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UK general practice in crisis: time for a rethink?
World Report
UK general practice in crisis: time for a rethink? Primary care in the UK is in crisis and requires a radical restructuring if it is to manage increasing patient demand amid cuts in resources, say experts. Emma Wilkinson reports.
Complex caseload In effect there are fewer GPs doing more work with less resource and it is simply not sustainable, says Martin Marshall, professor of health-care improvement at University College London. “There has been a doubling of consultation figures in the past 10 years but on top of that there is probably a doubling of complexity.” www.thelancet.com Vol 384 July 26, 2014
“GPs are not infrequently seeing 60–70 patients a day at 10-minute intervals and that is not sustainable or safe”, he says. An ageing population, a more proactive approach to care, and a growing number of responsibilities, have all increased the burden on GPs, he notes. “I would argue all that is a good thing but the resources haven’t come with that extra demand and responsibility.”
“‘We are loading more and more onto a model that hasn’t changed sufficiently to be able to cope...’” Better funding is part of the solution, he says (RCGP are calling for the sector to receive 11% of the NHS budget by 2017), but only alongside a rethink about what general practice does. “General practice needs to have a different vision of its role and be much prouder of the contribution it makes”, he says.
Outdated model Chris Salisbury, professor of primary health care at the University of Bristol and a GP partner in the city, has published research showing GPs are dealing with an average of three problems per consultation. “There is a building crisis due to the expectations put on general practice and what it is able to deliver”, he says. “We are loading more and more onto a model that hasn’t changed sufficiently to be able to cope with that.” Several policy initiatives have tasked GPs with keeping people out of hospital and preventing patients turning up unnecessarily to accident and emergency (A&E) departments, yet that cannot be done in 10-minute slots back to back, he says. “We need
to restructure how general practice works, I wouldn’t just throw money at the current system. “I would look at models like more nurses, fewer patients per doctor, and half hour appointments, and I would test that in a few practices.”
See Editorial page 281
Funding overhaul How much of the financial difficulties facing practices is to do with how the resources are shared? It is at least part of the problem, says Azeem Majeed, professor of primary care at Imperial College London. Capitation-based budgets, calculated with a fee per registered patient with weighting on factors such as age and deprivation, has been the mainstay of funding for decades. Majeed argues this means when GP workload increases because of demand or complexity, payment does not increase accordingly, unlike in the hospital sector. “Funding does not reflect the fact that some practices are working much harder than others”, he says. There are several ways of addressing this, he believes, including incorporating tariffs much like the payment-by-results system used in secondary care. Another proposal
UIG via Getty Images
Since 1948, general practitioners (GPs) in the UK have been funded by the National Health Service (NHS) to provide primary medical care to every man, woman, and child. Now 66 years on, the profession is warning in no uncertain terms that the system, like many of the patients it sees, is struggling under several chronic problems that have the potential to bring it to its knees. Substantially increased patient demand, staff shortages, and increasing pressure to reduce access to secondary care while extending opening hours, together with reduced funding have combined to put the future of general practice in jeopardy warn doctors’ leaders. It is far from the first time general practice has said to be facing a crisis—a Lancet report in 1950 told of exhausted and demoralised doctors, hurried work, and low standards—but the figures suggest the most recent warnings are not just hyperbole. Against a backdrop of dramatically squeezed budgets throughout the NHS, general practice now receives just 8·5% of total funding from above 10% a decade previously, according to the Royal College of General Practitioners (RCGP). Yet 90% of patient interaction happens in general practice, where the number of consultations is up 40 million from 5 years ago.
General practitioners are seeing more patients with more complex problems
295
Gustoimages/Science Photo Library
World Report
Some policies have tasked general practitioners with keeping patients out of A&E
would be for GPs to give up their independent contractor status and become NHS employees, something he admits would not be popular. But he says it is time for some radical thinking. He points to the recent annual GP conference where there was a vote on the introduction of GP appointment fees. Delegates voted against it but “a few years ago it would have been unthinkable even having a vote on it” and that is the danger of not coming up with alternative solutions, he says.
Recruitment and retention The profession is currently an “open door”, Barry Lewis, director of postgraduate GP education in the northwest of England tells The Lancet, and whichever way you look at it, the issues all come back to resources. “An awful lot of problems would be solved by an overt commitment to shift the funding imbalance in primary care and deliver the workforce that is needed”, he says. Other than that there is no easy solution, he admits, some of it is to do with better exposure to general practice during medical school, and there is also an issue with making the profession “more manageable”. Around 40% of women GPs have left the profession by age 40 years and although there has been no research, work–life balance and intensity at a time when women are also focusing 296
on family is likely to play a part. Lewis is starting a pilot project to help transition GPs who have taken time out to get back into work, something he admits is a “temporary solution” to the workforce crisis. In terms of making general practice more attractive, Lewis points to the Quality and Outcomes Framework, a performance management system introduced in 2004, as doing a lot of damage. “It set standards and that was fine but it has also been a stick to beat general practice with in terms of delivery of certain aspects of care and each year the hurdle becomes so many inches higher.”
“‘An awful lot of problems would be solved by an overt commitment to shift the funding imbalance in primary care and deliver the workforce that is needed.’”
Burn out Jennifer Napier, a GP in London and researcher funded by the National Institute of Health Research (NIHR) assessing wellbeing and distress in doctors says GPs seem to be “just surviving” at the moment, doing whatever they can to cope. “My serious concern is how long people can sustain that and what are they doing to themselves in the process.” Research done in rural Australia where retention of doctors was a real problem showed that it was never about money, she says. “The things they found quite important were mentoring and a collegiate network.” What has always surprised her, in view of the distressing problems GPs are faced with, is that there is no ethos of having space to offload and decompress, especially when burn out is such a massive issue. Jonathon Tomlinson, a GP in east London and NIHR researcher who has written for the Centre for Health and the Public Interest, says the future of general practice is going to be doctors
working part time having portfolio careers, doing other interests such as academia or teaching. “You will burn out if you do full-time practice, it’s just too stressful.” He too believes that better support for GPs is needed but also that it is time to have a conversation about what general practice can realistically do. One vital aspect that seems to be gaining traction is continuity, he says. “It is about safety, quality, and efficiency of care and there is a growing appreciation of continuity and devising systems to deal with that. And one of the downsides about the easy instant access we are supposed to provide is that it undermines continuity.”
Time to adapt 4 years ago, fed up of the 8-am race for patients to fill the available slots, Aneez Esmail, professor of general practice at the University of Manchester, switched to a doctorled phone triage system, only seeing patients when clinically relevant. “It has increased our capacity by a third and our practice has far fewer patients using A&E. I’m not saying it’s a panacea for everyone but these are the sorts of things that are within our control.” Esmail believes that although general practice is overburdened and under-resourced, the profession needs to bear some responsibility for adapting the way it works and it would not necessarily require massive upheaval. “The research shows this is a good model, it’s just that it’s being run on a shoe string...If you look at our practice budget when you take all the bits together we get £117 per annum per patient. That compares with £200 for a single visit to A&E.” “Just think what we could do with an extra £10 per patient. In our practice we could employ two practice nurses and another GP and it would transform our ability to provide care.”
Emma Wilkinson www.thelancet.com Vol 384 July 26, 2014
UK general practice in crisis: time for a rethink? Primary care in the UK is in crisis and requires a radical restructuring if it is to manage increasing patient demand amid cuts in resources, say experts. Emma Wilkinson reports.
Complex caseload In effect there are fewer GPs doing more work with less resource and it is simply not sustainable, says Martin Marshall, professor of health-care improvement at University College London. “There has been a doubling of consultation figures in the past 10 years but on top of that there is probably a doubling of complexity.” www.thelancet.com Vol 384 July 26, 2014
“GPs are not infrequently seeing 60–70 patients a day at 10-minute intervals and that is not sustainable or safe”, he says. An ageing population, a more proactive approach to care, and a growing number of responsibilities, have all increased the burden on GPs, he notes. “I would argue all that is a good thing but the resources haven’t come with that extra demand and responsibility.”
“‘We are loading more and more onto a model that hasn’t changed sufficiently to be able to cope...’” Better funding is part of the solution, he says (RCGP are calling for the sector to receive 11% of the NHS budget by 2017), but only alongside a rethink about what general practice does. “General practice needs to have a different vision of its role and be much prouder of the contribution it makes”, he says.
Outdated model Chris Salisbury, professor of primary health care at the University of Bristol and a GP partner in the city, has published research showing GPs are dealing with an average of three problems per consultation. “There is a building crisis due to the expectations put on general practice and what it is able to deliver”, he says. “We are loading more and more onto a model that hasn’t changed sufficiently to be able to cope with that.” Several policy initiatives have tasked GPs with keeping people out of hospital and preventing patients turning up unnecessarily to accident and emergency (A&E) departments, yet that cannot be done in 10-minute slots back to back, he says. “We need
to restructure how general practice works, I wouldn’t just throw money at the current system. “I would look at models like more nurses, fewer patients per doctor, and half hour appointments, and I would test that in a few practices.”
See Editorial page 281
Funding overhaul How much of the financial difficulties facing practices is to do with how the resources are shared? It is at least part of the problem, says Azeem Majeed, professor of primary care at Imperial College London. Capitation-based budgets, calculated with a fee per registered patient with weighting on factors such as age and deprivation, has been the mainstay of funding for decades. Majeed argues this means when GP workload increases because of demand or complexity, payment does not increase accordingly, unlike in the hospital sector. “Funding does not reflect the fact that some practices are working much harder than others”, he says. There are several ways of addressing this, he believes, including incorporating tariffs much like the payment-by-results system used in secondary care. Another proposal
UIG via Getty Images
Since 1948, general practitioners (GPs) in the UK have been funded by the National Health Service (NHS) to provide primary medical care to every man, woman, and child. Now 66 years on, the profession is warning in no uncertain terms that the system, like many of the patients it sees, is struggling under several chronic problems that have the potential to bring it to its knees. Substantially increased patient demand, staff shortages, and increasing pressure to reduce access to secondary care while extending opening hours, together with reduced funding have combined to put the future of general practice in jeopardy warn doctors’ leaders. It is far from the first time general practice has said to be facing a crisis—a Lancet report in 1950 told of exhausted and demoralised doctors, hurried work, and low standards—but the figures suggest the most recent warnings are not just hyperbole. Against a backdrop of dramatically squeezed budgets throughout the NHS, general practice now receives just 8·5% of total funding from above 10% a decade previously, according to the Royal College of General Practitioners (RCGP). Yet 90% of patient interaction happens in general practice, where the number of consultations is up 40 million from 5 years ago.
General practitioners are seeing more patients with more complex problems
295
Gustoimages/Science Photo Library
World Report
Some policies have tasked general practitioners with keeping patients out of A&E
would be for GPs to give up their independent contractor status and become NHS employees, something he admits would not be popular. But he says it is time for some radical thinking. He points to the recent annual GP conference where there was a vote on the introduction of GP appointment fees. Delegates voted against it but “a few years ago it would have been unthinkable even having a vote on it” and that is the danger of not coming up with alternative solutions, he says.
Recruitment and retention The profession is currently an “open door”, Barry Lewis, director of postgraduate GP education in the northwest of England tells The Lancet, and whichever way you look at it, the issues all come back to resources. “An awful lot of problems would be solved by an overt commitment to shift the funding imbalance in primary care and deliver the workforce that is needed”, he says. Other than that there is no easy solution, he admits, some of it is to do with better exposure to general practice during medical school, and there is also an issue with making the profession “more manageable”. Around 40% of women GPs have left the profession by age 40 years and although there has been no research, work–life balance and intensity at a time when women are also focusing 296
on family is likely to play a part. Lewis is starting a pilot project to help transition GPs who have taken time out to get back into work, something he admits is a “temporary solution” to the workforce crisis. In terms of making general practice more attractive, Lewis points to the Quality and Outcomes Framework, a performance management system introduced in 2004, as doing a lot of damage. “It set standards and that was fine but it has also been a stick to beat general practice with in terms of delivery of certain aspects of care and each year the hurdle becomes so many inches higher.”
“‘An awful lot of problems would be solved by an overt commitment to shift the funding imbalance in primary care and deliver the workforce that is needed.’”
Burn out Jennifer Napier, a GP in London and researcher funded by the National Institute of Health Research (NIHR) assessing wellbeing and distress in doctors says GPs seem to be “just surviving” at the moment, doing whatever they can to cope. “My serious concern is how long people can sustain that and what are they doing to themselves in the process.” Research done in rural Australia where retention of doctors was a real problem showed that it was never about money, she says. “The things they found quite important were mentoring and a collegiate network.” What has always surprised her, in view of the distressing problems GPs are faced with, is that there is no ethos of having space to offload and decompress, especially when burn out is such a massive issue. Jonathon Tomlinson, a GP in east London and NIHR researcher who has written for the Centre for Health and the Public Interest, says the future of general practice is going to be doctors
working part time having portfolio careers, doing other interests such as academia or teaching. “You will burn out if you do full-time practice, it’s just too stressful.” He too believes that better support for GPs is needed but also that it is time to have a conversation about what general practice can realistically do. One vital aspect that seems to be gaining traction is continuity, he says. “It is about safety, quality, and efficiency of care and there is a growing appreciation of continuity and devising systems to deal with that. And one of the downsides about the easy instant access we are supposed to provide is that it undermines continuity.”
Time to adapt 4 years ago, fed up of the 8-am race for patients to fill the available slots, Aneez Esmail, professor of general practice at the University of Manchester, switched to a doctorled phone triage system, only seeing patients when clinically relevant. “It has increased our capacity by a third and our practice has far fewer patients using A&E. I’m not saying it’s a panacea for everyone but these are the sorts of things that are within our control.” Esmail believes that although general practice is overburdened and under-resourced, the profession needs to bear some responsibility for adapting the way it works and it would not necessarily require massive upheaval. “The research shows this is a good model, it’s just that it’s being run on a shoe string...If you look at our practice budget when you take all the bits together we get £117 per annum per patient. That compares with £200 for a single visit to A&E.” “Just think what we could do with an extra £10 per patient. In our practice we could employ two practice nurses and another GP and it would transform our ability to provide care.”
Emma Wilkinson www.thelancet.com Vol 384 July 26, 2014