General practice in England is under intense pressure at the moment from a variety of sources, including the plan to keep surgeries open from 8am to 8pm, seven days a week. These are combining to overstretch practices in an unsustainable manner.
A key factor is that patient demand is constantly increasing because of an ageing population. By 2011 the number of people aged over 65 had surpassed 10 million, and by 2031 it is predicted to hit a new peak of over 15 million. As many of these patients enter their 70s and 80s, they will develop increasingly complex health needs that require longer consultations and more intense, complicated care from their general practice. By the beginning of the next decade, there will be one million people living with dementia alone, while many more will have other conditions such as heart disease, diabetes, and additional degenerative conditions. In the majority of cases an older patient will have a number of these conditions at the same time.
The issue for general practice is that it is not only the first port of call for these patients, but increasingly the deliverer of long term care in the community. This appears to be the government’s preferred direction of travel as it publicly states that care needs to be shifted from hospitals into the community. This of course has implications not just for the treatment of older patients, but for the wider population which continues to grow. 18 million patients in the UK have a chronic condition, with the majority managed in the community by GPs. More than half of all patients in England report having long standing health conditions that fall within their GP’s remit. The average member of the public now sees their GP six times a year, double the number from ten years ago.
General practice as a whole is doing its best to cope with these challenges. Consultations have risen by an estimated 40 million since 2010. A recent BMA survey of GPs revealed that many GPs are now working beyond their contracted hours on a regular basis.
But while GPs are working harder than ever before, they are being hamstrung by declining resources that are undermining their ability to overcome the obstacles they face. It is self evident that the inflation linked rises to NHS funding are not keeping pace with the avalanche of work facing general practices. Even more worryingly, GP income streams have declined by 11%, while there has been a 2.3% rise in the cost of running a practice (including the amount spent on keeping GP practice buildings in good shape, energy bills for GP practices, and the amount spent on GP staff, including practice nurses and receptionists). The cost of running a practice now accounts for 61.6% of GP budgets—a huge amount.
The practical reality of these factors is that GPs simply do not have the resources to spend on the services needed by their patients. This includes the recruitment of extra GPs and practice staff, such as nurses. This stark reality sits at odds with the government’s constant pronouncements on shifting yet more work and services into general practice. The government’s GP access fund pilot on extended hours is an interesting pilot, but ministers haven’t clarified how 8am-8pm opening will be sustained across the country once the £50 million allocated to the 1 in 8 practices taking part runs out in a year. Other than the £50m Challenge Fund—which is only for a year—there is no new money here.
At this present time, it’s essential that the government is honest about the money available to the NHS and that it targets the resources available to those with greatest need. That must mean that meeting the needs of frail, older people and young families should take preference over widening access for those with lesser needs during the weekends.
Tackling the crisis facing general practice requires solutions that are not just linked to more resources, although if we are to deliver everything that is promised by politicians we do clearly need more GPs, more staff, and more funding. In a time of austerity delivering this will not be easy, which is why other solutions need to be considered. These include:
Encouraging self-care—The NHS is more cost-effective if patients are more resilient, empowered, and self-confident, and have greater control over their health and their lives. We need to improve health education in schools and teach pupils about managing one’s own health. We also need a new public campaign that helps patients use services appropriately.
Addressing unacceptable variations in quality—there are potentially many mechanisms for achieving this from appraisals, support for doctors in difficulty, revalidation, CQC inspections, peer support, pressure and intervention, for example via CCGs.
The survival of general practice is the survival of the NHS.
Kailash Chand has been a GP for last 30 years. He is deputy chair of the BMA council and he was on the general practitioner’s committee. He was awarded an OBE in 2010 for services to the NHS. The views he expresses in his blog posts are entirely his own.