Written evidence submitted by the Patients Association (FGP0133)

Introduction

The Patients Association is an independent campaigning charity, founded in 1963. Our purpose is to ensure that everybody can access the health and care they need to live well, benefiting from services that are designed and delivered through equal partnership with patients. As well as campaigning for change, we advise people on aspects of health and social care that matter to them, and work with NHS organisations and others to develop new ways to deliver improved patient care.

This inquiry is extremely timely, as general practice is in a moment of unprecedented difficulty, for both the patients who need it and the clinicians, professionals and other staff who work in it. On the one hand, general practice has been centrally important to delivering the NHS’s largely successful vaccination programme, on which patients have given us overwhelmingly positive feedback so far. On the other, the challenges with patient access to primary care that this inquiry’s call for evidence explores are giving rise to considerable ill feeling among both patients and NHS personnel.

This difficult moment has been made more so by irresponsible media reporting of the situation that sought to pit GPs and patients against each other. We have declined numerous requests for comment from media outlets whose agenda has appeared to be to do this. Naturally we want to see primary care delivering services that meet patients’ needs: the way through the current difficulties, to find ways to achieve this, must be for primary care to work in partnership with patients.

As a general approach, we want to see primary care actively working to find out what patients want from services during the current difficulties, and what information patients need in order to be reassured that services are working in their best interests and doing all they can. We suspect that practices that have not fostered active and supportive patient participation groups (PPGs) may now be paying the price and finding this harder; we would be interested to see research on whether effective and active PPGs have helped practices reduce ill feeling and bad experiences among patients, both by equipping practices to direct their resources most effectively to address patients’ concerns, and by acting as a conduit for providing information to patients.

In September 2020, in our first report on patients’ experiences during the pandemic to date, we wrote:

“[R]espondents to our survey clearly expressed their frustration about a lack of information, inconsistent practice, and concerns about conditions getting worse. This feedback portrays a relationship between the NHS and its patients that has been very seriously disrupted.”[1]

Since then, the position of the NHS appears to have deteriorated, access to primary care in particular has become even harder, and the rupture in patients’ relationship with the NHS appears to have got worse. We explore this further in our submission below, which focuses on the two questions in the call for evidence where we are best able to provide a patient perspective.

We do not have an explanation of the causes of the build-up of pressure on primary care that differs from those widely in circulation. It appears to be arising from a complex combination of factors including, but not necessarily limited to: patients who had stayed away from primary care earlier in the pandemic now seeking assistance; some patients feeling less secure and confident about their health and/or the likelihood of help being available, and seeking care as a first resort when they might not have done previously; shortages and burnout among the primary care workforce; some work being shifted from secondary care to primary care; and the added demands of the vaccination programme.

To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?

Much of what is proposed in the Government and NHS England’s plan appears sound in its own right. However, numerous initiatives will bear fruit too late to ease pressures this winter, while it is unclear to us whether others will be sufficient to make a significant impact.

In the former category, where any benefits are still some time in the future, are the full adoption of cloud-based telephony, the measures to embed electronic fit notes in hospital systems, and the new real-time measure of patient satisfaction with general practice. Of the latter, we note that the proposal is only to ask patients about their satisfaction after appointments, so it will not capture the views of people who fail to access services, which may be a substantial number (see below). If too narrowly focused, it will also create the risk of perverse incentives for practices to focus only on certain aspects of their services, not their whole offer; the measure must capture patients’ views fully, while still being rigorous enough to provide meaningful insight (a challenge that the ‘friends and family’ test notoriously failed; this measure needs to do better).

In some of its other proposals, the plan appears to attempt to use the appropriate levers to drive improvement, for instance by requiring practices to achieve pre-pandemic appointment numbers (excluding vaccinations) in order to unlock funding; saying that, we don’t underestimate that the requirements are stretching for general practice. For all that the extra £120 million in commissioning budgets in primary care during the first half of the financial year, and the £250 million winter access fund are welcome extra funding, we are not well placed to identify whether these amounts are sufficient, or whether the necessary resources that this money should buy – mostly professional time – is readily available to be procured.

Numerous initiatives are also proposed that will help to optimise the use of existing resources, and therefore ease the extent of barriers to patient access, but on their own appear unlikely to bridge the gap between patient need and primary care’s ability to deliver. The contractual requirement on secondary care providers to assess processes that generate avoidable burdens for primary care is one example, and others are the Access Improvement Programme and the further intensive support offer to selected practices should help practices make better use of existing resources. If done effectively, this will show the value of good management, in identifying ways of working that maximise the benefits to patients of the available clinical time.

In respect of recruiting and training new personnel, to remedy the significant workforce shortages in primary care, the figures presented in the plan do not appear to suggest that recruitment and training of GPs and other primary care professionals will be adequate to keep pace with rising levels of patient need. We are staggered that the Government has still not produced a fully funded, comprehensive approach to workforce development in the NHS: the urgency of the need for this is abundantly clear, and was abundantly clear well before the pandemic.

There are other areas for intervention where, as the plan itself observes, it is not yet clear what the system should be aiming for. The plan requires practices to work out and deliver the optimal balance of remote and face-to-face appointments, taking into account clinical need and patient preference; it rightly observes that there is very little in the way of evidence-based professional standards to enable primary care to identify what this balance should be. In other words, it’s not really clear what proportion of face-to-face appointments primary care should be aiming to deliver. That said, it also rightly observes that the 15% of practices offering less than 20% of their appointments in person (as of August 2021) are surely not getting it right.

This is where practices can do well by working in partnership with patients. Practices must have a dialogue with their patients, to identify what patients see as appropriate for levels of face-to-face appointments, and when patients are happy to be seen remotely; also, what assurances patients want in order to feel confident in the NHS, and what form communication with them should take. Simply telling patients to stay away, or putting out bland, impersonal and jargon-heavy communication will fail to reassure many patients, and alienate some further.

What are the impacts when patients are unable to access general practice using their preferred method?

Our evidence of impacts on patients is drawn primarily from three patient surveys, conducted in May-August 2020, February-April 2021 and from November 24th 2021 to the time of writing. The results of the first two surveys have been published under the title Pandemic Patient Experience.[2] The third survey is ongoing, and will run until December 24th; results presented here are therefore not final. Full results will be published in January 2022.

While we believe these surveys offer valuable insight into patients’ experiences over the period of the pandemic, we also acknowledge their limitations. They are based on self-selecting samples which may well dispose them towards overly negative responses; the samples are largely of older white people in England, with the voices of some parts of the population (most working age people, BAME groups, people in the devolved nations) largely absent; and the sample sizes are modest (953 for the first survey, 453 for the second, and 597 at the time of writing for the third). However, the samples’ demographic characteristics are broadly consistent across all three surveys, and we have previously identified that the samples have behaved in consistent ways, rather than responding differently or randomly in each survey. We therefore have some confidence that changes over time demonstrated in the surveys are genuine, and offer meaningful insight.

Our first two surveys, which both asked respondents to tell us about the whole of the pandemic period up to that point (so, from spring to summer 2020 and from spring 2020 to spring 2021 respectively), showed that 36% of respondents had struggled to access GP services over the 12 months from the start of the pandemic. In August 2020 this figure had stood at 24%, and increased by half again in our second survey – the largest increase for any healthcare service in the survey. In our third survey, we again asked whether respondents had struggled to access GP services, but only in the six months prior to the survey: to date, 50% of respondents have said that they have struggled to access GP services in this six month period alone. This is a dramatic worsening, and appears to support reports elsewhere that the situation with GP access has deteriorated considerably over the middle and later part of 2021.

In our current survey, we also ask for more detail about what aspects of access people have struggled with. Among respondents reporting struggles to access primary care, the majority of respondents have indicated that these struggles include contacting the service by phone or any other method, getting a face-to-face appointment, and facing a long wait for appointments. Nearly half also reported struggling to see the type of professional they felt they needed, and nearly one in four reported struggling to get any help at all.

A struggle to access care does not necessarily mean a failure to access care: 41% of our respondents report having seen a GP face-to-face within the last six months, and 64% report having had a remote primary care appointment. We have also heard from patients that primary care appointments are far less likely to be postponed or delayed (14% having experienced this for primary care in the last six months) than hospital appointments (55%).

However, some people who are struggling to secure appointments appear not to secure them at all: respondents in our sample who report having struggled to access GP services and who also report not having had a primary appointment either remotely or in person number only a few dozen, so statistically it is impossible to draw conclusions from the data. Further analysis of the full response data from these patients will be undertaken to try to understand their situation in our full report, and some have certainly had appointments in secondary care. But it does seem possible that patients who have simply failed to get any support at all have started to appear in our survey results. This chimes with reports we are hearing from other voluntary sector organisations: that the number of people who are giving up on seeking care is increasing, either because they try and fail, or because they do not know how to go about it any more, or because they do not believe it is available for them and do not try to get it. Currently these reports are mostly anecdote, although increasingly plentiful: we would not be surprised to see them substantiated by further research over the coming months. We would also speculate that respondents to Patients Association surveys are more likely to be relatively capable and literate users of health and care services, given that they have taken enough of an interest in these issues to receive communication from us: if patients who are simply not entering the system at all have indeed started turning up in our samples, it would suggest that the problem may already be well advanced.

Remote appointments continue to be mostly by telephone, and satisfaction with them among our respondents continues to be low. Among respondents who had had a remote appointment with either a GP or someone else at their GP practice (n=346), 57% felt their phone consultation was not as good as it would have been in person, 33% felt that it made no difference either way, and 10% that it was better than it would have been in person. For online video appointments, live chat and email, the pattern of answers was similar, although respondent numbers were much lower (a matter of dozens for each). However, from other research we are aware that patients from younger demographics appear to be more positive about telephone consultations: this may be an area where patient preference is particularly correlated with age, and therefore where our data can only shed light on the experiences of patients in their 50s and older.

Finally, our evidence suggests that access to primary care makes a crucial difference to all-round outcomes and satisfaction for patients. We asked respondents whether they felt their health and care needs had been supported overall during the past six months, and the result was a near-exactly even split: 44% yes, 43% no, and the rest unsure. Considering this question with reference only to respondents who said they struggled to access GP services, however, only 22% of respondents said yes and 64% no. These results are both identical, to within a percentage point, to the same results in our second survey, in spring 2021. In fact this is somewhat confounding: if primary care is important to patients’ overall care needs being met, the overall picture across all respondents should have worsened in the most recent survey as access has become more difficult, instead of remaining the same. However, while the pattern of change over time may invite more questions than it answers, it seems clear that access to primary care has a significant bearing on whether patients report that their needs overall are met.

Dec 2021

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