Why Has Life in General Practice Become So Difficult?
Working in and around general practice and primary care means that I am frequently party to conversations about how difficult life in general practice has become and what makes it so. I am regularly asked to help practices with specific issues but I am also called in to support those that have simply not kept up with the requirements of modern general practice and so have fallen behind and become vulnerable as a result. There are always negative people who see their glass as half empty and complain to you every time you’re in their company. However, I have not been in the company of any GPs lately who are across-the-board content with their lot no matter how successful their practices may or appear to be. I have always appreciated the daily expectations of a GP – going from patient consultations where immediate threats to life need to be detected and dealt with swiftly and effectively one minute to the weekly social visit from a lonely patient where the greatest risk might be “heart-sink” on the part of the GP. Walk out of the consultation room and there is always clinical admin and ad-hoc clinical decision-making and a business to be run as well as countless other expected and unexpected matters, the management of which will absorb vast amounts of already limited time – all in a working day (or a day off which, in my experience, GPs often use just to try and catch up). It seems that GPs are getting much more negative press these days– something that has never really happened before. Are they just unhappy with their lot and giving voice to their complaints – more work for less pay like so many others since the 2007/8 recession led to cuts in the public sector – or is general practice being pushed so far that there is a real danger of general practice extinction looming?
Understanding Pressures in General Practice
In May 2016, just as the General Practice Forward View was being published, the King’s Fund published its report entitled “Understanding pressures in general practice”. This comprehensive report makes for very interesting reading, in particular, because it was not influenced in any way by – or put together in response to – the General Practice Forward View. In addition, the report is based on both qualitative and quantitative data so the narrative and opinion of the subjects can, to a large extent, be validated. Some of the data were collected over a five year period (30 million patient contacts in 177 practices over five years collected by ResearchOne, the not-for-profit research arm of TPP, the supplier of the GP clinical system, SystmOne.
The report describes general practice in crisis at the time. There has not been sufficient growth in either funding or workforce to meet the substantially increased general practice workload and an almost total lack of nationally available real-time data kept the crisis in general practice hidden from commissioners and policy-makers. The report sets out how it occurred and what has been found as the reasons for the crisis.
Based on the data used for the study, it appears that the number of consultations grows by more than 15% in the five years from 2010/2011 to 2014/15. Face to face consultations grew by 13% and telephone consultations by a staggering 63%. However, the GP workforce grew by a mere 4.75% and the practice nurse workforce by only 2.85%. To make matters worse, primary care funding – as a proportion of the total NHS budget – fell each year of the five years studied from 8.3% down to circa 7.9%.
Existing general practice pressures arising from workforce and overall demand/capacity issues are being compounded by the more complex and intense workload caused in the main by an ageing population with multiple co-morbidities and advanced social care needs all of which require a significant amount of GP time which started off as a slow creep but is now racing towards a non-existent finishing line – or one that continues to move and is never likely to become fixed. More and more general practice patients have complex health needs that used to be treated and managed in hospital. The burden on general practice is further loaded by unrealistically high patient expectation which continues to rise.
GPs are retiring earlier than before as a result of the pressures of the increased, more challenging workload which extinguishes their desire to continue to work longer than they need to financially, altruistically or for their own personal satisfaction. The change in the tax laws on pensions that has significantly cut the lifetime allowance has also played a major part in many GPs’ retirement earlier than previously expected – or anticipated by the NHS. Not all GPs have retired completely – some have taken 24-hour retirement and then reduced to part-time sessional or locum jobs or simply pursued other non-clinical, business development or managerial healthcare roles both within the NHS and outside.
Recruiting and retaining GPs is becoming more and more difficult with, in total, less and less GPs replacing those who have retired or simply left general practice. As mentioned above, this amount of GP workforce deficit was never anticipated and, therefore, no remedial plans were developed.
A large number of relatively recently retiring GPs have been full-time equivalents as well as partners in practices (the generally received wisdom here being that partners represent better value and put as much resource in as they take out in drawings) and their respective departures have left large gaps – which many practices have found extremely hard to fill – which has been very destabilising for general practice individually and as a whole.
Many GPs these days are choosing part-time salaried roles often as part of a portfolio career. Fewer and fewer GPs are willing to take on partnerships with all the accompanying clinical and business responsibilities and expectations of partners and staff.
Practice nurses and practice managers are equally difficult to find and hard to retain so, no matter how hard GPs may want to develop professionally and clinically and widen their operating model to take advantage of effective skill mix, they are often unable to achieve this without the people and roles these developments require.
Year upon year surveys demonstrate high public satisfaction with general practice: in general, people like general practice. The annual British Social Attitudes survey consistently finds general practice to be the most popular part of the NHS. However, the effect of the rising pressures on general practice means people are finding it increasingly hard to get an appointment with their own – or any – GP and satisfaction levels with general practice – while they remain high relatively – dropped from 77% in 2010 down to 71% in 2014 only five years later. The 2015-16 survey continued to observe the fall – down to 69%. The NHS GP patient survey supports these trends, demonstrating high levels of satisfaction relating to the overall experience of general practice with marked individual decreases in satisfaction for access and continuity which is no surprise in light of the growing logistical difficulties GPs are experiencing.
It was in response to the increasing concerns about general practice that NHS England published the General Practice Forward View which set out immediate actions to provide support and help create resilience. However, without up-do-date, informative and reliable centrally collected general practice data there is no way to accurately determine the causes of the pressures on general practice. Irrespective of this major issue, the data analysis in the King’s Fund report highlights changes in activity which may well account for the real feeling that general practice continues to be gripped by a crisis for which there is no quick fix.
The King’s Fund report concludes with “Prescription for the future?” which summarises the findings and sets out a number of proposals and ideas from understanding data at a system level, through new models of general practice and developing and sustaining a workforce for the future to ensuring capacity and funding match changing workload. Reading the report as 2017 draws to a close – eighteen months after it saw the light – it is clear the General Practice Forward View and the high-level wrap-around strategy and plans (eg STPs and the Five Year Forward View) are meant to drive a good deal of the King’s Fund’s prescribed items. It has yet to be seen, however, whether or not the treatment is beginning to work and the patient is responding accordingly.