UK: What's Happening In Primary Care And Whether A Rethink Of The GP Consultation Process Is Long Overdue?

Last Updated: 11 September 2017
Article by Karen Taylor

In November 2016 we published our report, Primary Care Today and Tomorrow; Adapting to survive, which highlighted the growing number of challenges facing primary care, including the fact that funding has fallen well below the funding of hospitals despite expectations that more care should be delivered in primary care. It evaluated the impact of rising demand in the face of an increasingly challenged workforce. It also acknowledged that a plethora of policy initiatives had been launched to tackle many of the identified problems, including the General Practice Forward View (GPFYFW). We concluded that the future of primary care, and in particular general practice, was at a tipping point, and that immediate action was needed to ensure it had a sustainable future. Some ten months later, the media headlines continue to highlight concerns over general practice, so I thought I would use this week's blog to look at the developments to date.

Our research for the above report was unequivocal that primary care is, and remains, critical to the future overall sustainability of the NHS, and that general practices need to remain the first port of call for their local patient population. Furthermore, its multiple roles, as care coordinators, coaches and providers of treatment, advice, and support for their local populations, is highly cost-effective. However, we concluded that if we are to realise the ambition for general practice to be the responsible and caring pivot in the healthcare system, the planned reforms needed to be implemented as intended and the increased resources allocated as promised, with a sense of urgency.

Some 16 months since the GPFYFV and nine months since our report, concerns are being raised that too little is being done, and what is happening, is happening too slowly. For example, research carried out by the University of Warwick, surveying 178 GP trainees in the West Midlands, who were within three months of receiving their certificate of completion of training, found that perceptions of work-life balance and low morale during training was leading many prospective GPs away from the NHS. The research revealed that only two-thirds of trainee GPs are planning to go on to work in general practice in the NHS; and, of the GPs who said they would stay in the NHS, around two-thirds (62.8 per cent) proposed working as a locum or a salaried GP rather than entering a GP partnership. Furthermore, more than half (56.4 per cent) also said that the current political and media commentary around general practice was having a negative influence on their career intentions. Their conclusion was that trainees are being put off from a career in general practice because they are seeing first-hand the intense resource and workload pressures.1

Separately, doctors have called on the government to introduce a "black alert" for GPs so that clinicians can alert authorities when surgeries are running over maximum safe capacity.2 Indeed, our research into changes in workload found that the workload has increased year on year by between 10 and 15 per cent (or 10.51 per cent increase between 2007-08 to 2013-14 to more than 15 per cent between 2010-11 to 2014-15) - depending on the number and size of practices, location of practices, software used to log consultations, and staff and criteria included within the underlying analysis.

For many patients, their ability to see a GP or practice nurse at times of need is something that is highly valued. Moreover, while the 2017 patient survey shows continued satisfaction with their GP practice (84.8 per cent rate their practice as good, 42.9 per cent very good and 41.9 per cent fairly good), an increasing percentage of patients couldn't get an appointment on the day they wanted (an increase from 11.4 in 2016 to 11.9 per cent in 2017) with increasing numbers now waiting longer than a week for an appointment.3 The Royal College of GPs (RCGP) analysis of this survey data found that in 21 Clinical Commissioning Group (CCGs), serving around 5.6 million people, more than a quarter of patients were waiting at least a week for an appointment with their doctor or practice nurse. The RCGP suggested that if current trends continue, the number of consultations where patients waited a week or more to see a GP will rise by more than 20 million over the next five years, from 80 million occasions in 2016-17, up to 102 million by 2021-22.4

Overall however, the NHS England GP Patient survey 2017, remains very positive, with more than nine in 10 (91.9 per cent) saying that they were confident in their doctors and trusted them to deliver quality care.5 However, the survey also raised some concern in terms of accessibility of surgeries. Indeed, only two-thirds (68 per cent) of patients said it was easy to get through to their GP surgery on the phone, a decrease of 1.9 percentage points since 2016; 18.3 per cent stated that they were unable to get in touch with their GP in the last six months due to the surgery being closed; only two-thirds (68 per cent) of patients said it was easy to get through to their GP surgery on the phone, a decrease of 1.9 percentage points since 2016.

Importantly, the uptake of opportunities to utilise technology to improve accessibility have only marginally improved. For example, patients using on-line ordering of repeat prescriptions increased from only 10.4 per cent in 2016 to 11.8 per cent in 2017; only 8.9 per cent used on-line appointment booking services (up from 6.8 per cent in 2015) and 1.6 per cent of patients had accessed their own records on-line (up from 0.5 per cent in 2015). These results, suggest that there is significant scope for surgeries to improve their patients understanding of alternative routes of accessing services.

Moreover, the latest figures from NHS Digital show that NHS England has failed to increase the GP workforce in line with the targets in the GP FYFV. Estimates for March 2017 found that there was a total GP headcount of 40,039 GPs in England (excluding locums), a decrease of 46 compared to December 2016, and 658 compared to when the GPFV established the target to increase GPs by 5,000 by 2020. However, Full Time Equivalent GPs did increase marginally to 33,423 FTE GPs (excluding locums), an increase of 36 (0.1 per cent) from 33,387 at 31 December 2016; this is still some way off the target of achieving the ambition in the GP FYFV.6

While the above update is somewhat depressing in terms of progress on this much needed transformation, I thought I would put the spotlight on what a typical consultation for a GP can look and feel like to suggest that perhaps we need to look at the challenges from the bottom up rather than top down.

A typical GP consultation
On average, GP's have between 10 and 12 minutes time slots allocated per patient, for those patients attending the practice (time will also be set aside for some phone consultations and home visits where required). In this 10-12 minute time slot, the doctor is expected to go to the waiting room to locate and invite the patient into a consultation room; introduce themselves; and try to ascertain why the patient's there (there is often more than one reason, which may only be revealed as the discussion progresses). If the patient is new to the doctor there will be a need to obtain details of the person's health history, which for an increasing number of the more regular attendees, the very young, the elderly or those with long term conditions, is often quite complicated. They are then likely to need to perform a physical examination (which may be delayed slightly due to need to physically help the patient or get a chaperone, and, in some cases, a translator). Then, clothes need to be replaced, hands washed (again); blood tests or swabs may need to be taken or as a minimum organised (these need forms and sticky labels). Concurrently, the information generated needs to be entered onto the patients' record, via the computer, checks done as to the types and timing of previous prescriptions and any allergies added? All the while the clock is ticking. 

Finally the GP discusses their diagnosis and treatment options, ideally as part of a two way dialogue with the patient. At the same time, the computer may alert the GP that the patient's blood pressure needs to be rechecked; in both arms, with the patient relaxed! There may also be expectations, from on high, that the GP will use each point of contact as an opportunity to identify and discuss obesity, alcohol consumption, domestic violence, physical activity, cyberbullying, and sexual problems — or whatever the latest awareness campaign is concerned with. For those patients with long term conditions, polypharmacy is common, as are medicine queries and uncertainties; not to mention the requirement for medicines to be routinely reviewed and choices discussed. Just as you're nearing the end of the consultation, and the patient feels more relaxed and confident, the GP catches their eye, or there's a pause or change in tone, and the patient now feels able to discuss what it is she or he really wants to talk about.

Can anyone really believe that all of this can be done safely and well in 10 minutes? Work flow estimates suggest that acceptably safe practice would take double that, and excellent practice would probably need more again to ensure that everything's in place for proper, shared decision making.

So while the GP FYFV could well be the lifeline general practice and patients need, it certainly needs to be delivered, in full, and as a matter of urgency. Moreover, I would also suggest that there needs to be a rethink about what is a safe number and length of consultations for patients who need to be seen physically by the GP. Indeed, the availability of individual and population health data, technology enabled triage systems, and developments in AI, mean it should become relatively easy to move away from 'one size fits all' appointments.

Correction: The original posting for this blog omitted a reference to the source of the synopsis -  'A typical GP consultation' - which was derived from an article 'Why GPs are always running late' by Margaret McCartney, a  GP partner in Glasgow and was first published in the BMJ. https://doi.org/10.1136/bmj.j3955 (published 29 August 2017): BMJ 2017;358:j3955.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Authors
Similar Articles
Relevancy Powered by MondaqAI
 
In association with
Related Topics
 
Similar Articles
Relevancy Powered by MondaqAI
Related Articles
 
Related Video
Up-coming Events Search
Tools
Print
Font Size:
Translation
Channels
Mondaq on Twitter
 
Mondaq Free Registration
Gain access to Mondaq global archive of over 375,000 articles covering 200 countries with a personalised News Alert and automatic login on this device.
Mondaq News Alert (some suggested topics and region)
Select Topics
Registration (please scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions

Mondaq.com (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of www.mondaq.com

To Use Mondaq.com you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.

Disclaimer

The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.

General

Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions