The State of General Practice in England: Implementing Reform or Supporting the Status Quo?
General practice in England, as in the rest of the UK, is in a “crisis” and indeed has been so for many years, prompting the use of much emotive language, including “failing,” “at the breaking point,” “on the brink,” and “in meltdown.” Politicians have, as would be expected, stepped in with yet another new series of suggested changes, some of them not particularly well thought out. Sir Keir Starmer, Labour Party leader, writing in The Telegraph on 14 January 2023, shared his most recent thoughts in a contribution provocatively titled “The NHS is not an out-of-bounds shrine. It needs unsentimental reform.” He seems keen to change the hallowed status of GPs from independent contractors into salaried NHS employees, just as he seeks improve access to their services, while also encouraging people to bypass their GPs altogether and self-refer themselves to specialists when they feel appropriate.
The crisis is almost universally accepted as the foreseeable result of rising demand for services outstripping the supply of providers, which has overwhelmed the capacity of the primary care sector to deal with its workload. The population continues to grow, GPs are reportedly seeing more patients than ever, patient expectations are rising (technological innovation, new treatments), and users of the service frequently have complex needs (elderly, multiple medical illnesses) or unaddressed mental health issues. To this list must be added the impact of the COVID pandemic, during which general practices took the lion’s share of administering vaccines, and the ongoing problems of Long COVID. On the supply side, funding of the service has not kept up with inflation and the numbers of GPs willing to commit to full-time patient care have lagged behind. According to NHS Digital, as of October 2022, there were 36,854 full-time GP equivalents (not absolute numbers), compared with 34, 392 in September 2015.
General practice has evolved from single-handed practitioner or two-partner practices to multi-partner group practices, which employ a range of allied healthcare professionals (nurses, nurse practitioners, healthcare assistants, physician’s assistants, pharmacists, physiotherapists, health coaches, etc.) and administrative staff (practice managers, receptionists). Their work is complemented by paramedics, who help keep patients out of hospitals. Specialists may also provide community-based services, typically in a polyclinic model, which has failed to develop within the NHS.
Since the NHS was established in 1948, partners in general practice have functioned as independent, self-employed contractors, rather than as salaried NHS employees, taking on a combination of clinical and administrative duties. But things are changing fast. Many GPs no longer provide full-time patient-related care, but have instead opted for part-time work or work as salaried GPs. Some prefer retainer work, lucrative locum jobs, or so-called portfolio careers, mixing primary care commitments with other duties. This allows them to stay clear of administrative responsibilities and allows for flexibility at work and a better work-life balance. Many GPs are also leaving the profession, either retiring early, moving abroad, or taking on alternative employment.
The traditional model of care from cradle to grave by a succession of named GPs has long disappeared, and now difficulties of access, lack of continuity in seeing GPs, and a lack of out-of-hours cover, whether on evenings, weekends, and holidays bedevil the system. Since 2004, GPs have indeed been allowed to opt out of providing out-of-hours cover, outside of core working hours. Access to a GP is a particular problem, and some practices, such as the 8 AM queue of phone calls by service users seeking an urgent appointment, and the inappropriate triage of calls by receptionists, can be considered unworthy of a 21st century healthcare system in a developed country-a view that is regularly reflected in GP Patient Surveys. Difficulties with access are encouraging more and more people to take out private health insurance and register with private GPs, who can guarantee urgent appointments, albeit at a cost.
GPs continue to provide a range of services to their local communities. These include the identification and management of illnesses, prescribing treatments, referrals to other services where appropriate, and supervising long-term medical care. GPs have traditionally performed a gatekeeper function, preventing hospital specialist services from being overwhelmed by inappropriate demand. Practices are also involved in health promotion activities, health screening, and immunisation. Some practices provide optional extras, such as minor surgery. The hope that GPs would take on a wider range of services has mostly not materialised, as they have been forced instead to supervise the care of patients under specialist hospital care.
The traditional face-to-face consultation, once a cornerstone of general practice, was dealt a massive blow during the COVID pandemic, as practices took to telephone and video consultations and email communications to reach out to their clients. Some practices even limited their consultations to the discussion of health problems one at a time. The remote provision of healthcare, such as through telehealth schemes, was boosted. Some groups of people were disadvantaged, including frail older people, the disabled, digitally excluded folks, and those who have yet to master the English language.
There can be no doubt that procedures need to be more centred around, and responsive to, patient needs, but it is particularly hard to push reform, encourage innovation, and drive productivity when there just aren’t enough providers, and those who are in the frontline often claim to be overworked, demoralised, and burnt-out. In other words, the NHS can be confirmed to be operating in crisis mode and only a complete system-wide overhaul, rather than merely tinkering at the edges and recommending reactive, ill-conceived, and unsustainable changes to the way the service is provided and funded, mostly to placate an increasingly dissatisfied general public.
In the short term, cutting down on paperwork and on target-related administrative tasks (related to the Quality and Outcomes Framework) should free up time for direct patient care, while collaborative work between local general practices, within integrated care systems, can better spread out the workload. GPs need to be provided with better access to specialised diagnostic imaging procedures, such as ultrasound and MRI scans. Continuing to build on existing fast-track referral pathways should ensure better care for patients with cancer, heart disease, and other conditions requiring specialist care in hospital. Many clinical duties can be, and are being, taken on by nurse practitioners, community pharmacists, physician’s assistants, physiotherapists, and other healthcare professionals, who can all enable patients to be treated at home and not in hospital wherever appropriate. Recruitment is a longer-term fix, requiring larger numbers would-be doctors in training and the setting up of new medical schools- aspirations that will not help with the immediate situation. Retention of existing GPs and encouraging the return to practice of recently retired GPs demands improved working conditions, including renovated practice buildings and up-to-date onsite facilities.
Existing models of primary health care in the English-speaking world and in Western Europe may have their merits, but none can provide a meaningful alternative to the woes of the NHS without moving away from the health service’s existing free-at-point-of-care access model and moving to models that entail health insurance and co-payments for services. It seems that the government is set upon tightening its purse-strings and that any promise of increased funding can never play catch up with the needs of the service. The NHS can, despite its considerable merits, be likened to a poisoned chalice, and the political will to tackle its issues boldly and head-on appears to be short supply at present.
Ashis Banerjee