Written evidence submitted by Cancer Research UK (FGP0320)

Key points

• Primary care is a key component of cancer care. Over 6 in 10 cancer patients begin their journey to diagnosis and treatment following a GP referral. Therefore, ensuring everyone can quickly and equitably access primary care is vital.
• The most significant challenge facing general practice in the next five years will continue to be a lack of capacity which is a significant barrier to patient access. Despite the Government’s manifesto commitment to increase the number of GPs in England by 6,000 by 2024, the number of full-time, fully-qualified GPs in England has reduced by over 1,700 since 2015, and Secretary of State for Health and Social Care Sajid Javid has recognised that the Government is off track to meet this target.
• Expanding capacity by addressing shortages in the GP and wider primary care workforce must be a key priority for the Government to ensure that every patient has timely access to care. Access and capacity are particularly challenged in areas of higher deprivation, which must be addressed via targeted interventions to improve capacity in deprived communities.
• In addition, the pandemic continues to put significant strain on primary care, and this will continue to be felt in coming years due to the patient backlog that accumulated during the first wave of COVID-19 and the presentation of more complex conditions due to delays. This increased demand will exacerbate existing capacity challenges in primary care.
• Preventable risk factors for non-communicable diseases – such as smoking and obesity – and the increased ill-health they lead to, will also continue to be a significant driver of demand for general practice and the wider health service.
• As the first point of contact between patients and the health system, general practice has an essential role to play in intervening before people develop serious disease due to preventable risk factors. By helping patients maintain healthier habits – for example by effective delivery of Very Brief Advice for smoking and obesity – general practice can help reduce health disparities, improve population resilience and reduce the strain on the NHS.

Inquiry Questions

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

Primary care workforce shortages remain the most significant barrier to timely access to general practice. Despite the Government’s pledge to increase the number of GPs in the England by 6,000 by 2024, the number of full-time, fully-qualified GPs in England has actually reduced by over 1,700 since 2015.[1] and the Health and Social Care Secretary Sajid Javid has confirmed Government is off track to meet the target.[2] This has directly impacted patient access to primary care, with the proportion of patients who found it easier to get through to their GP surgery on the phone falling from 80% to 65% between 2012 and 2020.[3]

Shortages in the primary care workforce place a huge burden on staff, with potentially devastating consequences for burnout and retention. The NHS Confederation have found that two years on from the establishment of Primary Care Networks (PCNs), workload remains a challenge both for PCNs and across the whole of primary care. They found that 96% of PCN clinical directors and managers surveyed agreed that the workload instigated by PCNs is greater than they expected.[4] The challenge already presented by workforce shortages would be seriously compounded if poor wellbeing among staff led to poorer retention.

Pressures in one part of the health system can have knock on effects in other parts of the system – meaning it is important that the wider impact of a lack of access to primary care is monitored. CRUK’s health professionals have raised the risk that patients may attend out of hours or A&E services if they’re not able to access primary care services.

Growing the GP workforce is essential to improving access to primary care, and it is vital the Government invests to make significantly more progress in meeting their targets for this. But in the short-to-medium term, there are steps that can be taken to support capacity – and therefore access – in the primary care workforce.

Improving retention will be vital to ensure that the pressure primary care is currently under does not lead to primary care losing its already limited workforce capacity. This is especially important because as older GPs retire, their invaluable experience is lost, meaning that replacing the value they add to their practice is not as simple as recruiting a newly trained GP. Measures that could help reduce attrition in primary care may include the provision of scaled-up mental health support supported by granular and timely data on staff wellbeing, flexible working opportunities or the increased availability of new opportunities such as in learning and development or research. Engaging with the primary care community to more fully understanding why people are leaving the profession is vital to any effective plan to reduce this. At a national and local level, comprehensive and standardised data on why people leave should be collected, to feed into future policies seeking to improve retention.

Moreover, roles supported by the Additional Role Reimbursement Scheme (ARRS), such as Clinical Pharmacists, Physician Associates and Social Prescribers, can help support GPs in delivering primary care services. For example, Clinical Pharmacists can clinically assess and treat patients for specific disease areas – and in some cases be a prescriber.[5] However, the scheme has not identified specific roles that can support the early diagnosis of cancer, missing a key opportunity to diversify the primary care workforce, maximise capacity and deliver on ambitions in the PCN service specification to improve cancer early diagnosis. Moreover, ARRS roles may also increase the bureaucratic workload for GPs, while the high workload caused by workforce shortages may prevent GPs from effectively supporting ARRS staff.[6]

Primary care plays a key role in the diagnosis of the majority of cancers. Public perceptions of capacity in primary care are important for help-seeking behaviour. In our Cancer Awareness Measure survey, not wanting to waste the health professional’s time has been repeatedly reported as a key barrier to people seeking help (unpublished data)[7]. In international comparisons, people in the UK were more likely to report that worry about wasting the doctor’s time would put them off going to the doctor[8]. Addressing these concerns is important for encouraging people with unusual health changes to seek timely attention, which we estimate could contribute 4 percentage points[9] to the NHSE Long Term Plan ambition of diagnosing 75% of stageable cancers at Stage I and II by 2028. In our most recent survey of 2,446 UK adults (September 2021, unpublished data)[10], finding it difficult to get an appointment was the most endorsed barrier (endorsed by 17%).

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

The onset of the pandemic rapidly accelerated the move to a ‘digital first’ model of care, previously outlined in the NHS Long Term Plan. Between February 2020 and April 2021, the proportion of GP appointments recorded as taking place over the phone rose from just 14% to 41%.[11] For some patients, this was clearly beneficial, with e-triage allowing them to access services without having to travel to their GP practice. Cancer Research UK’s Cancer Awareness Measure survey of UK adults in September 2021 found that 69% of 18-34 year olds who had experienced a remote consultation in the last 6 months[1] agreed with the statement ‘Remote GP consultations are more convenient for me compared with attending face to face’.[12]

However, just 37% of those aged 55+ agreed with the statement, suggesting that there are also potential risks for some groups that must be recognised and managed. For example, remote consultations could create barriers for certain demographics – such as older patients, people with lower digital literacy, people for which English is not a first language and more deprived groups who may lack access to technology. It is important that steps are taken to ensure that health inequalities are not exacerbated by the increased provision of remote consultations.

CRUK’s health professionals have also raised that when patients have difficulty accessing general practice, it can result in a loss of confidence in their GP, which may be difficult to regain.

In 2017, over six in ten cancer patients were diagnosed via a referral from a GP,[13] therefore timely access to primary care is vital to ensure cancers are diagnosed as quickly as possible. When accessing primary care, patient choice over their preferred method of appointment is essential as part of a patient-orientated healthcare model. The appointment format may have negative implications for people with cancer.

GPs have raised concerns with CRUK that remote consultations make it much harder to use their professional judgement when assessing a patient; it’s harder in some formats to properly examine a patient or read body language, for example. This could create particular challenges for some cancers where a physical examination is an important part of decision-making. Remote formats may also preclude or delay the option of conducting point of care testing, such as urine testing for microscopic haematuria (traces of unseen blood in wee), which could compromise the diagnosis of cancer and other diseases.

Moving from a clinical assessment lens to one of intervention delivery, this may also be more difficult in remote consultations, especially for some groups. [14],[15],[16],[17],[18],[19],[20] For example, a June 2021 survey of UK GPs commissioned by Cancer Research UK (CRUK) found that during the pandemic and the rapid shift to remote consultations, 40% of GPs surveyed net agreed that it was more challenging to deliver Very Brief Advice (VBA) for smoking cessation through remote consultation compared to face to face.[21] In addition, 80% of GPs surveyed found it significantly more or slightly more challenging to engage patients on smoking cessation whose first language is not English in remote consultations and 57% found it significantly more or slightly more challenging to engage patients from a lower socioeconomic group.[22] This highlights that, with remote consultations set to continue, more needs to be done to support access for these groups.

It is also important to consider the impact of a sustained shift to remote consultations on primary care teams themselves. There may be benefits for some primary care staff, including greater flexibility to work from home. But GPs and wider teams need to have access to the technology, tools, training, guidance and support that will allow them to make best use in routinely using digital tools in their practice. A recent RCGP survey has found that four in five GPs want more training and more guidance in order to get the most out of remote consultations.[23] More research is also needed to understand the impact a shift to a ‘digital first’ approach in primary care will have on the workload faced by those working in primary care. There is early evidence to suggest that it will increase general practice workload, unless consultations are shorter, and a higher proportion of patients are managed without subsequent consultation than observed in most published studies.[24]

3. 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?

Patient value GP continuity of care highly[25]. There is limited research into the importance of continuity of care in the context of cancer diagnosis. In theory, GP/patient familiarity might be a facilitator of cancer diagnosis where it allows a GP to spot changes to a patient’s appearance, behaviour or health status, but familiarity and overfamiliarity may also mean changes and new diagnoses are overlooked[26]. Indeed, there can be occasions in cancer diagnosis where unfamiliarity between patient and GP is helpful, bringing about a disruption to the status quo of how a patient is being managed, prompting a re-appraisal of approach and a diagnosis sooner than may otherwise have been the case. It is important for GPs to be alert to the risk of cancer in all of their patients.

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

The most significant challenge facing general practice in the next five years will continue to be a lack of capacity, caused by significant shortages in the primary care workforce. Unless addressed, it will continue to compromise patient access to primary care, as outlined earlier in this response.

The emerging long-term effects of the pandemic have the potential to compound these workforce challenges by reducing the capacity of the existing workforce, while increasing demand. COVID-19 has a damaging impact on the wellbeing of staff in primary care, risking higher levels of attrition and capacity deteriorating even further. A significant increase in the number of GPs leaving the profession – for example, a trend of earlier retirement – will harm patients as there will be a lack of appropriately skilled GPs to replace them.

Moreover, the pandemic is likely to lead to increased demand for primary care in the coming years. This is for a number of reasons, including the patient backlog that accumulated during the first wave of COVID-19, the presentation of more complex conditions due to delays, Long COVID prevalence and the impact of new modes of consultation and appointment systems.

Demographic factors are also likely to present a challenge in primary care over the next five years. England has a growing and ageing population. The BMA recently reported that by 2043, at least one in four adults in England will be aged 65 or over, while the number of people aged 85 years or over will have nearly doubled, from 1.6 million in mid-2018 to 3 million.[27] Older people are more likely to develop cancer, with half of all cancers in people over the age of 70[28], and are more likely to have complex care needs as a result of co-morbidities. This is likely to increase demand on an already stretched primary care workforce as well as make the process of diagnosing and treating cancer more complex.

Preventable risk factors for non-communicable diseases, such as smoking and obesity, increase pressures on general practice and will continue to do so in the next five years. Smoking remains the largest cause of cancer and preventable death in the UK[29],[30] and is associated with a range of other diseases.[31],[32] Smoking also costs the NHS alone £2.4 billion a year,[33] which translates to a sizeable burden on general practice, with people who smoke seeing their GP 35% more than those who don’t.[34]

Overweight and obesity is the second biggest cause of cancer in the UK[35], and obesity prevalence has been increasing since the early 1990s.[36] In England, two thirds of adults and 41% of children finishing primary school are overweight or obese.[37],[38] Furthermore, children who are obese are around five times more likely to be obese in adulthood[39] and obese adults are at greater risk of cancer, morbidity, disability and premature death.[40],[41] This may result in increased pressure on primary care in the future as this translates to preventable disease. General practice could also face an increasing financial burden as a result of increasing obesity rates. Obesity-related ill health already costs the NHS around £6 billion per year.[42] This will only be exacerbated as prevalence increases – further demonstrating the need, as set out earlier in this submission, to expand capacity in general practice.

Considering challenges facing primary care and the topic of sustainability of general practice in the longer term, needs to be examined with a longer-term lens on what the future of general practice could and should look like in order to deliver optimal experience and outcomes. This includes ensuring patients have timely and equitable access and can achieve as quick a resolution to their situation as possible, which could prompt renewed consideration of if and when patient ‘self-referral’ for tests or specialist advice might be appropriate. Moreover, research has, and will continue to, yield innovations and developments that can add value to clinical practice and patient care, raising critical questions about the best models for their delivery. Coordinated research and evaluation across public and third sector funders would be valuable, to inform the future direction of general practice and the health service more widely.

5. What part should general practice play in the prevention agenda?

General practice has an essential role to play in the prevention agenda as it is often the first point of contact between patients and the health system. It can therefore intervene before patients develop serious disease linked to preventable risk factors. Preventable disease and mortality continue to have a massive impact on our nation’s health and health services, and this has only come into sharper focus since the emergence of COVID-19. By helping patients maintain healthier habits, general practice can help reduce health inequalities and improve population resilience and outcomes.

Tobacco

Smoking remains the largest cause of preventable death in the UK. [43],[44] Due to higher rates of smoking among the most deprived,[45],[46] smoking is also one of the leading causes of socioeconomic health inequalities, [47] and accounts for approximately half of the difference in life expectancy between the lowest and highest income groups in England.[48] CRUK modelling estimates that there are nearly twice as many smoking-attributable cancer cases in the most deprived group compared to the least deprived in England.[49]

The important role that general practice plays in helping people to stop smoking was demonstrated by a recent CRUK report which modelled the impact of improving the delivery of smoking cessation support in primary care on different socioeconomic groups. This found that improved delivery would result in substantial additional declines in smoking prevalence across all socioeconomic groups. In addition, given the greater number of people who smoke in the lower socioeconomic group, improving delivery of smoking cessation support would see the greatest number of people quitting from this group.[50]

Figure sourced from Making Conversations Count for All: Benefits of improving delivery of smoking cessation interventions for different socioeconomic groups. UK-wide analysis.

To reduce the burden of smoking, it is important that the role of primary care professionals in smoking cessation is stressed and supported. Per the updated NICE guidelines,[51] all frontline healthcare staff, including GPs, should be trained to deliver VBA given its effectiveness in motivating people to quit.[52]

Unfortunately, a 2020 CRUK survey of Health Professionals identified that 19% of GPs disagreed with the statement ‘It's part of my role to encourage people who smoke to make a quit attempt’.[53] In addition, many healthcare professionals across the NHS are not receiving adequate training in, and regularly delivering, smoking cessation interventions.[54] Research from Asthma UK and the British Lung Foundation shows that over half of UK GPs have received no training in VBA and of those that did, only 2% said the training was comprehensive.[55] A 2019 study by CRUK also found that only 53% of GPs and practice nurses frequently completed all steps of VBA with people who smoke.[56] General practice staff must be supported and encouraged to regularly deliver VBA to patients.

It is important that primary care know where the stop smoking services are in their areas and remain up to date in how their patients can access them. Where no local services are available, primary care can discuss alternative options that may be available to support patient to stop smoking including e-cigarettes and local pharmacy provision. Primary care also has an opportunity through PCNs to influence Integrated Care Systems to commission stop smoking services where they are not currently available.

It is also important to make sure that there is a clear and consistent pathway for patients who have received stop smoking interventions in secondary care to ensure that they continue to receive support to quit in the community with no interruptions. This requires good communication between primary and secondary care, smoking status records to be kept up to date, and the need for any ongoing prescriptions to be noted.[57]

Obesity

Overweight and obesity is the second biggest cause of cancer[58] and obesity prevalence has been increasing since the early 1990s.[59] General practice has an important role in helping people manage their weight, as this may not only reduce individuals’ risk of developing cancer, but it may also help alleviate future pressure on the NHS from obesity-related diseases. Some components of weight loss interventions also have a direct beneficial effect on cancer risk, such as eating a healthy balanced diet and being more physically active. 

Although the best evidence for long-term weight loss comes from surgical interventions,[60] these are not appropriate for everyone and the best evidence for weight loss outside of surgery comes from clinical interventions, such as weight management programmes (tier 2 and tier 3).[61], [62] Overall, evidence on non-surgical interventions for weight loss suggests that behavioural support is the most important factor, and should be combined with diet and exercise modifications. However, tier 2 and 3 services are not universally available across the country. Weight management services should be readily available and accessible, and health professionals should be supported to refer patients to these services – particularly those from more deprived backgrounds who face a disproportionate burden.

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

There is regional variation in the prevalence of behaviours – such as smoking and obesity - that increase people’s risk of developing cancer. For example, in Richmond upon Thames, only 6.2% of the adult population smoked in 2020, compared to 19.8% in Blackpool.[63] Accordingly, people living in socioeconomically deprived areas have higher levels of health need.

In addition, areas of high deprivation also face significant challenges with lower GP staffing levels and high GP turnover.[64],[65] In the 2021 GP patient survey, people from more deprived areas were less likely to report their needs being met, had a poorer overall experience and a worse experience of making an appointment.[66] These challenges will likely put additional pressure on staff who continue to work in these areas. Strategic investment and impactful policy to address the imbalance between need and capacity/access are much needed[67] and vital to addressing the inverse care law.

There is also regional variation in the interventions that GPs can offer their patients. For example, GPs play an important role in offering support to stop smoking through prescribed medication. However, not all pharmacotherapies are universally available in primary care settings. In some local health communities, GPs are restricted on what they can prescribe, as certain stop-smoking pharmacotherapies are excluded from local formularies.[68]

Moreover, cuts to the public health grant since 2015/16 to 2021/22 has resulted in key prevention services, such as stop smoking services and alcohol treatment services, being cut.[69],[70] These prevention services can support and, in some cases, alleviate pressure on general practice yet they are not universally available for GPs to refer patients to. Furthermore, poor health is strongly associated with socioeconomic deprivation, yet cuts to the public health grant have been greatest in more deprived areas.[71] This will likely result in general practice seeing an increase burden and strain on their services in these areas.

About Cancer Research UK (CRUK)

Cancer Research UK (CRUK) is the world’s largest cancer charity dedicated to saving lives through research. We support research into over 200 types of cancer, and our vision is to bring forward the day when all cancers are cured. Our long-term investment in state-of-the-art facilities has helped to create a thriving network of research at 90 laboratories and institutions in more than 40 towns and cities across the UK supporting the work of over 4,000 scientists, doctors and nurses. In 2020/21, Cancer Research UK invested £421 million on new and ongoing research projects into the causes and treatments for cancer.

Produced by the Policy, Information and Communications Directorate at Cancer Research UK. For more information please contact Abigail Lever, Westminster Public Affairs Officer, at Abigail.lever@cancer.org.uk.

References

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