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Pressures in general practice

The NHS is currently experiencing some of the most severe pressures in its 70-year history. As the first point of contact for most patients, GP surgeries across the country are experiencing significant and growing strain, with rising demand, practices struggling to recruit staff, and patients having to wait longer for appointments. In addition, an ageing population coupled with the rising presence of multimorbidity (people who have more than one chronic illness) means that GPs face an increasingly complex and intense workload.

Although there is a lack of publicly available data on pressures in general practice, the BMA regularly monitors data on appointment numbers, patient experience, workforce data and practice closures, which can help us build a picture of the level of strain GP practices in England are under.

 

GP practices are caring for more patients, with fewer GPs

  • Over the past year and a half, the number of general practice appointments per month in England has increased overall.
  • However, in November 2019, the monthly appointment count (28.5 million appointments) decreased by 11% compared to October 2019 (31 million appointments), which was the highest monthly appointment count since the data began being recorded mid-2018.
  • Between the 1st of December 2018 and the 30th of November 2019, GP practices undertook 311 million appointments. There were 4% less appointments in November 2019 than in November 2018.
  • The overall increase in appointments underestimates the corresponding increase in workload for GPs, who must also deal with a variety of other patient commitments, such as looking at test results, writing letters, organising referrals, other administration, doing audits, participating in staff development, and travelling to home visits. These activities are not captured in national data.
  • The number of full-time (FTE) GPs has not kept pace with this growing demand – despite the number of doctors entering GP training being higher than ever (with 3,538 training places accepted in 2019), the overall number of FTE GPs has been decreasing since September 2017.
  • As of September 2019, there are 28,213 FTE GPs, a 1.2% (340) decrease from September 2018. However, this is an increase of 58 from June 2019, when there were 28,257 FTE GPs.
  • NHS England’s International GP recruitment programme set a target to recruit 2,000 overseas doctors into GP practices by 2020 to tackle these issues; however, as of September 2019 only 140 doctors have been brought in through this programme.

 

Patients are increasingly seeing other members of the general practice team

  • Increasingly, appointments in general practice are provided by other members of the general practice team, such as practice nurses, healthcare assistants, and practice pharmacists, to improve efficiency.
  • In November 2019, 12 million appointments occurred with a non-GP healthcare professional in England. This represented a decrease of 2.1 million (15%) compared to October 2019, and a decrease of 323,000 (3%) compared to November 2018.
  • This translates to 47.1% of GP appointments occurring with a non-GP healthcare professional in England in November 2019, meaning it is likely that a larger proportion of appointments were with non-GP healthcare professionals than GPs (5.4% of appointments were unknown). This is a similar proportion to October 2019 (49.2%) and November 2018 (47.2%).
  • The total number of direct patient care staff increased from 12,555 to 13,565 between September 2018 and September 2019 – this represents an 8.8% annual increase in staff.

 

As a result of these pressures, patients are waiting longer for appointments

  • In November 2019, 19.1% of patients waited longer than two weeks for an appointment – this is a 0.6% point decrease on November 2018, and equates to over 53.5 million occasions over the past 12 months where patients waited over two weeks for an appointment from booking.
  • Over the 12 months from December 2018 to November 2019, an average of 18% of patients waited more than two weeks for an appointment.
  • It is impossible to know from current data what proportion of patients are choosing to book later because the appointment is a pre-planned follow-up, scheduled review clinic, or a preference to see a particular clinician.
  • However, the 2019 GP patient survey found that only 3.8% of respondents wanted an appointment with a week or more wait, and 57.2% of all patients saw or spoke to someone at a time they wanted or sooner (58.2% in 2018). 64.7% of patients were satisfied with the general practice appointment times that were available to them (65.9% in 2018).

 

These pressures impact on GPs themselves

  • A recent BMA survey found that 79% of GPs are often or very often working beyond their regular hours – the highest of any branch of practice.
  • Despite these pressures, the 2019 GP Patient Survey found that 95.5% of patients had trust in the last healthcare professional they saw at their GP practice, and more than 8 in 10 describe their GP practice as ‘very’ or ‘fairly’ good, a credit to GPs’ hard work and dedication.

 

The number of GP practices is also falling

  • In September 2019, there were 6,867 GP practices in England, a decrease of 270 compared to September 2018 – meaning more than five practices closed every week over that period.
  • Some of this reduction is due to smaller practices merging. However, many of these closures are also likely to be due to practices becoming unviable due to lack of staff, particularly a shortage of GP partners.

 

Spending on general practice has not kept pace

  • The share of NHS budget invested in general practice (8.1% in 2018/19) remains significantly lower than in 2005/06, when 9.6% of the budget was allocated to general practice. The BMA’s GP Committee has called for 11% of the NHS budget to be spent on general practice to reverse this trend and expand primary care.
  • The January 2019 NHS Long Term Plan committed to increase spending on primary and community health services, including general practice, by £4.5bn by 2023/24 and promised that spending on these services will increase faster than the overall NHS budget (predicted average annual real-terms increase of 3.1% between 2019/20 and 2023/24).
  • The 2019 GP Contract, used to implement the NHS long-term plan, specified that core contract funding would increase by £978 million by 2023/23, with some practices receiving funding worth £1.8bn by 2023/24 for additional staff. These changes correspond to a 22.6% real-terms increase in overall general practice funding between 2018/2019 and 2023/24.
  • In their 2019 manifesto, the Conservatives pledged to increase the number of GPs by 6,000, the number of primary care professionals by 26,000, and the number of nurse associates by 7,500, as well as delivering 50 million extra GP appointments per year.