Written Evidence submitted by Professor Stephen Peckham[1]and Professor Kath Checkland[2] (FGP0147)

This evidence derives from our 20 years’ experience of researching the provision and commissioning of primary care services in England and internationally, and from Professor Checkland’s experience as a working GP since 1991.

 

Summary:

1. Access to primary care services

Research evidence and experience suggest that the biggest problem facing general practice and the biggest threat to good access is workforce shortages.

Recommendations:

 

2. Challenges facing general practice and possible solutions

The 10th GP Worklife Survey found that a significant proportion of GPs intend to quit within the next five years. It is therefore important that policy focuses upon ensuring that general practice is a desirable and sustainable career choice:

 

3. Conclusion:

Current policy around investment in general practice focuses upon encouraging and incentivising collaboration between practices. Such collaboration has theoretical benefits, but we do not yet have robust evidence to support this approach. Similarly, whilst broadening skill mix in primary care may address current problems of access, research suggests that its implementation is complex and it does not straightforwardly free up GP time. Additional investment in primary care is important, and should focus upon addressing regional and other inequalities, as well as supporting continuity of care as much as possible.

 

Evidence relevant to the questions asked by the Inquiry

 

What are the main barriers to accessing general practice and how can these be tackled?

Lack of capacity is the biggest single problem facing patients access and practices themselves. The failure to properly prioritise and plan the workforce around GPs to meet the demand has led to a continuing decline in GP numbers while demand has grown. Average list size continues to grow. The government has continued to miss recruitment targets. The BMA calculate that as of September 2021 there is an the equivalent of 1,704 fewer fully qualified full-time GPs compared to 2015.

 

List sizes per GP continue to increase. The number of patients registered at GP practices has grown from 60.5 million in November 2020 to 61.3 million in November 2021 (NHS Digital). There are now just 0.45 fully qualified GPs per 1,000 patients in England – down from 0.52 in 2015. Other staff continue to take on additional tasks, but the number of nursing staff has fallen slightly but there has been a small increase in other direct patient care staff in the last 12 months. While there has been growth in the overall population there has been disproportionally higher growth in the numbers of older people who are more likely to have a long-term or multiple long-term conditions and require additional support from general practices.

 

In September 2021 there were 28.5 million consultations (inc. 0.5 million COVID vaccinations) which compares to 26 million consultations in September 2019, and this rose to 30 million in October (excluding vaccinations). This reflects the significant increasing pressure on practices given workforce capacity is not increasing. While funding has increased after 2018/19 there was a slight drop in the proportion of NHS funding going to practices. However, real terms funding per patient has increased since 2010 but not as fast as other sectors of the NHS.

 

However, significant variations between areas remains with average GP practice sizes varying from under 1750 patients per GP to 3000. The mix of population is also important as some practice shave significantly higher proportion of older people. Fewer GPs, total direct patient care staff, and paramedics per 10 000 patients are also employed in more deprived areas. A recent analysis published in the British Journal of General Practice in October 2021 found that “Significant workforce inequalities exist and are even increasing for several key general practice roles, with workforce shortages disproportionately affecting more deprived areas.” (Nussbaum et al 2021). There is also a greater GP turnover in more deprived areas. A study published in 2021 found that between 2009 and 2019 (Parsi et al 2021):

 

Recommendations:

 

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

In terms of capacity the Government commits to recruiting an additional 6,000 GPs by 2024 and while the number of GPs in training has increased, the target is unlikely to be met by 2024. The Government also committed to recruiting additional primary care staff particularly through PCNs.

There has been some growth in direct patient care staff, but nursing staff numbers are not increasing and GP fte is decreasing.

 

More research is needed to understand the patient care impact of different degrees of staff mix on patients care in order to plan adequately for staff growth in general practice. The current approach is an assumption that non-GP staff can take on more direct patient care and release pressure on GPs but there is currently insufficient evidence to support this approach.

 

What role does having a named GP—and being able to see that GP—play in providing patients with the continuity of care they need?

Continuity of care is considered an important aspect of general practice. Drawing on the results of the patient survey, analysis by the Policy Research Unit in Health and Social Care Systems (PRUComm) found that larger general practice size in England may be associated with slightly poorer continuity of care and may not improve patient access. Close collaborative working did not have any demonstrable effect on patient experience (Forbes et al 2021).

 

What are the main challenges facing general practice in the next 5 years?

Workload remains a significant challenge. Currently due to COVID there are additional pressures on practices due to engagement in vaccination programmes and also due to pressures faced by secondary care leading to additional workload pressure.

 

Prior to COVID the 10th GP Worklife Survey conducted by the PRUComm in 2019 found that while overall hours of work showed a slight decline GPs feel they need to work increasingly intensively. Intentions to quit practice remained high, with 63% of respondents over the age of 50 reporting a considerable or high likelihood that they will leave patient care roles in the next five years (Walker et al 2019). An update of this survey is currently in progress and the results will be available in 2022.

 

How does regional variation shape the challenges facing general practice in different parts of England, including rural areas?

There are significant inequalities in resource allocation across the country. General practice in areas of high socioeconomic deprivation is relatively under resourced compared to more affluent areas. These areas are also under-doctored (Fisher et al 2020).  Practices in deprived areas tend to  have lower Care Quality Commission scores, lower QoF performance and lower patient satisfaction scores. Patients who live in areas of high deprivation have on average shorter GP consultations than those in wealthier areas, despite being likely to have more complex health needs (Gopfert et al 2021). Practice list sizes vary considerably with key shortages in more deprived areas.

 

Recommendation:

 

What part should general practice play in the prevention agenda?

General practice plays key roles in screening and secondary prevention (Peckham et al 2015).This review found that less activity is undertaken for primary prevention. The authors concluded that little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches with practices engaging in both primary and secondary prevention. Although many GPs do not take a population approach and focus on individual patients some do see health promotion as an integral part of practice – whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Based on our analysis we conclude that there is insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care. In addition, it is important to remember that, whilst prevention of illness is an important goal, it does not necessarily result in cost savings for the NHS, because lifetime resource use by individuals is largely driven by expenditure on health care in the final few years of life at whatever age that occurs. Thus, the prevention agenda must not be seen as a means of reducing overall NHS costs.

 

Links between general practice and local authority public health are often poor – particularly at a strategic level (Coleman et al 2014)Current incentives in the Quality and Outcomes Framework do not support more preventive care as the focus is not on primary prevention nor more holistic care (Langdown and Peckham 2014, Forbes et al 2017).

 

Most studies suggest that lack of time in consultations is a major factor for lack of preventive care and that longer consultations, training and peer support are the factors that would support greater engagement in prevention.

 

How can the current model of general practice be improved to make it more sustainable in the long term? In particular:

 

Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?

All the evidence points to patients preferring contact with a known GP. Continuity of care is highly valued by patients and research suggests that patients views of continuity worsen as practice size increases.  There is some evidence to suggest that smaller practices provide greater quality care but little evidence on whether organisational structure  is relevant. Research from Canada suggests that the problems associated by having larger practices (less continuity etc) are more dependent on practice organisational structures and working than size per se.

 

There is little research on the advantages and disadvantages of different organisational models. The 2019 review of practice partnerships concluded that a plurality of models was needed. It reported GP and others views about practice partnerships but did not analyse the impact of different models. This research would be valuable in England.

 

Do the current contracting and payment systems in general practice encourage proactive, personalised, coordinated and integrated care?

In 2014 PRUComm undertook a review for DHSC of the impact of primary care physician payment models (Fee-for-service (FFS), capitation, salary). The  evidence  reviewed  confirmed  the  theoretical  prediction  that  more  variable  payment  schemes, such  as  FFS  that  links  payment  to  output,  are  associated  with  higher  volume  of  services  than  more fixed  payment  schemes  such  as  capitation  or  salary.  Physicians  paid  under  FFS  were  found  to  have  a higher  number  of  patient  visits,  work  more  hours  and  spend  less  time  with  other  aspects  of  care such  as  indirect  care  or  teaching  and  administration  duties  compared  to  alternative  less  variable schemes.  With  regard  to  supplier  induced  demand  there  is evidence  that  physicians  induced  demand by  increasing  the  intensity  of  care  in  order  to  protect  their  incomes  although  this  was  not  observed in  all  studies. The  effect  of  reimbursement  methods  on  supplier  induced  demand  seems  to  depend on  the  structure  of  the  market  and  especially  the  way  fees  are  regulated  and  the  starting  levels  of competition. Capitation  and  salary  was  associated  with  more  referrals  than  was  the  case  for  FFS. Payment  method  did  not  seem  to  affect  levels  of  prevention  activity  or  patient  selection  (cream skimming).  Size  of  remuneration  also  had  no  effect  on  activity  volume (Peckham and Gousia 2014)..

 

PRUComm also undertook a review of the Quality and Outcomes framework impact. Forbes et al 2017) The key  findings were:

 

This was prior to changes introduced to QOF since 2019 to include quality improvement modules with practices. PRUComm is currently evaluating these changes and will report in June 2022. However, early findings suggest that the  quality improvement modules are broadly accepted in practice. Some reported concerns have been expressed about staff time needed, the challenges of working with other practices for review of quality improvement activities, the choice of topics by NHSE&I, and that focusing on specific areas may mean that other clinical areas would be deprioritised.

 

Has the development of Primary Care Networks improved the delivery of proactive, personalised, coordinated and integrated care and reduced the administrative burden on GPs?

PRUComm’s early research on the development of Primary Care Networks found that those in PCNs identified these as potential benefits but it is too early to identify whether such outcomes has been achieved (Checkland et al 2020, Warwick-Giles et al 2021). Our research is ongoing and will be published in the new year. We have also submitted a separate submission that details this research, authored by Dr Jonathan Hammond, Dr Lynsey Warwick Giles and Professor Kath Checkland.

 

To what extent has general practice been able to work in effective partnerships with other professions within primary care and beyond to free more GP time for patient care?

There is limited evidence on the appropriate staff-mix and impacts on patient care. NIHR have funded two recent studies. An analysis of the literature on team composition/skill-mix in primary care suggests that simply examining staff roles and their activities does not sufficiently provide solutions to improving patient outcomes and team or organisational performance. We identified four interconnected aspects that contribute to practice skill-mix:

 

  1. Organisational characteristics (practice type and size);
  2. Formal intention to collaborate (structures);
  3. Collaborative practices (specific collaborative interventions and their unfolding);
  4. Relationships and dynamics (climate and culture).

 

Current NIHR funded research that we have been involved in is exploring these factors in practice. We are currently conducting focus groups with practice staff in England. Current early themes emerging from focus group discussions highlight issues such as:

 

Skill-mix and the impact on patient care has to be examined within the organisational context in terms of how teams work, the processes and systems within practices etc. Staff mix and how tasks and roles are allocated between staff (eg substitution, new roles, expanded roles)  is not a sufficient indicator of impact on outcomes. We are also identifying issues in relation to staff in PCNs with roles covering more than one practice in terms of staff relationships and team-work.

             

Conclusion:

Current policy solutions are based on a presumption that larger practices or networks of practices will have efficiencies of scale. The evidence on collaborative practice working is still sparse and it is not clear whether the additional burden of building collaboration have benefits over simply resourcing existing practices although some shared roles may be beneficial (eg pharmcists). Simple policies that expand staff roles, focus on simple role substitution may not achieve desired improvements in capacity and patient care.

Co-ordination is an issue in terms of larger organisational models. In particular co-ordinating patient care to maintain continuity of care is an important area to pay attention to. There is limited research and evidence on organisational models in general practice as to what structures etc produce better patient care.

 

References:

 

Checkland K, Hammond J, Morciano M, Warwick-Giles L, Lau YS, Bailey S and Sutton M (2020) Primary  Care Networks:  exploring  primary care commissioning, contracting,  and  provision Policy Research Unit in Health and Social Care Systems and Commissioning

 

Fisher R, Dunn P, Asaria M, Thorlby R. (2020) Level or not? Comparing general practice in areas of high and low socioeconomic deprivation in England. The Health Foundation.(https://doi.org/10.37829/HF-2020-RC13).

 

Forbes, L.J., Forbes, H., Sutton, M., Checkland, K. and Peckham, S., (2020) Changes in patient experience associated with growth and collaboration in general practice: observational study using data from the UK GP Patient Survey. British Journal of General Practice, 70(701), pp.e906-e915.

 

Forbes, L., Marchand, C. and Peckham, S., (2017) Review of the quality and outcomes framework in England. Retrieved from the Policy Research Unit in Commissioning and the Healthcare System 

 

Gopfert A, Deeny S, Fisher R, Stafford M. (2021) Primary care consultation length by deprivation and multimorbidity in England: an observational study using electronic patient records. British Journal of General Practice; 71 (704): e185-e192 (https://doi.org/10.3399/bjgp20X714029)

 

Nussbaum, C., Massou, E., Fisher, R., Morciano, M., Harmer, R., & Ford, J. (2021). Inequalities in the distribution of the general practice workforce in England: a practice-level longitudinal analysis. BJGP open, 5(5).

 

Parisi, R., Lau, Y.S., Bower, P., Checkland, K., Rubery, J., Sutton, M., Giles, S.J., Esmail, A., Spooner, S. and Kontopantelis, E., (2021) Rates of turnover among general practitioners: a retrospective study of all English general practices between 2007 and 2019. BMJ open, 11(8), p.e049827

 

Peckham, S., Falconer, J., Gillam, S., Hann, A., Kendall, S., Nanchahal, K., Ritchie, B., Rogers, R. and Wallace, A., (2015) The organisation and delivery of health improvement in general practice and primary care: a scoping study. Health Services and Delivery Research, 3(29), pp.1-180.

 

Peckham, S and Gousia, K (2014) GP payment schemes review.  PRUComm 

 

Walker B, Moss C, Gibson J, Sutton M, Spooner S  and Checkland K ( 2019) Tenth National  GP  Worklife  Survey 2019 Policy Research Unit in Commissioning and the Health Care System.

 

Warwick-Giles, L., Hammond, J., Bailey, S., & Checkland, K. (2021). Exploring commissioners’ understandings of early Primary Care Network development: qualitative interview study. British Journal of General Practice

 

Dec 2021


[1] Professor of Health Policy & Director, Centre for Health Services Studies, University of Kent; Director, NIHR Policy Research Unit in Health and Social Care Systems and Commissioning; Director NIHR Applied Research Collaboration Kent, Surrey and Sussex

[2] Professor of Health Policy and Primary Care, University of Manchester; Associate Director, Policy Research Unity in Health and Social Care Systems and Commissioning; and General Practitioner