People’s inability to get a convenient appointment with their GP practice dominates conversations about the NHS and it wasn’t a surprise that political parties would look to address access in their election pledges.
So far, the parties have resisted suggesting a waiting times target. And that’s no bad thing—evaluation of the 48-hour access introduced in 2000 found that not only did most practices not meet the target, the over emphasis on rapid access interfered with providing access to appropriate care (Salisbury et al 2007). Overall patient satisfaction measured by the GP patient survey actually went down during that time.
This time the focus has been on increasing capacity and staffing in order to improve access. The Conservatives have pledged instead to increase available appointments by 50 million by having 6,000 more GPs by 2024/25 plus 6,000 more nurses, physiotherapists, and pharmacists. Labour have pledged a 40 per cent increase in GP training places.
Any commitment to improve capacity in general practice has to be welcome, but it will hinge on the ability to recruit, and—more importantly—retain enough GPs and other professionals. History suggests this may be a Sisyphean task. On the positive side, more GPs are being trained than ever, reaching a record 3,538 in 2019. The Conservatives have promised to further increase the number of training posts to 4,000 and Labour to 5,000. But the rise in trainee numbers to date has not been reflected in an increase in overall GP numbers which have at best been static as more GPs leave than join. It’s easy to see why the reaction from the profession to increasing workforce numbers through recruitment and retention initiatives appears to have been a bit of a collective eye roll, especially given the failure to deliver on the previous commitment to provide 5000 more GPs by 2020.
GPs are under significant pressure, with an increasing clinical and administrative workload (Baird et al 2016). The GMC’s 2019 State of medical education and practice report published earlier this year found that half of GPs often feel unable to cope and often work beyond their contracted hours (compared to a quarter of doctors overall) and were also significantly more likely than other doctors to have reduced their working hours over the past year. In addition to promising to address the pension issues that have driven a reduction in GP working hours, the Conservatives have pledged to do more on retention and to increase overseas recruitment. On the latter it’s worth noting that despite the efforts of NHS England to recruit 2,000 overseas doctors into GP practices by 2020, the international GP recruitment programme had brought in just 140 doctors by September this year.
If general practice is to continue to provide high quality, responsive and effective care it will need to use the diverse skills of a range of professionals, as the Conservatives have recognised. The numbers of other professionals working in general practice has been increasing: investment in clinical pharmacists, physiotherapists, paramedics, link workers and physician associates has been growing and will be supported through the new GP contract framework. But again, this is not a panacea particularly given an overall shortage of nurses and paramedics in particular. The GP estate is also creaking, and there will need to be investment here to make sure there is room for the new workforce. Labour have pledged investment in primary care estate although the detail is not yet clear.
So is workforce the solution to access? I believe that increasing the available workforce is essential, but key to that is a relentless focus on managing workload. There are practices who have managed to do just that, through a combination of team working, system redesign and investment in technology, but support for implementation is significantly lacking in primary care. Improvements in data and data analytics to fully understand the demand/capacity gap; investment in technological infrastructure to support digital consulting approaches and dedicated, expert service improvement support for general practice are all critical and will also need to be underpinned by engaging with patients and communities if the access issue is to be solved.
Beccy Baird, Senior Fellow, The King’s Fund.
Competing interests: None declared.