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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 rising 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. 

  • In December 2019, the monthly appointment count (24.2 million appointments) decreased by 12% compared to November 2019 (27.4 million appointments) – this is a larger relative decrease in appointments than was seen between November and December 2018 (10% decrease). There tends to be less appointments in December because of the holiday season. 

  • 1.42 million more appointments occurred in December 2019 than December 2018. 

  • Over all twelve months of 2019, 312 million appointments occurred in England – this is 3.77 million more appointments than over the same period in 2018. 

  • The overall increase in appointments underestimates the increase in workload for GPs, who must also deal with a variety of other patient commitments - these activities are not captured in national data.

  • The number of FTE (full-time) 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.

  • The current Government has pledged to deliver an additional 50 million appointments annually – this means that between 2019 and 2020 there will need to be a 16% increase in the total number of appointments, instead of the 1.22% increase seen between 2018 and 2019.

    These commitments will be hard to meet without large increases in primary care workforce, otherwise they will just result in an even higher burden of work for primary care workers. As part of their pledge, the Government has also promised to deliver 6,000 more GPs by 2024-2025. 

 

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 December 2019, 10.5 million appointments occurred with a non-GP healthcare professional in England - a decrease of 1.9 million (15%) compared to November 2019, and an increase of 929,000 (10%) compared to December 2018.

  • 45.3% of GP appointments occur with a non-GP healthcare professional in England in December 2019 - this is lower than November 2019 (47.1%) and higher than December 2018 (44.6%).

  • 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 December 2019, 17.3% of patients waited longer than two weeks for an appointment – this is a 1.8% point decrease on November 2019. 

  • Over the 12 months from January to December 2019, an average of 17.9% of patients waited more than two weeks for an appointment – the average in 2018 was 16.8%.

  • 53.9 million patients waited over 2 weeks for an appointment in 2019, and 47.6 million in 2018.

  • 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.