NHS satisfaction survey underlines need to support and nurture general practice

The results of the latest British Social Attitudes (BSA) Survey of satisfaction with the NHS and its services make grim reading for general practice.1 In 2021, satisfaction with GPs fell an unprecedented 30 percentage points to its lowest ever level of 38 per cent.2 This is a shocking fall: from the survey’s inception in 1983 until 2018, general practice had held the top spot over all other NHS services in every year, even if by 2018 satisfaction had already fallen from its last peak of 80% in 2009.

What’s driving this drop? It will probably be no surprise that the main reason for dissatisfaction with the NHS expressed by participants in the survey was the difficulty in getting appointments. The fall in satisfaction is not due to the quality of care received, it’s getting access to that care in the first place.

However, let’s be clear, this is not a problem caused by covid-19, even though it has been exacerbated by it. Activity has been rising and is higher than ever before, but year-on-year demand growth has outstripped available capacity. Longer term drivers of rising demand—a growing population with many experiencing long term conditions—have been magnified by covid-19 as people stayed away from the service at the beginning of the pandemic, but are now presenting with needs that must be addressed.

Increasing capacity may appear the obvious answer and the government has repeatedly announced targets of additional GPs (most recently in the 2019 general election), though with little actual success. Increasing capacity in the workforce, particularly the clinical workforce, to meet the demands of the population is critical—both recruiting more staff and retaining those that are already there. This is not likely to be a quick fix. Workforce shortages across the NHS mean that in the short term there is no additional pool of clinical staff waiting to be employed. And while the investment of 26 000 extra clinical roles in general practice has the potential to increase capacity this depends on careful implementation which at present most practices and primary care networks (PCNs) do not have the necessary capacity or skills to do.3 There is also a lack of agreement about whether the roles are primarily intended to deliver the additional requirements of the PCN contract or to do what might be considered the “core” work of general practice.

If it is hard (though important) to increase supply, then better management of demand and improved productivity may provide part of the answer. There is no shortage of technical and structural solutions available for practices to deploy to make the most of their capacity and a huge amount of guidance, national programmes, and case studies on how to improve access. The issue is not what model to choose, but how to help practices to implement change well. Capacity and skills to support transformation and redesign are lacking and general practice does not have access to the kind of support that might be available in other parts of the NHS (particularly Trusts). Some GP federations, clinical commissioning groups (CCGs) or local medical committees (LMCs) are providing support, but since the demise of primary care trusts (PCTs) there has been very limited local and system level capacity focused on primary care improvement.4 The high workload in general practice makes this lack of support even more critical as the case studies of best practice continue to grow. To turn this around, Integrated Care Systems will need a clear plan to provide organisational development, leadership skills development, and service redesign support.

General practice in England is incredibly diverse. It is this diversity and connection to local communities that allowed practices and PCNs to rapidly flex services and deliver an unprecedented vaccination programme. Yet this diversity also means that there can be no single solution and there is certainly no easy structural change for any government looking for a magic bullet to restore access (as if structural change in the NHS was ever easy). The upcoming Fuller Stocktake, led by Claire Fuller—the leader designate of the Surrey Heartlands ICS but also a practising GP—will provide the next opportunity for NHS England to set out proposals for general practice within a reformed NHS.5 The depth of the challenges facing general practice and primary care more generally, means these proposals are unlikely to be the last national review. But government desire for quick fixes will need to be balanced with the differing needs of primary care across the country.

The NHS has been focused on how to overcome long waits for planned care in hospitals. Yet the BSA results underline the even greater shock experienced by the public accessing general practice, coming as it does to a service already well off its peak levels of satisfaction. General practice and primary care are the bedrock of the NHS, where most people receive their care. We hope that this reminder of the importance of general practice will re-double efforts to support and nurture the service, and help walk the hard miles to raise capacity and help general practices make the most of the innovation and re-design available.