Are our GPS fit for purpose?
With rising numbers of patients struggling to see a family doctor, Rosie Taylor asks if Britain’s general practice set-up needs radical change
Last week, when a friend in London tried to book a doctors’ appointment, she was told the next available slot was at the end of November.
Another friend, who lives in East Sussex, tried to see his regular GP this summer but there was a six-week wait as the doctor now works part-time.
Last year, my uncle in Oxfordshire had to visit his GP three times before finally being referred to a specialist who diagnosed him with cancer.
This may be a tiny and unscientific sample, but these experiences are far from unique. All over the country, patients are complaining about long waits, problems getting appointments out of working hours and difficulties seeing the same doctor consecutively.
A national patient survey earlier this year found a third struggle to get through on the phone to make an appointment, a fifth found their surgery shut when they needed it, and fewer than half of patients are always able to see their preferred GP.
GPS are finding the situation equally frustrating. Thomas (not his real name), 57, who has served his Gloucestershire practice for nearly three decades, is retiring early due to burdensome bureaucracy and changes to pension rules. He understands why patients want to see the same GP.
“They don’t want to have to explain their background over and over again every time they go to the doctor, they want to speak to someone who knows their history,” he says.
And the problems don’t end once patients get an appointment.
The UK offers some of the shortest appointments in the Western world and the average 10-minute slot has been criticised by patient groups and doctors alike as “inadequate” time to deal with patients’ increasingly complex health issues. A lack of continuity of care and short appointments have also been partly blamed for the UK’S cancer survival rates lagging behind those of similar countries such as Australia, Denmark and Canada. Under-pressure doctors who don’t know their patients may be more likely to miss symptoms and refer patients to hospital later, affecting their chances of survival.
This could also be one factor why women in the UK get diagnosed later than men for most diseases. Men, who might be more likely to be direct in conversation about their symptoms, are less likely to need to see a GP multiple times before getting the right treatment, a study found this year.
Various government schemes have
‘Patients are waiting too long and GPS are burning out as they try to meet demand’
tried to improve access to GPS, but without great success. As far back as 2008, Gordon Brown was promising to extend GPS’ hours to the weekends and evenings, but was unable to make meaningful change.
The latest move, “extended access”, rolled out nationwide this year following a Conservative manifesto pledge, is meant to ensure all patients can access routine appointments at evenings and weekends.
In reality, extended access appointment slots are usually shared between groups of surgeries, which means patients are unlikely to see their regular doctor and, particularly in rural areas, may have to travel miles to a different practice.
There has been little government publicity around the move, few patients know they can ask for these appointments and some GPS seem reluctant to advertise them.
Another friend in London who booked a GP appointment for her daughter last week was initially given a slot 10 days later. “It was only when I asked about extended access that the receptionist admitted she could actually come in a week sooner on the Saturday instead,” she says.
An investigation by doctors’ magazine Pulse last year, before the full national roll-out of the scheme, found an average of one in four extended access appointments went unfilled. In the worst areas as few as three per cent were taken up on Sundays. It means GPS are being paid to sit in surgeries on evenings and weekends twiddling their thumbs, while waiting lists continue to grow during regular hours.
So why is the system not working as well as it should?
One major factor is a chronic staffing shortage, worsened by one in 20 senior GPS leaving the health service last year. NHS figures show that more than 1,000 GP partners – usually long-standing GPS who run practices – left in the 12 months to June 2019.
Despite government pledges to recruit 5,000 more GPS by 2020 and increase the number of training posts, the rate of GPS leaving continues to outstrip those joining.
The reasons why are complex, but doctors complain of struggling to juggle ever-expanding bureaucracy alongside growing demand from an ageing population with increasingly complex healthcare needs.
And although full-time GPS earn an average salary of £105,000 and benefit from a generous NHS pension on retirement, recent Treasury pension rule changes have had the unforeseen effect of unfairly punishing GPS by landing them with huge additional tax bills while they are still working – sometimes to the extent where they can earn the same by halving their hours.
The “pensions crisis” has triggered up to three quarters of GPS to cut or plan to cut their hours, according to the doctors’ union the British Medical Association.
“With fewer doctors, the rise in workload becomes untenable, waits for appointments increase and GPS are unable to dedicate enough time to individual consultations. We know this is upsetting for patients and it is equally frustrating to GPS,” says Dr Richard Vautrey, GP committee chair of the BMA.
Prof Helen Stokes-lampard, the chairman of the Royal College of GPS, agrees that general practice is facing “intense pressures”.
“We’ve had years of underfunding, we’re making more consultations than ever before, and GP numbers are falling. Some of the consequences are that patients are waiting too long for appointments, and GPS and our teams are burning out as they try to meet demand,” she says.
However, many GPS also choose to work part-time, taking advantage of what is one of the few professions to offer decent salaries and pensions as well as flexible working, which particularly suits working mothers, for example.
In response to a Pulse survey in May, NHS England admitted almost 9 in 10 salaried GPS are now working part time. But, crucially, is the way our GP system set up putting patients at harm?
Unlike in European countries such as France, Germany and Italy, NHS patients normally must see a GP before they can be referred to a specialist.
Experts are now questioning whether the UK needs to move away from this “gatekeeper” system.
“You have to ask whether we were kidding ourselves when we set up the NHS that this was the only way to provide healthcare,” says Prof Roger Jones, emeritus professor at King’s College London and editor of the British Journal of General Practice.
He points to France, where people visit different specialists depending on their symptoms, so someone with a headache visits a neurologist and someone with stomach pain sees a gastroenterologist.
“It can lead to some missed targeting [where patients accidentally choose the wrong specialist], but when you look
‘Were we kidding ourselves that this was the only way to provide healthcare?’
at French health outcomes they’re not bad at all,” he adds.
Beccy Baird, a senior fellow in health policy at The King’s Fund who has researched GP models worldwide, believes a “team-working” structure used widely in countries like New Zealand works best.
“It’s about seeing a doctor as leader of a wider team of professionals, all of whom have a really good role to play. These people need to all operate as a team: meeting in the morning, looking in at who’s coming in that day and who the best person is to see them, whether that’s a doctor, a nurse or another healthcare professional,” she says.
Baird says international models show this can work. In Alaska, for example, a mixed team of healthcare professionals sit in a central area and whoever is most appropriate visits patients in consulting rooms.
In New Zealand, healthcare assistants carry out work like helping elderly patients get undressed before a doctor comes in, meaning GPS have more time to focus on medical care.
While many practices in England are exploring similar systems, Baird admits they can be hard to implement, especially as many British GP surgeries are based in converted old houses, which can be difficult and expensive to restructure to suit team-working.
Technology has been suggested as a potential answer to some of the problems. When patients can email or video call a GP, it can be easier and more efficient than a face-to-face appointment. But systems offering virtual consultations, like Babylon’s GP at Hand app, have been criticised for failing to support patients with long-term conditions – who make up the vast majority of people regularly accessing GPS.
“Technology should be part of wider provision, not separated from it,” says Baird. “There’s no reason you can’t offer email or video consultations within normal general practice.”
Prof Stokes-lampard believes that, instead of changing the GP system, the Government could help it thrive by providing more funding and reducing bureaucracy.
“The model of general practice in the UK is what keeps the NHS sustainable, but it is also what allows us to forge such strong and important relationships with our patients – and why, despite the intense pressures we face, and frustrations they have with access, our patients consistently report having very high levels of trust and confidence in their GP,” she adds.