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New plan for supporting general practice in England

BMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2585 (Published 22 October 2021) Cite this as: BMJ 2021;375:n2585

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Some of the goals of the NHSE proposals are good, but the solutions are not radical enough and look too simple

Dear Editor

Alderwick and Fisher are right to point out that many current problems in GPs are long term and need long term solutions.

But the NHSE plan doesn't propose much that is new or long term and what it does propose is often simplistic and may not work.

The authors rightly point out that the short term proposals for improving performance might be counterproductive. This will happen if the proposals are seen as a way to do "performance management" not improvement and are based on simplistic metrics. Specifically, a target for the proportion of patients seen face to face is far too simplistic and ignores the issues of patient choice and patient satisfaction

For example, many practices offering online access pre-pandemic saw just ~30% of patients requesting a face to face response (given a choice of video, message, phone call, f-to-f...). During the pandemic these practices saw that preference fall sharply and many are still seeing only about 10% of patients requesting a face to face response. This will probably rise as worries about covid decline but a target of >20% will run contrary to what patients want and will damage patient satisfaction which the proposals also claim to care about.

And the report fails to mention other important metrics relevant to both patient satisfaction and clinical outcomes. For example, how long the patient has to wait for a response. Some online systems achieve 80-90% same day responses (including f-to-f, messages and phone calls). Pre covid GPs across england averaged significantly less than 50% and many patients waited more than a week for their f-to-f appointment. If one consequence of demanding higher levels of f-to-f is that long waits again become common, this may make both satisfaction and outcomes worse. NHSE should not impose a target for levels of f-to-f appointments without taking those other trade-offs into account.

Tackling inequalities and variation in service are important. If one outcome of the report is that we get much better practice-level data that helps identify variation and tackle it that will be useful. But this won't work if simplistic targets are set for what performance is expected. We need to understand in detail how GPs are handling their demand (what mix of response types are being used, how fast GPs respond and how satisfied their patients are). Since perhaps only 50% of practices offer any digital access (NHSE hasn't published the data so this number is a guess) we need to see what the others are doing. And we need to see which digital systems work well for both patients and practices (there are perhaps 20 different tools and some are far more effective than others (again NHSE has not yet published data that might help GPs decide which is which).

One last thing the report shys away from is a major overhaul of the GP funding formula. This would be the single most effective way to tackle major variation in the GP:patient ratio across different regions. The formula mostly ignores deprivation and overweights age. This means GPs in deprived cities get far less money than those in rural retirement hotspots and leads to more than twofold variation in GPs per patient across the country. There is a big opportunity to finally address this problems by directing more funding to deprived patients. That would be a good long term fix that is long overdue.

Competing interests: No competing interests

24 October 2021
stephen black
data scientist
(None)
biggleswade, bedfordshire