General practice on the brink: how did it get there?

A combination of increased demand, staff burnout and deteriorating patient experience are threatening the stability of general practice.   

Sitting at the heart of low public satisfaction with the NHS – now at a miserly 36% according to the recently published British Social Attitudes survey, the lowest level recorded in 25 years – is frustration with access to GP appointments. Two-thirds of people who were dissatisfied with the NHS said that this was due to waiting times for a GP or hospital appointment.  

This is not only a critical issue for patients, but a political headache too. As we await further detail on government proposals for the future of general practice, it seems the right moment to reflect on how these problems came about and what lessons can be learnt from them. 

Growing patient need

It’s important to first acknowledge that problems with access to GP appointments are not new, but Covid-19 has exacerbated an already difficult situation. Pressure on appointments in general practice was already a significant issue before the pandemic – driven in part by demographic changes that mean people are living longer, but with more years spent in poorer health and often with more than one long-term health condition (multimorbidity).

Added to this is the growing issue of workload pressure due to follow-up care transferred to GPs from hospital consultants. And with more than six million patients on elective surgery waiting lists, many of whom will be living with worsening symptoms and needing help from their GP, demand for appointments is rising inexorably.    

GPs in short supply

The lack of access to GP appointments is a manifestation of a much more intractable problem: the chronic shortage of GPs. 

Again, this is a well-known issue. Jeremy Hunt promised 5,000 more GPs for England, before Boris Johnson updated this with a promise of 6,000 more by 2024, in order to deliver a promise of 50 million more appointments. According to Sajid Javid, these pledges – a key promise in the Conservatives’ general election manifesto in 2019 – are unlikely to be met. The evidence is revealing: it shows a drop GP numbers in England every year since 2015.  

Policy-makers have wisely tried to add workforce capacity in other ways, by making better use of a wider group of health professionals in primary care such as physiotherapists, physicians’ associates and pharmacists. It’s an intelligent approach, but evidence shows limited policy success.   

While the policy vision for allied health professionals in primary care is broadly sound, the way this was implemented meant the policy itself has not delivered on what was needed – and what was promised in the NHS Long Term Plan.

The wrong policy response

Policy-makers too often reach for quick fix solutions to address the many problems facing general practice. We can see this in the over-optimistic view that a shift to digital and online appointments will make care higher quality and more efficient, when research evidence and modelling work provides very limited support for this. And while online appointments may improve access to care for some, there is already some evidence that they can create a new digital inverse care law.  

Similarly, too much focus on the benefits of more rapid on-the-day access overlooks the risk of supply-induced demand making the situation for general practice worse by driving up demand for appointments. With one in three GP practices forced to stop offering routine appointments in the last year due to a combination of unprecedented patient demand and staff shortages, the negative impact of a zealous policy enthusiasm for enhanced access has to be taken on board.    

The problem with a policy approach dominated by rapid access and a desire to shift towards more transactional models of care is that it means we end up with care that works well for patients who are living broadly healthy lives and don’t often need to see a GP, but much less well for those patients in poor long-term health living with multiple complex conditions, who would benefit from personalised care over time with a GP who knows them well. This also reflects deeper problems with current policy, which are measurable in the worsening of patient satisfaction with care and increased workload for staff.

A political problem

At its heart, the problem facing general practice is a simple mismatch between supply and demand: falling numbers of GPs and rising demand for their care.

But the government’s manifesto pledge to provide 50 million more GP appointments every year speaks of a political obsession with the wrong solution. These additional appointments would only be valuable if policy-makers pursued the right mix of access: rapid for some patients and pre-bookable with continuity for others. If not, this will push limited capacity towards just one goal, making it even more difficult to provide support for patients who need more than just one fast appointment with any GP. 

It is time for a better set of solutions that respond intelligently to the crisis in general practice. Solutions that focus more on getting access right, and less on the numbers of appointments, rapid access or headline-grabbing pledges of more GPs.