Tackling the crisis in general practiceBMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i942 (Published 17 February 2016) Cite this as: BMJ 2016;352:i942
- 1Cambridge Centre for Health Services Research, University of Cambridge, Cambridge CB2 0SR, UK
- 2Tower Hamlets Clinical Commissioning Group, Mile End Hospital, London E1 4DG, UK
- Corresponding author: M Roland
Hospitals’ financial problems always make headlines, and The BMJ’s recent editorial by Chris Ham, chief executive of the think tank the King’s Fund, emphasised the crisis that hospitals in England are facing.1 A £2bn (€2.6bn; $2.9bn) funding deficit certainly sounds dramatic, but hospitals don’t go bust: someone usually picks up the bill. General practice doesn’t have that luxury, and its share of the NHS budget has fallen progressively in the past decade, from a high of 11% in 2006 to under 8.5% now. Many practices will see further reductions over the next three years.
On performance, hospitals again grab the headlines. But stories about breaches of waiting time targets in emergency departments rarely consider why more and more patients go to hospital—namely, the strain on general practice. Recent research shows levels of stress among general practitioners that are unprecedented since surveys began in 1998,2 with increasing workload and overwhelming regulatory burdens. GPs now do an estimated 370 million consultations each year, 60 million more than five years ago.3 Seeing 60 patients a day is not uncommon.
A recent international survey by the US Commonwealth Fund found that only 22% of UK GPs reported that the NHS was working well, a dramatic drop from 46% in 2012, and that they experienced higher levels of stress than primary care doctors in any of the other countries surveyed.4 Comments by GPs at a recent national conference encapsulate the sense of despair: “The pressure of work leaves me in constant fear of making mistakes,” and, “I am now worried about employing more staff in general practice—the reviews of our contracts and many other cuts means I have no idea what my real budget is going to be.” Confidence in the sustainability of general practice is critically low, and GPs are finding it harder to recruit trainees and to find partners to replace those who are increasingly retiring in their 50s.
NHS England’s Five Year Forward View last year presented ambitious plans for moving services into the community.5 Yet in nearly every year of the past 20 years the number of GPs as a proportion of NHS doctors has fallen,6 and in the past 10 years the number of hospital consultants has increased at twice the rate for GPs.7 Politicians and NHS leaders argue that more care should be moved into primary care, but increases in funding move inexorably into hospitals. In 2014 the consultancy Deloitte estimated, taking into account inflation and increasing demand, that the shortfall in general practice funding would be £3.36bn by 2017-18, an estimate made before “new models of care” promised to move even more work out of hospitals.8
Jewel in the crown
General practice has been described as the jewel in the NHS crown.9 GPs currently manage the great majority of patients without referral or admission to hospital. If the current strain on general practice were to shift this balance only slightly, hospitals would be overwhelmed. Figures from Scotland show that cuts to general practice funding since 2006 have been associated with a clear rise in emergency admissions, despite investment in community services.10
It is general practice that makes the NHS one of the world’s most cost effective health services—the £136 per patient per year for unlimited general practice care is less than the cost of a single visit to a hospital outpatient department. Primary care needs fair funding to deliver on the NHS’s ambitious plans, and GPs need to feel valued rather than continually criticised by politicians and regulators. For their part, hospitals need incentives to manage whole populations so that they can’t constantly shift work into general practice without resources following.
What are the solutions?
So, what’s to be done? First, general practice needs a substantial injection of new funding—like, for example, the £500m rescue package given to emergency departments in 2013. This would enable more staff to be employed to solve the two key problems facing GPs: an increasing workload and burgeoning bureaucracy. Reviews of practices’ contracts that threaten serious financial destabilisation should be put on hold while a fair funding formula is developed to replace the 25 year old Carr-Hill formula that allocates funding to individual general practices.
Second, leaders in GP federations and networks need support to help their local general practices develop new roles to take the strain off clinical staff, including physician associates, pharmacists, advanced practice nurses, and additional support for mental healthcare. These new roles also include medical administrative assistants who could release the equivalent of 1400 extra GPs by doing much of the routine paperwork that GPs have to do.11 NHS England must also tackle spiralling indemnity costs, by providing crown indemnity similar to that for hospital doctors. This is essential as GPs are increasingly asked to take on roles previously provided by hospital doctors. Bureaucracy could be slashed, in part by changing the current £224m Care Quality Commission inspection regime (a sum that doesn’t include the major cost to the NHS itself of these inspections) to one where perhaps only the 5-10% of practices found to be struggling are revisited within five years.
These things can all be done in the short term. In the medium term, there needs to be a new relationship between GPs and specialists. Consultants’ job plans need to ensure closer working with staff in primary care. The Choose and Book referral system needs radical reform to allow effective communication between primary and secondary care. We estimated that communicating by phone, email, and online video link might cut outpatient attendance by as much as 50% in some specialties.12 The Payment by Results system for funding secondary care must become a population based, capitated budget that incentivises hospitals to support patients and clinicians in the community. Leadership boards are needed to plan care for local communities, coordinating service providers in general practice, hospitals, community and mental health services, and social care. Without these, the “new models of care” outlined in the Five Year Forward View5 have little hope of achieving widespread system change.
Also in the medium term the NHS needs more staff in primary care—more GPs, through rapid implementation of the “10 point plan” agreed between NHS England, Health Education England, the BMA, and the Royal College of General Practitioners,13 and more nurses, who, lacking any clear career structure, face problems of recruitment and retention similar to those of GPs and thus need a parallel plan. We also need training courses to produce the wider multidisciplinary teams envisaged in the recent report The Future of Primary Care.6 Medical schools need incentives to produce young doctors who want to be GPs, and Health Education England’s plans to expand GP recruitment should be expedited.
Elephants in the room
Two elephants in the room can no longer be ignored. First, links to social care are crucial. Cuts to social care make it harder for hospitals to discharge patients and may also reduce primary care’s scope to support patients through “social prescribing” schemes that connect patients to beneficial activities in the community.14 Second is the NHS’s overall funding. The United Kingdom has fallen well behind its European neighbours, 13th of 15 in terms of healthcare expenditure as a percentage of gross domestic product.15 In 2000 Prime Minister Tony Blair promised to raise NHS spending to mid-European levels. Today this would require another £22bn a year.
Urgent action is needed to restore the NHS. But the crisis will not be averted by focusing on hospitals. If general practice fails, the whole NHS fails.
Competing interests: MR is a member of the BMA and a fellow of the Royal College of General Practitioners. SE is a member of the BMA Council and of the Royal College of General Practitioners.
Provenance and peer review: Commissioned; not externally peer reviewed.