Our second poll was conducted between 8 August and 1 September 2014, via an online survey. Seventy-five of our 100 panellists responded. Of the 75 respondents, 30 are senior NHS managers, 29 are clinicians or clinical leaders, nine are from the social care sector, and seven are from local Healthwatch bodies. Of the managers and clinicians, 23 are from acute hospital trusts; 16 from CCGs; six from private or voluntary sector providers; six from acute mental health trusts; four from NHS ambulance trusts; and four are from NHS community trusts. The panel members are named on our website, but their individual responses to the survey are anonymised.
This survey is accompanied by a separate policy briefing 'Is General Practice in Crisis?, which explores in more detail many of the issues and themes raised in the survey. This briefing is the first in a series on the issues and challenges facing the political parties in the run-up to the General Election.
- 99% agree that general practice is either in crisis or in need of reform.
- 2 in 3 said access to urgent care in the community could reduce pressure on A&E.
- 94% support the concept of general practice federations.
- Over half support more funding for general practice.
- 3 in 4 agree that 'single handed' GP practices are 'no longer fit for purpose'.
- 46% were in favour of reintroducing the 48-hour access target.
Question one: "How would you assess the state of general practice in the English NHS?"
We asked our Health and Social Care Leaders' Panel to assess the current state of general practice in the NHS, and as the chart above shows, two thirds consider that it is in need of reform and the other third that it is in crisis. This paints a picture of significant concern about general practice; it also points to a uniform view among our panel that something needs to be done to support and change general practice.
Question two: "Thinking about your local area, to what extent do you agree with the statement: 'single-handed or small GP practices are no longer fit for purpose'?"
When we asked the panel members about the extent to which they agree with the statement: 'single-handed or small GP practices are no longer fit for purpose', 77% agreed or strongly agreed, with just 8% disagreeing. This suggests that the health and social care leaders subscribe to the view that smaller practices are struggling to provide the range of health and community services typically expected of modern general practice.
Question three: "Do you think that GP practices need to be a part of larger groups or federations to meet the needs of the population over the next five years and beyond?"
Emerging networks and federations of general practices represent a way in which practices can remain small and local while benefiting from the economies of scope and scale that a larger primary care organisation can offer. Indeed, almost all of the leaders responding to this second survey (94%) reported that they think practices need to be part of larger federations or groups if they are to meet the needs of the population over the next five years and beyond.
Question four: "Do you think general practice needs and injection of funding?"
The NHS' budget has remained almost static in real terms in recent years. As our recent report Into the Red? shows, this, coupled with rising demand for health services, means that the NHS faces an increasing financial challenge.
When asked whether general practice needs an injection of funding, our panellists were undecided, with 57% agreeing, 20% disagreeing and a further 23% not knowing.
The qualitative responses to the funding option illustrate this ambivalence about the need for funding increases. A few respondents were clear that increased funding is a pressing need for general practice, arguing for example that the sector ‘cannot provide better services while practice income is dropping’ and that a ‘massive’ increase was needed, especially to address the problem of overcrowded premises. Others argued that the problem is not simply about more money, but about workforce, pointing to current shortages of GPs and other kinds of practice staff. Most respondents were wary of the idea of any unconditional injections of new funds. Some singled out a lack of transparency about current funding arrangements – ‘it is a mystery what practices receive as [it is] all separate payments’ and the need for ‘data on increased workload and complexity of need’ to underpin any funding increases.
Question five: "In 2010 the 48-hour access target, which guaranteed patients a GP appointment within 48 hours, was abolished. Do you think it should be reintroduced?"
Under the Labour Government from 1997 to 2010, the use of access targets was a core part of health reforms, and general practice was no exception to this. A target that guaranteed patients an appointment with a GP within 48 hours was central to attempts to reduce waiting times, increase responsiveness and secure modernisation of care pathways.
The Coalition Government abolished the GP access target in 2010, arguing that change should be driven by focus on outcomes rather than process targets. However, there have recently been reports of lengthening waiting times for GP appointments. We asked our panel of leaders if they felt that the 48-hour access target should be reintroduced, and as can be seen in the chart above, views were divided, with 46% saying yes, 39% saying no, and the remainder undecided. This may reflect a more general ambivalence in recent years, about the role of targets to drive performance in health and social care, and the sense that wider reforms to general practice as a whole may be important.
Question six: "Thinking about your local area, which three of these have the biggest potential to reduce pressure on general practice?”
We asked our panel to choose three options for reducing pressure on general practice, and the results are set out in the chart above. Interestingly, the development of larger and coordinated primary care networks is again chosen as the main priority for reform, an option selected by almost two thirds of respondents. This perhaps reflects a desire among the leaders for far more extensive and sophisticated primary care networks and organisations that will have the capacity and capability to plan and implement new models of care (see our publication - Securing the Future of General Practice: New models of primary care and the outputs from our 2013 Euro-Summit)
After the need for networks in primary care, the next most popular mechanisms chosen by the panelists were:
- Seven day opening of GP practices
- More investment in case management for long-term conditions
- Increased funding for community-based mental health care
This reflects the growing awareness among practitioners and policy-makers that primary care needs to be able to provide tailored and well-coordinated services for people with complex needs, alongside accessible and responsive care for those needing more episodic support from their practice. Our briefing paper on general practice sets out ideas about the policies needed to enable this, and our earlier reports on models of primary care review examples of organisations in the UK and overseas that are already using the benefits of networks and scale to deliver a wider range of care to local populations.
Question seven: "Thinking about your local area, which three of these have the biggest potential to reduce pressure on emergency departments in acute trusts?"
When we asked the leaders about ways in which pressure on emergency departments might be reduced, the most frequent response was to call for more access to urgent care in the community, an option selected by over two thirds of respondents. Indeed, longer opening hours at GP practices was the second most cited response to this question about how to ease emergency department pressures, followed by a need for more social care and more non-acute intermediate care beds.
Question eight: “Thinking about your local area, which three of these have the most potential to reduce demand for non-urgent hospital services (e.g. outpatient and diagnostic services)?"
When asked about ways to ease pressure on non-urgent hospital services (such as outpatient clinics and diagnostics), respondents to the survey identified a need for more capacity for diagnostic testing and for treatments such as wound care in primary care rather than in hospital, and the co-location of hospital specialists in general practice. There was much less support for the development of more centres that specialise in elective surgery, suggesting interest in reform of primary and intermediate care services - presumably in collaboration with hospital and social care services.
Question nine: “What are the biggest barriers to developing alternatives to hospital care?”
We asked the health and social care leaders on our panel to identify what they consider to be the biggest barriers to developing alternatives to hospital care in their local area. System rules (such as payment systems and procurement) were most frequently reported (70%), followed by ‘ability to implement change’ (57%) and ‘opposition to change’ (46%). This suggests that while there is widespread support among the health and social care leaders represented in our panel for the need to implement new models of primary, community and hospital care, there is a very real concern about the capacity and skills to do so. In some of the open-ended responses to this question, some panel members felt that there was still an absence of available evidence to guide service redesign.
A lack of capacity was a common theme, partly due to the pressures of day-to-day management of the current level of services, but also, because there were so many redesign projects running concurrently.
In the view of some respondents, this lack of capacity at organisational level was compounded by an absence of support and strategic direction elsewhere in the system (including from NHS England, and its regional and local teams). This meant that individual organisations tended to default to self-preservation.
Despite the caveats, the panellists also offered a range of ideas about how care should be organised, many of them linked by the theme of ‘holistic’ patient-centred care as an idea around which to organise professional and organisational roles.
Question ten: "Which groups do you think are most at risk of falling through the cracks in your local area as budget cuts bite in health and social care?"
We asked respondents to tell us which groups of people they felt were most at risk of falling through the cracks in the their local area, as budget cuts bite in health and social care. Frail older people with multiple conditions were cited by almost three quarters (72%) of the leaders, closely followed by people with serious and enduring mental health problems (70%) and then children and young people with mental health problems (58%). A further 49% percent thought carers were also at risk. This underlines the importance of current work on parity of esteem for mental health services and their users, and that work to redesign primary and community services needs to focus as much on the needs of people with mental health problems as those of the frail elderly population.
This second survey in our series underlines how strongly the health and social care leaders feel about general practice and other community services, as quality and access to health and social care services are seen to be buckling under the strain of budget constraints. The leaders’ opinions suggest there is an appetite for redesigning care around new models of out-of-hospital services and a reformed general practice, particularly if it can work on a greater scale and become more responsive. But there is also a clear message that any reform efforts initiated by Government need to be adequately resourced in terms of supplying evidence of what works, capacity to support managers and clinicians to focus on change, and providing enough ‘overlap’ resources to invest in new services before old ones are dismantled.
Alongside this survey report, the Nuffield Trust has also produced a policy briefing 'Is General Practice in Crisis?, which explores in more detail many of the issues and themes raised in the survey. This briefing is the first in a series on the issues and challenges facing the political parties in the run-up to the General Election.
Find out more about our General Election work here
We are also asking a series of survey tracker questions to assess whether there are shifts in the views of the health and social care leaders over time. These questions cover access to health and social care, any perceived changes in the quality of both health and social care, and the long-term viability of comprehensive, publicly funded healthcare. You can look at the trackers as they shift over time here.
Smith J and Thorlby R (2014) Health leaders' panel survey two: the state of general practice. Nuffield Trust, 29 May 2014.