Background and context

General practice is in crisis. GPs are faced with unmanageable workloads coupled with a rapidly shrinking and exhausted workforce. The Covid-19 pandemic has generated a vast backlog of care. This backlog is so far largely unmeasured and unrecognised in general practice. It is exerting increasing pressure on a system that is already at breaking point.

The contractual changes imposed by NHS England in April 2022 did nothing to recognise these pressures. It was a failed opportunity to support GPs, their practices, staff and patients. The present crisis is so severe that we recommend practices take urgent action to preserve patient care and protect the wellbeing of their staff.

Understanding expectations of the NHS England guidance

The average number of patients each GP is responsible for has increased by nearly 17% since 2015 to 2,260. There are now just 0.44 fully qualified GPs per 1,000 patients in England – down from 0.52 in 2015. 

In October 2022, the highest number of GP appointments ever was offered. The great majority of GP appointments are face-to-face and consultation rates per patient have increased. Fewer GPs providing care for more patients increases the risk of harm and suboptimal care through decision fatigue. This also risks GPs becoming burned out.

This guide is designed to help GP practices make decisions that will allow them to best prioritise care. We suggest you can do this by deprioritising certain aspects of your daily activities when they fall outside of your core requirements. We offer ways of doing this that still enable you to stay within the constraints of the GMS contract.

Inevitably, some patients with non-urgent problems will have to wait longer. Other patients with issues your practice is not equipped to deal will have to be directed elsewhere. Overall, the steps we outline will allow your practice to devote its resources to those patients it is best placed to help.

Appointments

Practices must provide enough appointments to meet the reasonable need of their patients. This must be done in a way that is safe for patients and GPs.

Remote consulting and triage are safe and effective ways of delivering care. Utilising these methods may allow practices:

• to provide patient appointments more flexibly
• direct patients to the most appropriate provider of care
• prioritise care for those most in need.

We strongly recommend practices take immediate measures to move to 15 minute appointments. This is permitted by the GMS contract.

Most practices still provide care at 10-minute intervals that include note keeping, and housekeeping between patients. This is at odds with many other similar primary healthcare systems. It also is at odds with evidence around quality of care.

By extending appointments to 15 minutes, practices can reduce the need for repeated consultations with patients whilst still preserving quality of care and patient satisfaction.

This can be done without increasing the total time GPs spend consulting in their day, but itcould mean a reduction in the absolute number of appointments per session. This is in order to remain at safe levels for clinicians and patients.

Current BMA standards for a session of GP care is 4 hours 10 minutes. No more than 3 hours of this should be spent in consultation with patients. Within these limits, adequate rest breaks must be taken. Extending sessions beyond this time risks harm to patients and clinicians.

For salaried GPs who are regularly exceeding their contracted hours, a reduction in appointments is one possible intervention, whether these be face to face, telephone calls, visits, or e consults.

Unsafe working contacts

The European Union of General Practitioners and BMA have recommended a safe level of patient contacts per day in order for a GP to deliver safe care at not more than 25 contacts per day. 'At Your Service', published by the Policy Exchange and forwarded by Sajid Javid, states that 28 patient contacts per day is safe.

Present contacts per day by GPs in England are significantly in excess of this. “At Your Service” highlights that GPs are seeing on average 37 patients per day.  We recommend that practices take urgent action to move towards safe consultation numbers per day. Excess demand beyond safe levels should be directed to NHS 111, extended access hubs, or other providers.

We strongly recommend moving away from a ‘duty doctor’ system with uncapped demand. This is where clinicians may be expected to maintain unsafe levels of patient contacts in a day. In order to provide extra capacity for patient care, alternative sources should be taken advantage of wherever possible.

Care co-ordinators and appropriately trained reception staff may safely direct patients suitable alternative services that work to protocol and are under good clinical governance. This is in addition to present triaging arrangements used by many practices. These alternative arrangements could include (but are not restricted to):

• extended access appointments
• walk in clinic services
• clinical pharmacy consultation service (CPCS)
• ARRS staff with their role diverted to maximally support core provision of patient care

NHS 111 can directly book GP appointment slots to a maximum of 1 appointment per 3000 patients. It is for the practice re-triage these patients and decide how to manage them..

Many GPs now have access to remote working solutions and utilise these to manage their working day and current patient demand. Remote access can encourage a working culture that means GPs work more. For example, by logging in on evenings and weekends. This working culture should be avoided as it can disproportionately impact women and part-time GPs.

Sessional GPs are an integral and crucial component of practices. We advocate involving them in discussions at all stages when you are making changes. This is to comply with employment law related to changes in working practices, but also to utilise their expertise and experience to help shape the provision of patient services.

Waiting lists

We advise general practices to move to a waiting list system for appointments as demand currently greatly outstrips capacity.

There has been pressure on GP practices to provide near immediate assessment and management of all patient problems regardless of actual clinical urgency. This is impossible to maintain and not required by the GMS contract.

Practices are obliged by their GMS contract to provide for the reasonable needs of their patients and for the assessment of urgent problems arising in their patients in their practice area. Emergency or urgent problems can be directed to emergency departments, 999, or 111. Patients that can wait should, be placed on the waiting list if safe capacity for appointments is exceeded for the day.

General practices should have waiting lists that are based on clinical need. This is the approach that exists in secondary care. even if it means that patients with non-urgent problems may wait a number of weeks for an appointment. This only formalises the already existing informal waiting lists for patients that cannot get an appointment at a convenient time. This will allow GPs to focus their resources on those with the greatest need.

A patient’s clinical condition may well change whilst on the waiting list. You may consider reviewing the urgency at this point if you have capacity at your practice. Otherwise you may direct the patient to another service eg NHS 111 or a UTC (Urgent Treatment Centre).

Patient Participation Groups (PPGs)

Practice PPGs are a crucial ally and resource for practices. We encourage practices to engage their PPGs and to openly discuss the challenges and pressures facing general practices both in general and locally.

It’s vital to consult PPGs and get their support for any changes that you are considering. GMS regulations allow practices to provide "services delivered in the manner determined by the contractor's practice in discussion with the patient". PPGs are an important means for communicating these changes and the reasons for them to the wider patient population.

PPGs may also be able to help practices in the relations with ICBs by directly lobbying them and by demonstrating the practice’s patient engagement. They can also give crucial insight into the needs and priorities of the patient population.

Measurement of workload

NHSE (NHS England) measures GP workload based on appointment data. This gives an incomplete picture of GP activity and fails to reflect the huge number of non-appointment patient contacts.

We encourage all practices to account for patient contacts within their appointment books as a way of recording this workload. When accounting for workload, work performed in relation to repeat prescriptions and documents can be counted separately to direct patient contact. This data is not currently collected by NHSE.

By doing so, it is possible for practices to better measure and account for all patient contact. This includes even brief and informal types of contact like discussions with community teams regarding specific patients, calling patients about results, and home visits.

Accurate data allows practices to make informed decisions as to how best care for their patients. It also allows GPCE to discuss workload more effectively with NHSE.

For GPs on an employed contract, we encourage the monitoring of worked hours using a diary like Dr Diary, so that extra contractual hours can be identified, remunerated or if preferred by both employee and employer recognised with time in lieu

External un-resourced workload

Practices do not have capacity to undertake work passed to general practice from outside agencies. This may include non-contractual work coming from secondary care that is not resourced. For example, undertaking tests or referrals on behalf of secondary care providers.

Practices have no contractual obligation to undertake this work and should pass requests back to the provider. We have produced a pack of template letters for this purpose. Many practices already have protocols in place to do this.

On clinical preview of documents, GPs can highlight inappropriate work for the practice to undertake. Non-clinical staff can then use template letters to pass the work back. It is important that any protocols do not result in increased workloads.  

These actions will likely help deter local systems from passing on work that is not properly resourced. Raising instances where this has happened in LMC liaison meetings with local trusts/ICS will likely also help. If local systems fail to change their practices in relation to work that is not resourced, general practices should escalate the issue to national teams.

For a salaried GP external un-resourced workload is work which takes them over their contracted hours. This needs to be measured and then discussed with the employer so that work demands of the salaried GP can be delegated to others, prioritised such that when contract hours are delivered any remaining demands for work are handed back to the practice to manage.

In the longer term, careful job planning can be used as a tool to identify which of the various demands on a salaried doctor’s time are prioritised for delivery within the contracted hours, or a new contract with increased hours and remuneration can be agreed if both parties wish.

Job planning process are illustrated clearly in our BMA GP retention webinar.

'Core' general practice

It is crucial that GPs and practices devote their time and energy to providing services and care that are commissioned and resourced.

It is not always clear which services are included within ‘core GMS’ There is a risk that practices in different areas can interpret which services are included in different ways. This can result in some practices potentially providing services that are not separately commissioned and resourced.

Generally, if a service is commissioned locally in one area of the country, it cannot be part of core GMS anywhere in the country. We offer a list of locally commissioned services, which by definition are not core general practice, and should be locally commissioned nationwide.

If these services are not locally commissioned, then practices should decline to provide this unfunded and non-core work. It will be for the local ICS (Integrated Care System) to either then commission this within general practice or elsewhere within the system. This list may not be exhaustive and if there are services commissioned locally in your area and not on this list, please advise us and we shall add them. By defining what our core offering from general practice is, it enables us to provide the best possible care for our patients, and not be diverted into unresourced work that should be provided elsewhere, or commissioned separately.

Practice list closure

General practices should consider closing their practice list if they have reached the limit of their workforce’s capacity to provide safe care to patients.

There is a clear protocol for undertaking this action within the GMS contract and Regulations. Practices should initially consult with their patient participation group (PPG) and then with their Integrated Care Board (ICB).

Once closure is granted, assignments to the patient list can remain closed for up to 12 months.

Workload prioritisation

We strongly recommend that practices cease all non-contractual work and divert their resources to core services. This may include giving notice on enhanced services if you consider these to be low value. 

Practices are obliged to provide care for their patients as defined in the core GMS contract. Care outside of the core GMS contract is detailed in DES (Directed Enhanced Service), LCS(Locally Commissioned Services), QOF (Quality and Outcomes Framework) and IIF (Investment and Impact Fund) arrangements. Providing patient care within these arrangements is voluntary for practices and attracts payment separate to core GMS.

PCN DES (primary care network directed enhanced service)

NHSE (NHS England) rolled out the PCN (Primary Care Network) DES in 2019/20 and has invested further in the DES since that time. Whilst 95% of practices in England are part of a PCN, the perceived success of PCNs for practices and patients has varied hugely across the country.

Many feel that the requirements of the DES outweighed the benefit brought by the investment into practices and ARRS (Additional Roles Reimbursement Scheme) staff.

By signing up to the DES, practices receive a payment of £1.76 per patient (network participation payment) and PCNs receive £1.50 per patient. Further income streams come from the IIF, ARRS reimbursement, and PCN clinical director payments.

NHSE has published its proposals for PCN requirements for 2022/23 without agreement from GPCE.This asks PCNs to meet greater requirements than before.

Practices will need to consider if the PCN DES enables them to offer safe and effective patient care within the context of their wider practice and their present workforce. 

There is a mechanism by which practices may express that they no longer choose to continue within the DES between 1 April and 30 April 2023 to their ICS, or at any point at which there is a change to the PCN DES by NHSE.

If practices remain within the DES they are contractually obliged to provide the requirements as set out, though the IIF is paid on activity. Many of the IIF activities probably derive little direct patient benefit, and the incentive associated may not be cost efficient for PCNs to undertake. As such, PCNs may elect not to undertake this work.If you choose to leave the DES, the payments to your practice associated with it would stop.

ARRS staff would no longer be able to provide services to patients on your practice list and the PCN itself could be at risk. ICSs are obliged to provide services for patients registered with practices not signed up to the PCN DES. This should mean patients continue to benefit from the services provided by PCNs, without the requirement on their practice.

Managing workload as a salaried GP

Salaried GPs are on a time-based contract and must be remunerated for every hour they are expected to work including clinical care, indirect clinical care (letters, scripts, tasks etc) and other activities like meetings. All time at work counts as work and all work must be paid for (including work done remotely). This is in keeping with the SiMAP and Jaeger rulings under the EWTD (European working time directive).

Indirect clinical care does not include necessary time spent in team meetings.

Salaried GPs are currently working on average 25% additional hours on top of contracted hours (according to the University of Manchester national GP Worklife Survey). Urgent steps must be taken to identify these hours, which can then be paid promptly or where mutually acceptable should be recognised with time off in lieu (TOIL). The use of a diary or the BMA’s Dr Diary application may help in identifying these additional hours.

Where demand for additional work arises unexpectedly (for example to cover sickness absence) the salaried doctor should be offered remuneration or TOIL for this time. This hourly rate for this work may be higher than the standard salaried hourly rate reflecting its impact (unscheduled) and lack of accrued benefits for this time (annual leave, CPD, sick leave).

For ongoing predictable demand which exceeds contractual hours, in addition to payment, there needs to be urgent discussion to reach agreement on one of 2 possible solutions:

1. a) prioritization: identify which areas of work can be dropped from the salaried doctors workload (whether admin/ indirect clinical care or appointments reduced) to enable them to continue to work within their contract
2. b) revised job plan, hours and pay: agree a mutually agreeable change to the working hours and the payment rates for those hours. The job plan should reflect a realistic case load for the contracted hours ideally based on 15-minute appointments with 3:1 ratio for indirect clinical care, having deducted time required for team meetings.

Increased demands on general practice must not cause salaried GPs to work beyond their contracted hours or terms of employment, and effective planning and discussion must take place at the earliest opportunity.

Managing workload as a locum GP

Locums work in a self employed capacity. As such, they should define the terms of the service they offer, including a clear description of the caseload (both direct and indirect clinical care where relevant) they will offer within a given time period.

This is to ensure they are working safely within their capacity and competencies. It should recognise that a lack of familiarity with patients, processes, referral pathways and teams contributes a level of risk for the clinician which they need to manage through their terms and conditions.

This may be reflected in the clinician choosing to offer different terms of service in different services. Any additional work asked of the locum outside of the terms of service they have offered is subject to their agreement, and additional mutually agreed remuneration.

Conclusion

Our first duty is to our patients. We want to be able to provide safe, high-quality care to our patients, without risking others or ourselves. At a time of unprecedented pressures, we must make changes to our systems to preserve patient care in the face of a shrinking workforce and rising workloads. All this must be done within the constraints of the present GMS contract.

The changes detailed here are not exhaustive but provide an example for practices. The BMA and LMCs are able to support and advise practices further on specific proposals.

It is likely to be the case that practices provide fewer services to their patients in order to preserve the central core services of general practice. This may make it appear that practices are providing less care but. It will in fact mean we concentrate our resource, staff and energy on providing what only we, as GPs, are able to offer, and cease to offer that which other parts of the NHS should be doing.

We cannot care for our patients if we do not care for ourselves and our colleagues.