After an initial period of decline, spending on general practice has increased by nearly 12% since 2010. Challenges remain: the Government is struggling with GP numbers, and demand pressures are rising as long-term conditions become more prevalent. New ways of working are emerging to face these challenges but there are signs that more patients are facing difficulties accessing general practice.
Spending in general practice has increased by nearly 12% in real terms since 2009.
Between 2010/11 and 2016/17, annual current and capital spending on general practice increased by 11.5% in real terms overall. However, this increase did not take place across the whole period. There was a 2.1% real-terms drop in spending up to 2012/13. Spending began to rise in 2013/14, and has been supported since 2016 by the publication of the General Practice Forward View, which committed to spend an additional £2.4bn a year on general practice by 2020/21. Simon Stevens, Chief Executive of NHS England, has emphasised the importance of this increase in spending, writing that “if general practice fails, the whole NHS fails”.
Complex cases are increasing GPs’ workload.
GPs are required to balance both rapid-access and ongoing care. Population ageing, the rising incidence of long-term conditions and improved techniques for early diagnosis have increased the volume and complexity of their workload, as people live for longer with medical needs (see Box 2.1). General practice workload is thought to have increased faster than population growth, with Deloitte estimating a 26% increase between 2009/10 and 2016/17.
However, there have been no nationally collected data on general practice activity (such as the number and length of consultations) since 2008. This obscures how demand and workload within general practices are changing, necessitating the use of proxy indicators and making performance monitoring difficult.
One measure of the complexity of GPs’ workload is the number of referrals they make to hospitals. Between June 2009 and June 2017, the number of referrals from GPs to provider trusts increased by 21%, from 2,902,626 to 3,499,613 (see Figure 2.2). As a referral occurs when a patient requires a clinical specialist, this can be taken as a proxy of either increasing demand or increasing complexity of cases, given the lack of other data on consultations.* A policy-driven emphasis on treating more patients through primary care, rather than in acute settings (that is, hospitals), will only add to the general practice workload.
Box 2.1: Living longer with health complications
Between 2009/11 and 2013/15:
As the rise in LE is outpacing both HLE and DfLE, people are living longer lives but with more years of poor health (an additional 0.3 years for men and 0.4 years for women) and more years of disability (an additional 1.1 years for men and 1.7 years for women).
The future of the general practice workforce is under question.
The data suggest that the number of full-time GPs is falling. As of September 2016, there were 28,458 full-time equivalent (FTE) GPs in England (excluding locums, registrars and retainers), equating to 2,033 patients per GP. Following growth between 2010 and 2014, the data indicate that there was a 2.6% fall in FTE GPs between September 2015 and 2016 (although methodological changes prevent like-for-like comparison across the period) (see Figure 2.3). Provisional figures for June 2017 suggest a further drop to 3.1% below 2015 levels. Meanwhile the number of FTE locum GPs increased by nearly 80% (from 567 to 1,006) between September 2015 and June 2017.
The Government has promised to achieve by 2020 an overall net growth of 5,000 extra GPs from 2014 levels, although there are signs of difficulty in reaching this target. Part of this ambition was training 3,250 new GPs each year, but only 85% of these training places were filled in 2015/16, and 93% in 2016/17. Furthermore, the Government appears to have increased the extent to which it will rely on international doctors. While the General Practice Forward View stated that up to 500 GPs would be recruited from overseas, recent evidence suggests they could make up half of the new practitioners.
There are also issues with retaining and fully utilising existing GPs. General practice has an ageing workforce; in June 2017, there were twice as many FTE GPs (excluding registrars, locums and retainers) over the age of 55 (6,233) as under 35 (3,043). Between September 2015 and June 2017 the number of GPs under 35 fell by 6.6%, while the number over 55 rose by 17.5%.
GPs are also reporting high levels of stress relating to rising workloads. Between August 2016 and February 2017, a Royal College of General Practitioners’ survey saw an increase in respondents ‘unlikely to be in the profession in three years’, from 32% to 39%. Furthermore a survey of more than 300 GPs in training by The King’s Fund, a health think tank, found that less than a third of respondents intended to work full time in practice one year after qualification, due to the ”intensity of the working day”.
In the face of increasing workloads, there has been a concerted effort to ensure that GPs are not dealing with patients who could be treated by other medical professionals. The General Practice Forward View committed more than £150 million (m) by 2020 to help other staff in practices play a role in care giving and navigation. The data indicate that the number of FTE nurses in general practice has risen, by nearly 3% between 2010 and 2014, and a further 3% between 2015 and 2016. There has also been an increase in other FTE practice staff responsible for direct patient care (such as dispensers, pharmacists and physician associates), by 32% and 9% in the respective time periods.
GP practices are beginning to adopt new ways of working to meet challenges.
The nature of consultations has slowly begun to change, as GPs have found new ways to spread resources further. Between 2012 and 2017 the percentage of participants in the GP Patient Survey who said they had a telephone consultation with their GP rose by just over 3 percentage points (from 4.8% to 8%), while the percentage who had an in-person appointment with a nurse in a surgery also rose slightly (from 20.6% to 22.4%). However, the percentage reporting an in-person appointment with a GP still remains a large majority (72.5% in 2017).
There has also been a movement away from traditional ‘corner-shop models’ of general practice. Between 2009 and 2014, polyclinic and larger practices with more GPs increased, as practices sought to pool resources, improve their finances and aid recruitment. The percentage of single-handed GP practices fell from 15.4% to 10.7%, whereas the percentage of practices with five or more GPs rose from 40.4% to 45.6% (although data between 2015 and 2016 suggest a slight resurgence in single-handed practices). Overall, practice numbers fell by 701 between 2009 and 2016, to 7,527.
Another change has come in the form of greater use of technology within general practice: for example, between 2012 and 2017 the percentage of patients booking appointments online nearly tripled, from 3.0% to 8.7%. Furthermore a 2015 study by The Health Foundation found that the UK is an international leader in the use of electronic medical records, with 98% of GPs routinely using them. However this change is not all encompassing – 83.4% of 2017 GP Patient Survey respondents had not used online services for managing appointments, prescriptions or medical records – and the General Practice Forward View has committed a £45m national programme to stimulate the use of online consultations within every practice.
General practice services are becoming harder to access.
Accessing general practice is becoming more difficult. While the number of people receiving an appointment on the same day as requested actually increased between 2012 and 2017 (from just under 36.6% to 38.1%), general practices are increasingly having to prioritise patients, and the percentage who reported waiting a week (or more) for an appointment rose from 12.8% to 20.0%. Between 2012 and 2017, patients’ positive ratings of making an appointment decreased from 79.3% to 72.7%, while the percentage of patients who said it was easy to contact their GP by telephone also declined, by nearly 10 percentage points, from 77.9% to 68.0%. There was also a slight increase in the percentage of people unable to make an appointment or speak to someone, from 8.9% to 11.3%.
Government has initiated work to address difficulties with access, such as extending general practice to a seven-day service. As of March 2017, extended access offers (pre-bookable appointments outside of core contractual hours) were fully provided in 23.6% of practices, and partially provided in 87.1% of practices (both increases of 5.1 and 0.8 percentage points respectively from 2016). But pressures persist. In 2017, 76.2% of patients were satisfied to a degree with their GPs’ opening hours, a 5.1 percentage-point decrease from 2012. NHS England has been instructed to ensure that everyone has access to routine weekend and evening GP appointments alongside effective access to out-of-hours and urgent care services by 2020. However, the National Audit Office (NAO) has argued that government has “not fully considered the consequences and cost-effectiveness of their commitment to extend access”, which would cost around 50% more than normal working hours.
Patient satisfaction is still high.
General practice has remained the most popular element of the NHS, but this popularity has decreased; 72% of people were satisfied with the service in the 2016 British Social Attitudes survey, compared with 80% in 2009. People who described their overall experience as good or very good decreased slightly from 88.4% to 84.8% between 2012 and 2017, reflecting the trend of high but slipping patient satisfaction. In particular, the percentage of patients saying that GPs were good at giving them enough time fell by 2.4 percentage points (to 84.4%). Furthermore, pressures on access, the increase in larger practices and more part-time staff have had implications for continuity of care. Between 2012 and 2017 there was a decline in how often people with a preferred GP saw them ‘always, almost always, or a lot’, from 65.3% to 55.6%. However, patient confidence and trust levels in GPs have remained high, at 91.9% in 2017 (compared with 93.0% in 2012).
Indicator scores from the Quality and Outcomes Framework (QOF) suggest that the quality of general practice services has been maintained, or even improved (see Box 2.2). However, there has been a lack of clinical quality data for general practice. Recent Care Quality Commission (CQC) inspections have provided new, and broadly positive, insight into the state of general practice, with 90% of practices rated as good or outstanding. There was some variation in performance across indicators: 97% of practices were good or outstanding at ‘being caring’, but only 85% of practices achieved these levels of ‘being safe’. However, there was also evidence of improvement among practices; of those that were initially rated ‘inadequate’, 80% had improved upon re-inspection.
Box 2.2: QoF scores
QOF is a voluntary annual reward and incentive programme for all GP surgeries, which provides additional funding for good practice. The national average QoF achievement score for all indicators rose by 1.6 percentage points between 2009/10 and 2015/16, and now stands at 95.3%. Of the indicators that were measured consistently between these dates:
* Referral management practices in some clinical commissioning groups have contributed to this increase, by preventing consultant-to-consultant referrals. This means patients are referred back to their GP if they need to see a different specialist.