General practice is the cornerstone of the NHS, dealing with 90% of all patient contacts in our health services and helping to ensure the delivery of safe, effective patient care.1 Yet in recent years concerns have been mounting that a number of pressures facing GP surgeries are pushing UK general practice to breaking point.
GENERAL PRACTICE UNDER PRESSURE
A central part of the problem is that practice workloads have been rising relentlessly for some time. NHS England estimates that surgeries in England dealt with 340 million consultations in 2011 to 2012, up from around 300 million in 2008 (the last year for which the most robust data is available).2 Anecdotal evidence, and the findings of a poll commissioned by the Royal College of General Practitioners (RCGP) in 2013, suggest that most GPs are now dealing with a workload of 40–60 patient contacts every day.3
Despite this growth in demand, general practice has suffered from a chronic lack of investment over the past decade, with its share of UK NHS spending now standing at a record low of 8.39%. In 2011 to 2012 around £8.7 billion was spent on general practice in Britain (including both local and national contracts, but excluding prescription costs): almost three-quarters of a billion pounds less, in real terms, than in 2005 to 2006. This represents an 8% drop at a time when the overall NHS budget in Britain has increased in real terms by 18%. General practice in Northern Ireland (for which comparable data is unavailable) has seen its funding share drop for 3 consecutive years down from 8.22% of Northern Ireland health spending in 2010 to 2011 to 7.96% in 2012 to 2013. In real terms, funding for general practice services across the UK has fallen for 3 consecutive years from 2011 to 2013.4
For some reason, when decisions are made about where investment in the NHS should be directed, general practice and the patients who rely on it are missing out.
Alongside this, serious questions have been raised about the current and future capacity of the general practice workforce. Worryingly, the headcount number of GPs (including registrars) in England actually fell in the year up to September 2013. Although the number of full-time equivalent (FTE) GPs has been slowly rising, rates of recruitment are lower compared to many other specialties. In the decade between 2003 and 2013, in FTE terms the number of GPs rose by 4451, but over the same period the number of hospital doctors increased by 12 673 (both excluding registrars).5 Furthermore, the general practice workforce is unevenly spread across the country, with the fewest doctors in the most deprived areas, exacerbating health inequalities.6
CRISIS OR OPPORTUNITY?
If some of this makes for grim reading, it’s worth reminding ourselves that this crisis comes at a time when the skills of the expert medical generalist are more important to the delivery of safe and effective care than ever before.
Demographic change has undoubtedly been a key factor in rising demand, and the two age groups that are expanding the fastest, that is children and the over 75s, are those that have the most to benefit from the continuity of care that we know a well-resourced general practice can provide.7
Closely linked to this is what is probably the single biggest challenge facing the NHS in the coming years: the dramatic increase in the number of people living with multiple morbidities. Those living with more than one long-term condition are expected to rise from 1.9 million in 2008 to 2.9 million by 2018.8 A 2011 study indicates that these patients account for around 78% of consultations in general practice.9 There is also evidence that around 65% of those aged >65 years are living with multiple morbidity, and that its prevalence increases with deprivation; with people in deprived areas having the same prevalence of multiple morbidity as more affluent patients who are 10–15 years older. In particular, physical and mental health comorbidity has been shown to be almost twice as common in the most deprived than in the most affluent areas.10 What is clear is that for the NHS to have a realistic chance of tackling this challenge, a shift of focus will be needed, away from treating single diseases in isolation and towards the whole person care that GPs provide.
Alongside this, a consensus has been growing for some time that many patients can and should be much more effectively cared for in the community rather than in hospitals. This makes good sense not only from a clinical and practical point of view, but also in terms of the financial sustainability of the NHS as a whole, given that a single episode of care in hospital can potentially cost as much as a year of care in general practice.
ANOTHER WAY — INVESTING IN THE FUTURE OF PATIENT CARE
If given more time to plan care with patients, particularly the vulnerable older group, GPs could help refocus the NHS on providing more personalised care that takes into account the patients’ family, work, and home life, achieving a shift towards preventing ill health in the community rather than treating it in hospital.
Increased resources would give practices greater scope to provide more flexible opening hours for those patients who consider this a priority. The RCGP has raised concerns about the impact of poor access to general practice on patient safety, with data from the GP Patient Survey suggesting that people are having to wait more than a week for an appointment on as many as 27 million occasions every year.11 Investing in new technologies would also help practices to pioneer greater patient access to health records, consultations, and treatments remotely.
Much of this is already happening and there is growing evidence that investing in general practice leads to improvements in patient care.12
Despite being under huge pressure in recent years GPs have still managed to lead the way in terms of developing new models of delivering primary care. Federations of practices, in particular, have been identified as a model that can drive the delivery of more joined-up primary care at scale.13 GPs are also well positioned to lead the creation of multidisciplinary teams, working with colleagues across primary, secondary, mental, and social care. With more time and resources to dedicate to leadership and service development general practice could accelerate these initiatives.
SIGNS OF PROGRESS, BUT A LONG WAY TO GO
In England, the government’s recent Transforming Primary Care initiative,14 demonstrates that the agenda could be about to swing towards promoting an old but still powerful concept: the GP–patient relationship. The £250 million announced by NHS England to support the development of new personalised services for vulnerable older people as part of this is a starting point from which we can build.
However, much more will be needed. It has been estimated that if action isn’t taken, general practice’s share of the UK health spending will slump to 7.29% by 2017, and that to simply stand still funding will need to increase to at least 9% of current UK NHS spending.15 However, to enable general practice to really transform patient care in the ways described above, the RCGP has estimated that an investment of 11% of the NHS budget across the UK will be needed by 2017, including a significant workforce boost.6 The alternative, that is continued disinvestment in general practice, simply isn’t an option if we want to put patients first.
Notes
Provenance
Commissioned; not externally peer reviewed.
- © British Journal of General Practice 2014