GP services - are we at a breaking point?
Public satisfaction with GP services has dropped to its lowest level in 35 years. It has been steadily falling since 2009 and one of the largest reasons has been the difficulty and time taken in obtaining GP appointments. Patients have first hand experience of the NHS struggling to cope with rising demand. Despite many warnings about GP recruitment and understaffing across the NHS, lack of progress means that the capacity gap remains the biggest challenge facing the NHS.
Source: The King's Fund
Patients in England are now waiting an average of 13 days for a routine GP appointment. There is increasing difficulty getting through to their surgery on the phone and less patients are able to get an appointment, especially to see someone specific. British Medical Association analysis revealed 6.5% less patients reported a positive experience with getting a GP appointment in 2017 compared with 2012.
The King’s Fund report a drop in public satisfaction of 6% in just the last year. They conclude that this is unsurprising given the rising numbers of patients with chronic conditions and complex needs. They also state: “The situation is exacerbated by a workforce crisis: more GPs and other primary care staff are needed, but GP numbers at the end of 2017 were lower than in 2015.”
By the end of 2017, the number of patients registered at GP practices rose to over 58.9 million. This is a 2.3 million increase since 2013 according to NHS Digital.
Through data collection, NHS Support Federation have established the number of GPs available compared to the number of GPs needed across England. Every STP area in the country are short of the numbers of GPs needed to sustain the number of patients, with some regions being up to 43% short (Milton Keynes, Bedfordshire and Luton).
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Many GPs believe that the increased workload is affecting safety. BMA guidelines suggest that daily face to face consultations between GPs and patients should be below 25 a day for sustainable activity, comparably to standards in other European countries.
However, a Pulse survey in early 2018 revealed that GPs in the UK have on average 41.5 patient consultations every day. This is 60% higher than the number generally considered to be safe.
There was a recent analysis on 100 million NHS primary care consultations, led by a team at Nuffield Department of Primary Care Health Sciences between 2007 and 2014. It showed there were substantial increases in both the numbers of consultations being requested by patients and increasing lengths of consultations.
Alongside demand increases, the complexity of patients health is rising. 10% more patients over 50 have more than one long-term health condition. NHS England describes this as one of the greatest challenges facing the service today and GPs are at the frontline in dealing with it.
The pressure is leaving some parts of the service at breaking point, with many GPs leaving their job or retiring early, according to a BMA survey of 2000 practices.
NHS digital data confirms that GPs are leaving faster than they can be replaced. There was a net reduction of 1252 full-time equivalent GPs as of March 2017. NHS England’s plan for primary care intends to boost the number of GPs by 5000 in the next few years.
Despite this pledge, latest official figures show that the number of full-time equivalent GPs fell by 1,340 between March 2016 and March 2018. Alongside this, figures show that around a third of GPs are over 50 years old whilst early retirements have doubled since the start of the decade.
This falling number of GPs is affecting practices ability to recruit GPs. Moreover, the visible stresses and pressures the GP service is under is making it less attractive to prospective medical students. General Medical Council data shows that the number of students specialising in General Practice across the country has nearly quartered since 2012.
New analysis by the BMA estimates that England is set to lose between 618 and 777 practices in the next 4 years. Whilst some of this may be the result of mergers, the BMA claims many would have been forced to merge or have closed as a result of the continued pressure on general practice.
These closures are a result of a decade of underinvestment. Even with GP Forward View funding, general practice is set to be £3.4bn short of the share of NHS funding it needs by 2020/21.
Commenting on the findings of the report, Dr Richard Vautrey, BMA GP committee chair, said: “Patients already face unacceptably long waits for appointments, and without urgent government action and significantly more investment this will only get worse as millions more are left without a practice and struggling to find a new one. As GPs face the mounting pressures of increased demand, unmanageable workloads and lack of resources, more and more are leaving the profession or handing back their contracts. At the same time, too many medical school graduates are seeing the situation unfold in general practice and understandably choosing other specialties.”
Moreover, a survey of GP practices revealed that a high percentage would consider or had temporarily suspended patient registration at their surgeries. Some even considered formal list closure due to increased demands. Practice closures over the last few years have seen more than a million patients displaced since 2013.
Source: BMA GP survey
Reduced job satisfaction
A research team from the University of Manchester carried out the 9th National Survey of GPs in 2017. 9 out of 10 respondents reported feeling considerably high pressure in their jobs due to increased workloads.
This increased pressure meant that 39% of the respondents reported that they were highly likely to quit direct patient care in the next 5 years. The reported number of GPs intending to quit has risen substantially from 19.4% in 2005 to 39% in 2017.
Dr Richard Vautrey, BMA GP Committee chair, said: '”We know that unmanageable and unsafe workload is the primary reason behind doctors leaving general practice, which is leading to serious issues including practices closing to new patients and other surgeries closing entirely. This workload pressure also means GPs are increasingly suffering from burnout and patients are being put at risk of unsafe care.”
A King’s Fund report has emphasised other problems contributing to the current pressures facing GPs: high levels of deprivation, a decline in self-management of minor illnesses, higher expectations, particularly of new services, and a fall in general practice funding.
Where does this leave us?
The Royal College of General Practitioners estimate that by 2022 there will be over 100 million incidents of a patient waiting a week or more to see a GP or practice nurse. More worryingly, the RCGP has suggested that the growing GP workload may affect patient safety. A BMA survey found that 93% of GP respondents reported that their workload had had negative effects on patient care.
GP services were long the highest achievers out of the NHS services for public satisfaction but since 2010 that has rapidly fallen. This highlights the dire situation the service is in from increased demands and years of underfunding leading to high stress levels and reduced workforce.
Source: The King's Fund
Falling satisfaction with the public is mirrored by GP themselves. Increasing numbers now suggest they wish to leave general practice in the near future. Stress levels associated with increasing workloads, having insufficient time to do the job justice, paperwork and changes to meet requirements from external bodies are all negatively impacting the service.
Dr Richard Vautrey, GPC deputy chair, said: “These figures clearly demonstrate that the crisis in general practice is getting worse, not better. GP practices across England are struggling to provide enough appointments because they do not have the GPs to see the sheer number of patients coming through the surgery door.”
The Health Secretary has finally admitted that the 5,000 new GPs by 2020 is unreachable. The Prime Minister has pledged to lay out a long-term funding plan for the NHS later in the year. The BMA and RCGP are calling for primary care to be a central part of that discussion.
Dr Richard Vautrey, commented: “General practice has been the foundation of the NHS for the last 70 years. It’s time the government takes urgent action to guarantee its future for the next 70 years and more.”