous A III. Baker R. Does better access to general practice improve detection of chronic disease, or does more detected disease make delivering access more difficult? British Journal of General Practice. 2012;e337-343. DOI:10.3399/bjgp12X641456

 

[2]. M Bankart, Mohammed Anwar, Nicola Walker, Arch Mainous III, Baker R. Are there enough GPs in England to detect hypertension and maintain access? Cross-sectional study. BJGP. 2013;63:251-2 (abridged version. Full version: DOI:10.3399/bjgp13X667204)

 

[3]. Levene SL, Baker R, Bankart MJG, Khunti K. Association of features of primary care with coronary heart disease mortality. JAMA 2010;304:2028-2034

 

[4]. Baker R, Bankart MJ, Rashid A, Banerjee J, Conroy S, Habiba M, Hsu R, Wilson A, Agarwal S, Camosso-Stefinovic J. Characteristics of general practices associated with emergency department attendance rates: a cross-sectional study. BMJ - Quality & Safety 2011; doi:10.1136/bmjqs.2010.050864.

 

[5]. Agarwal S, Bannerjee J, Baker R, Conroy S, Hsu R, Rashid A, Camosso-Stefinovic J, Sinfield P, Habiba M. Potentially avoidable emergency department attendance: interview study of patients’ reasons for attendance. Emergency Medicine Journal. 2011. doi:10.1136/emermed-2011-200585

 

[6]. Baker R, Honeyford K, Levene LS, Mainous AG III, Jones DR, Bankart MJ, Stokes T. Population characteristics, mechanisms of primary care and premature mortality in England: a cross-sectional study. BMJ Open 2016;6: e009981. doi:10.1136/ bmjopen-2015-009981

 

7. Bankart MJG, Baker R, Rashid A, Habiba M, Banerjee J, Hsu R, Conroy S, Agarwal S, Wilson A. Characteristics of general practices associated with emergency admission rates to hospital: a cross sectional study. Emergency Medicine Journal. 2011;28:558-563

[7] 

[8]. Levene L, Baker R, Walker N, Wilson AD, Williams C, Bankart M. Predicting declines in perceived relationship continuity using practice deprivation scores: a longitudinal study in primary care. British Journal of General Practice 68(671):e420-e426 (7 pages) Jun 2018

 

[9]. Gunther S, Taub N, Rogers S, Baker R. What aspects of primary care predict emergency admission rates? a cross sectional study. BMC Health Services Research. 2013, 13:11 doi:10.1186/1472-6963-13-11

 

[10]. Baker R, Freeman GK, Haggerty JL, Bankart MJ, Nockels KH. Primary medical care continuity and patient mortality: a systematic review. British Journal of General Practice 70(698):26 Aug 2020

 

[11]. Tarrant C, Windridge K, Baker R, Freeman G, Boulton M. Falling through gaps: primary care patients’ accounts of breakdowns in experienced continuity of care. Family Practice 2014, 1–6  doi:10.1093/fampra/cmu077

 

[12]. Mainous AG III, Baker R, Love MM, Gray DP, Gill JM. Continuity of care and trust in one’s physician: evidence from primary care in the United States and the United Kingdom. Family Medicine. 2001;33:22-27

 

[13]. Boulton M, Tarrant C, Windridge K, Baker R, Freeman GK. How is continuity of care produced? A mixed methods longitudinal study in primary care. BJGP 2006;56:749-55

 

[14]. Turner D, Tarrant C, Windridge K, Bryan S, Boulton M, Freeman GK, Baker R. Do patients value continuity of care in general practice? An investigation using stated preference discrete choice experiments. Journal of Health Service research and Policy 2007;12:132-7

 

[15]. Rogers S, Gildea C, Meechan D. Baker R. Access, continuity of care and consultation quality: which best predicts urgent cancer referrals from general practice? Journal of Public Health doi10.1093/pubmed/fdt127

 

[16]. Levene LS, Baker R, Wilson A, Walker N, Boomla K, Bankart MJG. Population health needs as predictors of variations in NHS practice payments: a cross-sectional study of English general practices in 2013–2014 and 2014–2015. Br J Gen Pract 2017; DOI: 10.3399/bjgp16X688345

 

[17]. Levene LS, Baker R, Bankart J, Walker N, Wilson A. Socioeconomic deprivation scores as predictors of variations in NHS payments: a longitudinal study of English general practices 2013-2017.  British Journal of General Practice 2019;69(685):E546-E554

 

[18]. Royal College of Paediatrics and Child Health. The State of Child Health in the UK.  https://stateofchildhealth.rcpch.ac.uk/ (accessed 07/12/21)

 

[19]. Williams TC, Drake AJ. What a general paediatrician needs to know about early life programming. Arch Dis Child 2015;100:1058–1063.

 

[20]. Bellis MA, Hughes K, Leckenby N, Hardcastle KA, Perkins C, Lowey H. Measuring mortality and the burden of adult disease associated with adverse childhood experiences in England: a national survey. Journal of Public Health 2014;37(3): 445–454. doi:10.1093/pubmed/fdu065

 

[21]. Grummitt LR, Kreski NT, Kim SG, Platt J, Keyes KM, McLaughlin KA. Association of childhood adversity with morbidity and mortality in US adults. A systematic review. JAMA Pediatr. 2021;175(12):1269-1278

 

[22].  Batley M. Health Inequalities. An introduction to concepts, theories and methods. 2nd edition. Cambridge, Polity Press, 2019.

 

Dec 2021