Understanding Pressures in General Practice

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General practice is in crisis

  • Workload has increased substantially in recent years; this has not been matched by growth in either funding or in workforce. A lack of nationally available, real-time data means that this crisis has been until recently largely invisible to commissioners and policymakers.
     
  • GPs warned the government about allowing general practice to be consistently overwhelmed, with clinical staff on the edge of burnout due to years of working under extreme pressure to meet public demand.
     
  • The Kings Fund carried out an analysis of 30 million patient contacts from 177 practices over a 5-year period and found that consultations grew by more than 15 per cent between 2010/11 and 2014/15. The number of face-to-face consultations grew by 13 per cent and telephone consultations by 63 per cent. Over the same period, the GP workforce grew by 4.75 per cent and the practice nurse workforce by 2.85 per cent.
     
  • Funding for primary care as a share of the NHS overall budget fell every year in the Kings Fund’s five-year study period, from 8.3 per cent to just over 7.9 per cent.
     
  • Pressures on general practice are compounded by the fact that the work is becoming more complex and more intense. This is mainly because of the ageing population, increasing numbers of people with complex conditions, initiatives to move care from hospitals to the community, and rising public expectations. Surveys show that GPs in the NHS report finding their job more stressful than their counterparts in other countries.
     
  • Practices are finding it increasingly difficult to recruit and retain GPs. GPs reaching the end of their careers are choosing to retire early in response to workload pressures. They have also been affected by changes to the tax treatment of pensions which create disincentives to work when the lifetime allowance for pensions has been reached.
     
  • As a result, there are now just 0.46 fully qualified GPs per 1000 patients in England – down from 0.52 in just 6 years.
     
  • Fewer GPs are choosing to undertake full-time clinical work with more opting for portfolio careers (a number of different roles) or working part-time. This is true for both male and female GPs.
     
  • Trainee GPs are often planning to work on a salaried basis which makes staff retention more challenging. This also continues a long-term trend in which fewer doctors aspire to become partners in their practices thus threatening the medium to long term future of independent GP practices.
     
  • There are also challenges with recruitment and retention of other members of the primary care team particularly practice nurses, practice managers and allied health professionals such as pharmacists and physiotherapists. This makes it difficult for some of the work of GPs to be taken on by other staff who are also in short supply.

Securing the future of general practice cannot be achieved simply through ‘more of the same’, even though more investment is needed. It requires a willingness to do things differently building on examples of approaches already in development in several areas.

 

The Perfect Storm

Public perception may be that GPs no longer offer face-to-face appointments and that the traditional model of GP practice is eroding, but it is important to recognise the factors that are affecting delivery of healthcare. 
In addition to the structural and funding pressures outlined above there is also increasing demand on GP services from the patients themselves:

Demand is also heavily impacted by rising public expectations for convenient and personal care.

  1. Increasing life expectancy over time has largely plateaued over the last 10 years (ignoring COVID related changes in 2019 and 2020) but the long-term effect is still dramatic.  Important to note in this context, however, is that “healthy life expectancy” has not increased at the same rate so more years are spent in poor health i.e.
    • Although an English male could expect to live 79.8 years in 2017–19, his average healthy life expectancy was only 63.2 years – i.e he would have spent 16.6 of those years (21 per cent) in ‘not good’ health2.
    • In 2017–19 an English female could expect to live 83.4 years, of which 19.9 years (24 per cent) would have been spent in ‘not good’ health. And although females live an average of 3.6 years longer than males, most of that time (3.3 years) is spent in poor health3.

      More years in poor health means greater demands on the NHS.
       
  2. Demand is also heavily impacted by rising public expectations for convenient and personal care.
 

What patients want, versus what they need

Given this background, delivering the “perfect” service in general practice is impossible. Consider the following graphic:

 

The diagram above shows just how difficult it is to meet all 3 expectations. What does good look like? What is the reality versus the expectation? The panacea in the middle, simply doesn't exist. What are the options? 

  • Primary Care can provide a ‘fast and cheap’ service, but it won’t be good.
  • Primary Care can provide a ‘fast and good’ service, but it won’t be cheap.
  • Primary Care can provide a ‘cheap and good’ service, but it won’t be fast.

To meet this challenge, Primary Care must adopt new ways of working; better utilisation of all healthcare professionals and resources; integration of technology; and a better understanding of our local population healthcare will be required to enable Primary Care to move forward.

 

Meeting the Challenge 

As a Primary Care Network, and as individual practices, we are working hard to ensure we achieve a balanced approach to our current challenges that is not only effective now, but sustainable in the longer term.

 

Focus on Population Health

The new GP contract (Network Contract Designated Enhanced Service) requires Primary Care Networks (PCNs) to deliver services efficiently, safely while directing the care according to local population health needs. PCNs are being asked to improve physical and mental health outcomes, promote wellbeing, and reduce health inequalities across our entire population (currently over 38,000 patients in Jurassic Coast Healthcare).

Jurassic Coast PCN will evaluate local health, social and demographic information to understand the areas of healthcare priority. Health is no longer the sole responsibility of the family GP and we also need to find ways to encourage individuals to take on more responsibility for their own health. Working closely with our colleagues across the NHS and other public services (including councils, the public, schools, fire service, voluntary sector, housing associations, social services, and police) the PCN will shape service delivery to offer a wider range of services, closer to home. For the public, it should mean that health and care services are more proactive in helping people to manage their health and wellbeing. We aim to make best use of resources and change the way we work to give all patients a service that meets the needs of the local population by improving access and providing more personalised care for those most at risk and in need.

 

Focus on self-care

Given the pressures on our services we need to understand that health and care needs are changing, i.e.

  • Our lifestyles are increasing our risk of preventable disease and are affecting our wellbeing.
  • We are living longer with more multiple long-term conditions like asthma, diabetes and heart disease and the health inequality gap is increasing.

We will look to new ways of working to promote self-care which should additionally improve patient’s access to services and make better use of other healthcare services available outside of a GP practice.

 

Focus on Multi-skilled Team Working

As quoted earlier, to address the issues outlined we will work differently to make the best use of the staff and resources available. These changes need public commitment, engagement and understanding of why we must change the model of general practice. We can no longer accommodate the historical benchmark of a named GP for life, but what we can offer is the best use of our skilled and highly trained clinical workforce to provide a holistic approach to care.

The integration of Advanced Nurse Practitioners, Paramedics, Mental Health Workers, Social Prescribers, Pharmacists and other allied health professionals alongside GPs and nurses means we offer patients a wider option of support that is not solely dependent on a single GP. The objective is that this should offer patients

  • Improved access to care
  • The opportunity to liaise with the right clinician at the right time

We aim to be at the forefront of this change by encouraging the further development and integration of the primary care workforce using nurses and pharmacists and allied health professionals. We aim to maximise the integration of non-clinical roles such as health coaches, care navigators, and the use of volunteers to support the work of the specialist clinical teams and further promote self-care.

We will be supporting patients to access the wider team through better signposting, making it easier for patients to seek advice not only from GPs, but also directly from the wider primary care team.

 

Focus on Team Development

We will work alongside the Our Dorset Workforce Hub and Health Education England to develop our workforce strategy to support more sustainable careers for GPs and their fellow team members, promoting sustainable and fulfilling options for development and recognising changing career preferences amongst them all.

These measures are designed to improve the experience of patients and deliver care that is accessible and offers continuity.

 

Focus on Technology

As healthcare demands have grown, so too has the use of technology. Whilst this is uncomfortable for some, it is an inevitable way forward. Accelerating the uptake of technologies and alternative ways of working can help practices deal with growing pressures more effectively. We will further embrace the use of telephone triage and email consultations, where appropriate. Face-to-face consultations will be protected for those patients whose need is greatest and who will benefit the most.We will work with our local health system partners to continue to develop new and innovative models of general practice and maintain care at 'place' and are keen to engage with our patients to ensure we listen and shape care according to their needs.

 

Current Projects

GP Community Pharmacy Consultation Scheme

This project aims to identify ways that individual patients can self-manage their health more effectively with the help of community pharmacists, and to recommend solutions that could encourage the use of pharmacy as a first point of contact for minor illness symptoms in the future. The purpose of the GPCPCS is to reduce the burden on general practices by referring patients needing advice and treatment for certain low acuity conditions to a registered community pharmacist, rather than a GP. Its aim is to improve access to the same levels of care, close to home and with a self-care emphasis and to reduce pressure on GP appointments. The scheme will help to create some additional capacity for our practices to book our most vulnerable and acutely unwell patients into appointments within a reasonable timescale; appointments that might not otherwise have been available due to the weight demand from patients with minor, self-limiting conditions. The service is intended to be a high quality and effective clinical urgent care service provided by community pharmacy through a referral from a GP practice, enabling convenient and easy access to a healthcare professional for patients.

The Access Hub

To support entry into our services we will be working towards the development of an integrated Triage Hub. This multidisciplinary team, consisting of GPs, Advanced Nurse Practitioners, Pharmacists, Paramedics, Care Navigators and Allied Health Professionals will ensure our patients receive the right care at the right time by the right clinician.

Supported by trained Access Coordinator, the model allows us to direct patients to the appropriate form of appointment with an appropriate clinician, resulting in reduced waiting times and appropriate GP contact for our most vulnerable and acutely unwell patients. This will improve patient satisfaction whilst improving efficiencies in our services.

Currently in its infancy and about to formally pilot at Ammonite Health Partnership, the service is being “shaped” with a view to possible roll out across Jurassic Coast PCN. We will be engaging with members of our Access Working Group (whose membership comprises patient representation from all practices) to ensure we develop the service in line with patient views.

 

In Summary

Whilst we face a challenging time, we are committed to improving patient care and experience. We are working hard to foster a culture of continuous improvement and ask that our patients join us in our new way forward.

 

References

  1. Understanding Pressures in General Practice. The Kings Fund. May 2106
  2. General Practice Forward View. NHS England. April 2016
  3. The Kings Fund (this data predates the COVID 19 pandemic)