Written evidence submitted by The Nuffield Trust (FGP0349)

The Nuffield Trust is an independent health think tank. We aim to improve the quality of health care in the UK by providing evidence-based research and policy analysis and informing and generating debate. We welcome the Committee’s decision to hold an inquiry into general practice, which holds a pivotal role in the English NHS yet has come under ever increasing strain before and during the Covid-19 pandemic. This submission looks at where these pressures and difficulties come from; how general practice can survive and provide as much value to patients and the NHS as possible; and what policymakers can do to support this.

Key points

 

1. Issues facing general practice today and in the coming years

 

General practice has come under increasing stress in the last several years. At the core of this trend is a failure to secure enough GPs for the increase in what has been asked of them. Other, related developments are also important to recognise.

 

1.1 Underlying mismatch between staffing and the demand for care

Over the last decade, the number of general practitioners has grown more slowly than other doctors, more slowly than the NHS budget, and often more slowly than the UK population itself. In 2016 NHS England’s GP Forward View noted that the numbers of GPs had been growing a third as fast as hospital doctors and that this was linked to rising workload, and promised an increase of 5,000 in the next five years.[1] However, this did not happen. The number of full-time equivalent GPs in England has fallen slightly.

 

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The 2019 Conservative Party Manifesto contains a commitment to increase doctors in general practice by 6000 by 2024/25 (possibly including registrars).[2] It remains unclear so far that this has been any more successful. Throughout this period, multiple analyses have suggested that demand or need for the health service has risen at 3% to 5% each year.[3] [4] This suggests a steadily and quite rapidly growing gap. The failure to increase GP numbers reflects both a failure to meet training targets, especially in the first half of the previous decade, and increases in early retirement which may be themselves partly influenced by the pressure and stress of understaffing.[5]

 

Reflecting this, until the Covid-19 pandemic the GP Patient Survey showed steadily worsening access to appointments and steadily worsening levels of patient satisfaction – albeit from a very good starting point. The proportion of patients reporting a good experience overall fell from 88% in 2012 to 85% in 2017, and then, after a data change, to 82% in 2020.[6] Remarkably, it then actually improved to 83% this year: other measures in the patient survey also show stabilization or improvement during Covid-19.

 

Over the last decade, given these trends, recruiting other staff groups has become an increasing priority in order to try to absorb workload. While this has seen more progress than for general practitioners, a target for other qualified health professionals was also missed.

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Shortages are not spread evenly across England. Deprived areas tend to have fewer practitioners per person, perhaps reflecting the ability of doctors to choose where they work in a context of overall shortage. Given that deprived areas typically have worse health outcomes and higher need, this long-standing paradox has been called the “inverse care law”.[7]

 

1.2. Risks for the future

The underlying reality of a mismatch between GPs and the care they are asked to provide runs alongside or causes several other problems, and profound underlying shifts away from the way general practice has worked for most of the history of the NHS.

 

As the Committee notes, the traditional model of a partnership run as a small business by one or more senior doctors who also hold full ownership is under pressure. This partly reflects a cultural shift among younger doctors away from this kind of investment and risk.

 

The various core contracts which GPs hold with the NHS – GMS, PMS, and APMS – specify relatively little about what is to be delivered, and are increasingly heavily supplemented by fees paid by the NHS for specific services, which tend to take first priority. The shift of out-of-hours services away from practices following the 2004 GP contract fragments patient interactions into multiple different providers at the front door of the health service. Competitive digital-first providers such as Bablyon and Livi have pulled younger and healthier patients towards alternatives, either within the NHS or on a private fee-for-service model.

 

Particularly during the pandemic, wider use of technology has reshaped the way patients interact with practices. At the same time, buildings and land owned by practices are in many cases unsuited for the new models being proposed or to reform the way care is provided.

 

The immediate post-pandemic situation may involve added challenges of burnout; of resentment from some patients over periods of shifted priorities like the current redeployment towards booster vaccines; and even of litigation risk over decisions during the pandemic.

 

2. How can general practice survive and help as many patients as possible?

  

For the next few years general practice will continue to struggle to do all the NHS or patients ask of it. It is vital to choose an approach which maximises how much value it can deliver given these constraints. We proposal four principles based on existing[8] and ongoing research.

  

2.1. Good access is not the same as rapid access  

 

The mismatch between demand for appointments, and capacity in the GP workforce to meet this demand, is one of the biggest current challenges. With limited supply of care there is a risk that triage arrangements and pressure to provide rapid access for new illnesses – even those which might resolve on their own – will crowd out access for severe problemsRapid access needs to be reserved for those with the highest clinical acuity, instead of encouraging GP practices to see all patients as soon as possible.

 

The shift to phone or online triage driven by the pandemic has strengths and weaknesses and is not yet working well enough. Current triage systems and pressure for same day access blur the boundary between sorting and prioritising appointment requests and full consultations. The rapid and transactional nature of triage works well for directing simple clinical problems. But for people with complex or undifferentiated symptoms, it risks simply adding one more stage to what may be a long journey through the NHS system. Some evidence challenges the assumption that telephone triage reduces workload, with one study finding that it can result on average in an 8% increased workload for GPS.[9] It may change the threshold for patients to get in touch, effectively increasing demand.

Much of the work of general practice does not require same-day access, but policy is continuing to push for this as a priority. 

Data held by NHS digital extracted from GP practices makes it difficult to disentangle triage from consultations, and better data on GP is urgently needed to inform policy solutions. Rapid evaluation of initiatives - potentially including basic biometric information gathered through pharmacists or other local settings – would also help us learn how to make triage work.

Recommendations:  Policy needs to focus getting people access to the care they need, not just on the fastest possible access. Triage systems need to be carefully monitored to make sure they add value, rather than just adding an extra stage.

2.2. Different health problems require different approaches   

 

The ‘functions’ of general practice encompass several different types of activity that need to be supported in different ways.  Some require standardised input (e.g. smears/immunisations); some require a single, short, transactional encounter (e.g. acute tonsillitis); some require coordination, advocacy and collaboration with other professionals (multi-morbidity, end of life); and some requires ongoing assessment and interpretation of symptoms and holistic assessment (undifferentiated and complex needs). 

 

Much of this work does not need fast access to on-the-day appointments and could be managed by other providers such as community pharmacists or by patients themselves. Recent policy about rapid access has increased patient expectations to be seen on the day, using scarce capacity for minor illnesses rather than more serious conditions.

 

For patients with acute illness requiring clinical examination, there is scope to develop rapid access clinics accessible to all patients, delivered by teams including paramedics, nurses and others. This can then free up GPs’ time to manage severe and complex illness. Examples of such teams organised across a cluster of practices or a Primary Care Network demonstrate how working at larger scale can tailor care to individual clinical need with GP supervision and ample peer support.

 

However, entirely splitting off rapid access from the other functions of general practice risks failing to recognise that the same patient may move between these different types of clinical need in unpredictable ways. Practices need ways to identify in advance when needs will changeA cluster of practices around the country, such as the Foundary Practice in Lewes, are working in this way, adapting the style of care and the staff who provide it in response to whether a patient has simple or complex clinical needs at the time. In doing so, they provide rapid access for acute problem and preserve continuity for patients with complex or undifferentiated symptoms. Evidence suggest this can reduce missed and delayed diagnosis, repeat investigations and hospital referrals

 

This raises questions about what is the best organisational form, service design and incentives for general practice to deliver this broad array of ‘functions’. 

 

Recommendations: The future model of general practice should avoid separating acute and transactional care from the other forms of care GPs provide. It should learn from practices and organisations which successfully combine both approaches.  Policymakers need to avoid building an expectation among patients that on-the-day appointments are the answer for minor illness, and demonstrate that they can be supported to care for themselves and take advice from pharmacists.

 

2.3. No group of patients should be left behind 

 

To reduce the risk of digital exclusion widening inequalities in access, we must ensure everyone can access GP services on an equal footing – with policy makers re-emphasising this as a key priority for the NHS. 

 

Online booking and e-consultations are welcomed by and work well for some patients - younger, affluent, or living with mobility problems. But shifting primary care online can make accessing care more difficult for others – often those who are less well and already materially disadvantaged.   Flexible access routes, in person and by phone, are needed for many groups, including those with learning disabilities, dementia, sensory & communication difficulties and autism, and homeless people.

 

Recommendations: Making access easier for people who are more likely to be healthy increases health inequality.  To avoid widening inequalities and avoid a new ‘digital inverse care law’, practices must provide multiple ways to book appointments and access services, co-designed with patients, with online access as an option rather than the ‘default’ expectation.

 

2.4. General practice reduces demand for the wider NHS through several different roles.  

 

At the heart of work in general practice sits a generalist model of care: two essential characteristics of which include the ability of GPs to manage uncertainty and hold risk in the community, and to provide continuity of care over time.  Where continuity of care is provided for complex ongoing problems there is evidence for better outcomes, greater patient satisfaction and lower use of wider NHS services.[10] [11]

 

General practice also reduces demand for the wider NHS through:

 

The current policy focus on rapid access to reduce A&E attendance and shift to more transactional care risks undermining some of these. It risks replicating the function of other parts of the NHS (A&E) at the expense of holding on to the real contributions of general practice and the generalist model of care above to the NHS as a wider system and to population health.

  

Recommendations: Preserving the role of general practice in moderating demand for wider NHS services needs both improved access for acute problems, and improved and better targeted continuity of care for people with complex and long-term problems. Future policy should aim to combine both approaches, without splitting them into separate organisations.

 

3. Policies to support positive change

Even with general practice in a chronic state of low capacity relative to need, matching the right care to the right patient and retaining core capacity can allow more value to be provided to patients. Policymakers will need to use the levers at their disposal carefully to help find solutions.

 

3.1. Objectives

In the difficult task of prioritising what general practice can do, the Government’s approach needs to balance several important objectives which at times are overlooked:

 

3.2. Flexibility of organisational form

Using teams of different professionals, and data to reallocate patients who need different types of general practice care, will often be easier with larger organisational forms. However, this should not be forced as a one-size-fits-all approach given the variation across the country. The way that Government and the NHS commission, instruct, and work with general practice should reflect this.

 

Primary care networks (PCNs) – local groupings covering around 50,000 patients – appear to be large enough for the supervision and peer support needed to hire and train new staff types. They also have the potential to serve as the units of collaboration with other services such as NHS trusts and social care. However, they are probably too small to house the IT, HR and training infrastructure and buildings. This may be a role for larger networks or federations. These could take different forms and do not necessarily mean the loss or merger of an independent small business model.

 

PCNs could serve as the unit of organisation for extended rapid access that is fully integrated with other types of GP care.

 

3.3. Accelerate the pace of learning

Increased use of technology at every stage has greatly increased the information available and should enable general practice to rapidly learn from what does and does not work. This should enable positive lessons to be drawn from variation between practices, and local innovations that work to be expanded and rolled out more widely.

 

In order to enable this policymakers should consider:

 

3.4. Role of the GP contract  

The core GP contract and pays a rate per person based on local needs for the delivery of the core functions of general practice. It is increasingly supplemented by different forms of payments that GPs can achieve for meeting care quality standards (the Quality Outcomes Framework) and providing specific services, from minor surgery to health checks and even Covid-19 vaccinations.

 

In its current form, from 2015, the contract is probably not specific enough about what GPs should deliver in their core roles. There is room to add more standards. There is a perverse incentive for practices to focus on the additional services and processes rewarded by extra money first.

 

However, although the functions and standards expected could be more codified, it is important to resits the urge to over-specify the methods or the shape or governance of organisations. Space for innovation needs to be protected. Diversity and experimentation are important strengths of general practice as a sector, and are needed to provide lessons as to better ways to work.

Dec 2021

 


[1] https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf

[2] https://www.conservatives.com/our-plan

[3] https://www.england.nhs.uk/wp-content/uploads/2016/05/fyfv-tech-note-090516.pdf

[4] https://www.health.org.uk/news-and-comment/news/cost-pressures-on-the-nhs-will-only-grow-it-needs-a-long-term-funding-solution-and-that-is

[5] https://www.nuffieldtrust.org.uk/news-item/is-the-number-of-gps-falling-across-the-uk

[6] https://www.nuffieldtrust.org.uk/chart/how-has-patients-overall-experience-of-their-gp-practice-changed-over-time-1

[7] https://www.nuffieldtrust.org.uk/news-item/poor-areas-left-behind-on-standards-of-gp-care-research-reveals

[8] https://www.nuffieldtrust.org.uk/research/delivering-general-practice-with-too-few-gps

[9] Newbould J, Abel G, Ball S, Corbett J, Elliott M, Exley J et al. Evaluation of telephone first approach to demand management in English general practice: observational study BMJ 2017; 358 :j4197 doi:10.1136/bmj.j4197 https://www.bmj.com/content/358/bmj.j4197

[10] Gray D P, Freeman G, Johns C, Roland M. Covid 19: a fork in the road for general practice BMJ 2020; 370 :m3709 doi:10.1136/bmj.m3709 https://www.bmj.com/content/370/bmj.m3709

[11] https://www.nuffieldtrust.org.uk/files/2019-01/improving-access-and-continuity-in-general-practice-evidence-review-final-update-01-2019.pdf

 

[12] Atherton H, Brant H, Ziebland S, et al. Collection and analysis of routine consultation data (Chapter 6) in The potential of alternatives to face-to-face consultation in general practice, and the impact on different patient groups: a mixed-methods case study. Southampton (UK): NIHR Journals Library, 2018