General practice acts for many as the front door to accessing health services. But as with all parts of the health system, the restrictions imposed by the last few months of lockdown have significantly affected how GP surgeries – and indeed all primary care – have been able to operate. So what has changed, and is there anything from this that we want to keep for the future?
There is limited data to support our understanding of what happens in general practice, and the pressures of lockdown have hampered our knowledge even further. The new release of data on appointments in general practice – despite some concerns around its quality and robustness – allows us to start asking some questions around how activity has changed over the last few months and the implications for staff and patients.
People saw their GP less
The latest NHS Digital data shows that there were one third fewer GP appointments in April and May this year compared to April and May 2019, continuing the pattern that began in March. That is consistent with Public Health England data showing drops in consultation rates for a range of conditions.
By the time lockdown measures were announced on 23rd March, the number of appointments had fallen significantly. Within a fortnight, the government was encouraging people to “get help if they need it” – but the numbers of appointments were still well below what we might expect in usual times.
The ways that people are seeing their GP have changed
While it is perhaps not a surprise that appointment numbers have not yet bounced back to pre-Covid levels, there is data to suggest that if and when the numbers do recover, the types of consultations offered will have changed.
In February and before, face-to-face appointments outnumbered telephone appointments by more than five to one. Yet by April and for the first time, NHS Digital reported more telephone consultations taking place than face-to-face. It is difficult to tell from the data we have whether those face-to-face appointments have been replaced by other modes.
That data does not capture the extent to which online appointments have been used, and these are likely to be underreported in the appointments dataset[i]. This is difficult as online appointments are not always coded correctly – as recording systems require GPs (or other practice staff) to switch code settings between consultation types. For simplicity, shifts are often set to the type that the majority of consultations will be (e.g. face-to-face or telephone), and it can be easy to forget to switch to the appropriate consultation type.
But other data backs up the shift to online delivery: RCGP research surveillance data suggests that in the four weeks to 21st June, more than seven in 10 routine consultations were conducted remotely.
Alongside fewer appointments happening ‘in the flesh’ and fewer referrals to hospital settings, it seems there may also have been a shift in how patients have sought out primary care – perhaps from fear of contracting the coronavirus.
An opportunity for change?
The proportion of appointments booked more than a week in advance has dropped (see chart below), and the proportion of appointments booked and seen on the same day has increased from 42% in April and May last year to 63% this year.
The shift could result from an increased capacity among GPs, as well as a cancellation of routine appointments for patients with long-term health needs. The latter is worrying, as many patients with long-term conditions may have had essential care, such as medication review appointments, put on hold – with likely implications and many unanswered questions around how these patients have been able to manage, and will continue to manage, their conditions.
But the period has contained positives for general practice, with many practitioners suggesting a return to the status quo may not be desirable and that we should embrace the opportunities that have arisen.
We have heard from colleagues that they used the period of reduced demand for acute problems in April and May to undertake proactive check-up appointments with patients with long-term health needs. Face-to-face appointments constituted only 47% of appointments this May, compared to 80% in May 2019. Now is the time to discuss which of these could be better managed through other delivery modes in the future – taking account of course of those patients who cannot use digital alternatives to traditional general practice and who should not be left behind.
Crucially, as secondary care strives towards getting back to ‘normal’ (even if that is not any time soon), we will need to ensure that pressure from the backlog doesn’t shift instead to primary care – at the risk of creating more burnout and retention issues among GPs of the kind we have seen in past years.
Better data to inform future practice
We still have a long way to go to have a good idea of what happens in day-to-day general practice – not just for GPs but for the many other important roles that are essential to primary care.
What is clear is that understanding what worked – and didn’t – as lockdown progressed will be essential to shape what the future of primary care might look like. If we are to improve primary care we will need better data, but it is vital we focus our efforts on understanding the experiences of patients and staff.
[i] The NHS Digital data is currently reported as Experimental Statistics due to historical variations in practice coverage, but now covers around 95% of practices and patients in England. They also give reasons why shifts in the delivery of appointments may be under-reported in the data. For example, the number of video or online appointments reported is well below 1% of all appointments recorded, and has shrunk since March. The NHS Digital data may not include all data for all appointments, as multiple telephone calls could be counted under a single appointment slot, and practices using online or video appointments may not yet be reporting them in the same way as their other appointments.
Spencer J and Oung C (2020) “How has lockdown affected general practice and where do we go from here?”, Nuffield Trust comment.