This blog is part of a series called ‘Fact or fiction?’, where experts from the Nuffield Trust give their take on the data and evidence behind some of the current perceptions of what is happening with the NHS.
Headlines and stories about the ‘crisis’ in general practice have become commonplace over the last year or so. A demoralised and squeezed workforce is struggling to meet the needs of increasing numbers of patients demanding immediate appointments. Or so the narrative goes.
There are mounting concerns that patients unable to get an appointment with their GP are putting pressure on other parts of the system (largely A&E), which are unable to cope.
A well-functioning primary care sector should play a central role in a country’s health system: keeping people well, offering diagnosis and treatment, managing long-term conditions, and making sure only those who need more specialist care are directed to the hospital doors.
But, how true is it that general practice is now so stretched that it is unable to meet demand from patients for appointments?
What we know
Understanding pressures on general practice is a complex business. Data suggest that patients are finding it increasingly difficult to get appointments – the number of people who have failed to get an appointment has climbed slightly from 9 to 11 per cent since 2011/12 , which suggests that there is some growth in unmet demand. What is not clear is what volume of activity is actually taking place in general practice or how that has changed over recent years.
It is estimated that 90 per cent of all NHS contacts take place in primary care. In 2013, the number of consultations in general practice climbed to 340 million –a rise of 13 per cent since 2008. But these figures are estimates arrived at by extrapolating activity based on trends in a sample of practices over the previous decade. Whilst such extrapolation can be helpful, it assumes that there is no change in the role of general practice and the way in which practice teams deliver services.
In sharp contrast to the hospital sector – where monthly publicly-available figures tell us exactly how many people were treated, for what conditions, and how long they stayed – levels of activity in general practice remain something of a ‘black box’. Although GP data are collected for the purposes of the Quality and Outcomes Framework (QoF), there is no national repository or routine public reporting of GP activity data. This makes it difficult to get a handle on what is happening in general practice and what exactly is causing the well-documented feeling of increasing pressure within this part of primary care.
To illuminate the ‘black box’, the Nuffield Trust has analysed a subset of GP practice data held by CPRD. Taken from 337 practices in England between 2010/11 and 2013/14, the sample covers over 3.2 million registered patients. Although the dataset is large, there are several health warnings to be heeded. Coding discrepancies and a lack of clarity over how some patient contacts are recorded by different practices make it difficult to analyse the data. Without accessing the addresses of practices in order to adjust for local contextual factors, it is not possible to establish the representativeness of the data, so we have some doubts about how far the sample can be ‘scaled-up’ to give an accurate picture of national trends. However, while we are cautious about exact numbers, the data is the most extensive on which any published work has been based since 2009.
What do the data show?
Activity in the sample of general practices increased since 2010. The total number of consultations rose by around 11 per cent and the number of consultations per person per year registered on a practice list also rose – from 7.6 to 8.3. This is in line with what we would expect from trends over the previous decade .
However, when the data are further broken down, we start to see some interesting patterns.
While activity in general practice has increased, most of that increase is amongst staff groups other than GPs. Consultations with GPs rose by approximately 2 per cent, whereas consultations with nurses rose by 8 per cent and consultations with ‘other’ staff (a long list of professionals including pharmacists, physiotherapists, and speech therapists) grew by 18 per cent.
If these trends are indicative of a wider national pattern, it seems that there has been a relatively modest rise in recording of direct consultations with GPs. So what could explain the sense of rising pressure and crisis among GPs?
Are there fewer GPs doing the same work? Government bodies are certainly concerned about too few medical students choosing general practice , and there has been a rise in the number of practising GPs who plan to leave the profession . However, the full-time equivalent GP workforce (excluding registrars and retainers) over the period in question has not shrunk, but grown by 2.3 per cent – around the same rate as the number of consultations.
Could it be that the nature of consultations is changing? GP colleagues report that patients are presenting with increasingly complex needs. Indeed, we are living longer and the number of us with multiple long-term conditions continues to rise . It is, therefore, likely that there has been a rise in the complexity of patients who require longer and more in-depth consultations, although there has been no research into whether this is the case.
Might the pressure on GPs be coming from non-direct clinical and administrative work, and not patient demand? The time spent on Clinical Commissioning Group activities is estimated to range from an average of 11 hours per week for a locality lead up to 24 hours per week for a clinical chair . Although that time is funded and back-filled, our recent publication reports that GPs are struggling to find the time undertake their role effectively .
A national survey of GPs in 2013 reported the highest levels of stress amongst GPs since the survey began in 1998, the primary causes of stress being ‘increasing workloads’ and ‘paperwork’ . Whilst revalidation and CQC inspection may play a small contributing role, GPs tell us that this increase in paperwork is actually a result of changes in other parts of the health and social care system.
Anecdotally, GPs report that much of this non-direct patient work involves chasing hospitals for results and outcomes – something that has become increasingly onerous as patient choice and new entrants into the market mean there are more providers to coordinate. In addition, the block on consultant-to-consultant referrals means that every referral must now go back to the GP. Furthermore, in an attempt to better control tightening budgets, some local authorities have stopped self-referrals for certain services, requiring instead a GP referral. GPs also report rising demand for their input into such processes as Disability Living Allowance (DLA) appeals, Blue Badge applications, school sick notes and insurance reports.
Fact or fiction?
What is clear is that there is a sense among GPs of rising and unsustainable workloads. What is not clear is exactly where that pressure is coming from.
Our analysis provides some insight into what has happened to consultation trends since the last formal publication of estimates in 2009, showing that the largest increases appear to be for nurses and staff other than GPs. That raises questions about the assumption that a rapidly rising number of consultations is driving pressure on GPs.
Whilst our analysis throws some light on general trends, what it cannot illuminate is specific changes in activity that could help understand in detail the pressures felt by GPs. Neither can it tell us the extent to which other non-direct clinical and administrative demands and the changing nature of consultations are putting pressure on the workforce.
What is needed are more systematic and nuanced ways of looking at GP activity through combining data across practices to enable accurate assessment of real trends. Availability of such data would also allow for full and transparent scrutiny of what is, after all, a publicly funded service. Until a general practice data warehouse is available, all we can generate are broad estimates that do little to properly inform what has become an area heavy on assertions but rather thin on facts.
Fact or fiction?
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