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Long read: Accessing GP primary healthcare in England 

As government plans to increase access to GP-led primary care in England get underway, Public Policy Projects explores to what extent the reforms and support packages will truly deliver "Modern General Practice Access".

By Professor James Kingsland OBE, Dean Thompson PhD and Samantha Semmeling

Key insights

 

  • GP-provided primary healthcare services are under increasing pressure, with rising service demand, greater case complexities, and a proportionally smaller GP workforce.

  • As the provision of integrated care services is extended into community settings through multidisciplinary team-based care, there needs to be a cultural shift among both clinicians and patients to changing dependency on a GP as first contact.

  • Government-imposed changes to the GP contract will compel practices and PCNs to offer patients prompt care pathways and care that might not involve a GP.

  • Financial assistance from government of up to £60,000 has been offered to practices and PCNs to procure the necessary technologies so that care navigation can be rolled out.


 

Introduction

 

As a patient, being seen either in person or virtually by a primary care physician is perceived to be a foundational component of healthcare. While another provider of primary care might be an appropriate clinical option for the patient, such as a pharmacist or an optometrist, being seen by a general practitioner (GP) first and immediately remains a strong reflexive care choice for the British public. However, being able to make an appointment with a GP in England has in recent years become increasingly difficult. Politically for the UK government, the issue is a growing pain point. In particular, media and opposition party campaigning against the so-called 8am rush has resonated with citizens and their lived experience of the clamour for a now rare GP appointment.

Getting an appointment with a GP is an issue that in 2022, Dr Claire Fuller discussed in a stocktake of primary care in England in the lead up to the roll-out of the integrated care systems (ICSs) in July 2022. The Fuller Stocktake report focused on developing a vision for primary care that centred on the ease of access to proactive and multidisciplinary care, prevention, and the interdependency between these issues. Addressing ease of access as identified by Dr Fuller, may not only increase public trust with the NHS, but will also ensure community members stay healthier for longer because they have been able to access the appropriate type and level of care.

Perhaps cognisant of the public’s frustration with an inability to access GPs as their chosen provider of primary care, the government has opted to focus on ease of access to care. In the follow up white paper entitled Delivery plan for recovering access to primary care (the Delivery Plan), proposals enabling easier access to clinically appropriate primary care were laid out. One such proposal is the Modern General Practice Access (MGPA) programme. As part of this programme, the government is re-targeting £240 million to make it available to primary care networks (PCNs) and practices to help them plan and implement MGPA. The funding is available specifically for investments in digital telephony technology to stop the ‘8am rush’ and to train care navigation teams so that patients are directed to the most appropriate care provider within a PCN.

To further support access, the Delivery Plan also promised to invest £645 million over two years to expand community pharmacy services. The Pharmacy First service, which launched in February this year, means that community pharmacy teams can now treat and prescribe for seven common conditions. In addition to the contraceptive and blood pressure check services established at the end of 2023, the Pharmacy First service supports reducing pressures on general practice and aims to free up to 10 million additional GP appointments each year.

Analysis by the The Institute For Public Policy Research of the GP patient survey helps demonstrate the increasing demand for GP appointments and the subsequent pressure this has put on acute services.5 It revealed that patients are finding it harder to get GP appointments and turning to A&E for basic care needs. In 2021, 31.5 per cent of patients who tried to get a GP appointment were unable to get one, 2023 saw this figure climb to 40.8 per cent. In 2021, 860,000 people went to A&E because they couldn’t see a GP. In 2023 it was more than two million, an increase of 131 per cent.

The findings support the importance of addressing access to primary care as crucial step to securing the future sustainability of the wider healthcare system. Ultimately, enhancing the digital capabilities of GP practices to ensure people in England get the right access to care will have immediate and positive systemic impacts on population health and the wider healthcare system.

The following presents a background to the current state of access to GP primary care in England, the current access requirements on practices delivering primary care, and what is required of the new Modern General Practice Access programme.


 

Part I: The current state of access to GP primary care

 

Primary healthcare encompasses a wider range of clinical services, provided in a wider range of settings, than what is perhaps typically thought of by the general populace. As a first point of contact with the healthcare system, a primary care provider such as a dentist, optometrist or pharmacist will be able to provide a range of early interventions, treatments, and diagnostic functions that play a critical role in preventing serious illness and maintaining overall good health. However, the community expectation of primary care being delivered chiefly by a GP has brought intense focus on the number and availability of doctors working in the community.

The demand for GP delivered primary care is evident in the data collected by NHS England. There were 31.6 million appointments made in March 2023 within PCNs. Of those appointments more than 15 million, or 47.6 per cent, were with a GP, while nursing staff carried out an additional 6.6 million appointments. By comparison, in March 2019 (prior to the Covid-19 pandemic) there were approximately 26.2 million appointments made within PCNs, of which 13 million were carried out by a GP. Therefore, not only has the number of primary care appointments within that four year period risen by more than five million (an increase of 20.6 per cent), GPs across England carried out an extra two million appointments (an increase of more than 15 per cent).

A person will ask to make an appointment to see a GP for a variety of reasons. However, sometimes that person may be better served by an alternative health or care professional; it has been estimated that more than 25 per cent of GP appointments could be considered as avoidable. These avoidable appointments include patients that could have been seen by a pharmacist or directed to self-care, and patient requests for sick notes or other paperwork for benefit claims lodged with government departments.

Unsurprisingly, the number of GPs in practice has not kept pace with the substantial increase in demand for their services. In March 2023, there were 27,305 fully qualified, full-time equivalent (FTE) GPs working in England. Again, when compared to March 2019, there were 28,487 fully qualified FTE GPs. This represents a 4 per cent drop in the number of doctors available to manage the additional two million appointments required of them in March 2023. There was also a 19 per cent decrease in GPs working more than 37.5 hours per week, while those working 15 hours per week or less in March 2023 rose by more than 11 per cent from March 2019. Perhaps in response to the increased work demands and attempts by doctors to establish a work-life balance, fewer GPs worked full-time or undertook more hours.

The decline in the number of doctors and their paid working hours, when combined with changes in demographics over the same period, has exacerbated the inaccessibility of GP appointments. From the last census in 2021, it was estimated that the population of England had grown by almost 3.5 million people (6.6 per cent) since the last count in 2011. No region of England experienced population declines over that period. The result has been an increase in the number of patients per practice from 8,513 in March 2019 to 9,740 in March 2023, while the number of patients per doctor increased by 190 to 2,285 over the same period.

The announcement of the NHS Long Term Workforce Plan signals that some relief for doctors and patients alike may be working its way through the healthcare system. The plan sets the ambition to increase the number of GP speciality training places by 45-60 per cent by 2031/32 to meet demands. Further, a recent update from NHS England explains that the NHS has recruited 34,000 additional staff into healthcare roles in general practices across the country since 2019, and that this is well ahead of their target of 26,000 by March 2024.

Health Education England has also reported that it has met the government’s annual recruitment target of 4,000 GP training placements per year for the last two years. The number of trainees has indeed been building since March 2019, when 6,039 trainees were in place, to 9,123 in March 2023. However, as the Workforce Plan recognises, simply increasing the number of trainees while not developing comprehensive strategies for retention and satisfaction for doctors to remain in-place will not make the difference required in the long run.

The UK demographic figures outlined above do not indicate that the demand for GP provided primary care will diminish anytime soon. Yet, modelling developed by the Health Foundation suggests that even at current demand, the estimated shortfall of GPs is over 6,500, and is projected to increase to 15,000 by 2036/37. Therefore, even with the initial implementation of the plan committing to grow GP speciality training places by 500 in 2025/26, it will take time for this to produce fully qualified GPs who can contribute to addressing the immediate shortfalls.

Crucial though to understanding the predicted shortfall in GP numbers is developing a clear picture of what the healthcare demands in the near and long-term future will consist of. At a local level, that includes developing an understanding of the health needs of a practice’s catchment area. National and global factors such as the present economic crisis and the legacy of the Covid-19 pandemic will also shape the demands placed on primary care doctors.

To develop a sound understanding of a catchment area’s demographics and health needs and preferences means knowing the area’s age, gender, income level, and ethnic or racial composition. Other factors such as educational attainment and geographic dispersion of the population will also shape how the demand for GP provided primary care is expressed and how patients are able to physically access it. Local authorities in England can have a range of data points relevant to an area’s demographic health determinants and administer policies in neighbourhood design, housing, environment, and transport that could be co-opted into developing a picture of GP provided primary care needs.

In addition to the above, the long-tail of Covid-19 has changed and will continue to influence the nature of GP provided care. During the pandemic, appointment data revealed that large numbers of people delayed seeing their GP. At the first stages of national lockdowns and emergency response in April 2020, there were approximately four million fewer consultations with GPs than the month before. The Health Foundation has noted that the resultant unmet health needs due to these missed appointments and newly developed illnesses in mental health compounds pressure on general practice today.

An analysis of chronic condition diagnoses reveals the potential scale of the problem. There has been an observed drop in the incidence of chronic heart disease, asthma, and chronic obstructive pulmonary disease. Other reported disease, such as type 2 diabetes, dropped for now recognisable reasons during the pandemic, but diagnoses rates have since returned to pre-pandemic levels. Emergent literature has also begun to uncover the compounding effects of Covid-19 itself on pre-existing chronic conditions and socio-economic deprivation. The combination of Covid-19 complications along with undiagnosed and untreated conditions during the pandemic years has since increased case complexity for GPs and placed additional workload on associated healthcare practitioners. Therefore, not only has the quantity of work increased for GPs post-pandemic, so too has the complexity of patient care.

A final aspect to the delivery of primary care today has been the rapid change in the principal method of patient interaction with a primary care doctor. In the initial phase of the Covid-19 pandemic response, practices quickly altered contact arrangements with patients away from face-to-face appointments toward virtual and telephone consultations. Research into GP and patient satisfaction with this transition has demonstrated an overall happiness with the arrangements. However, that happiness is largely contingent on the availability of suitable technologies with appropriate training to use it and clinical suitability for ongoing remote care. Others have noted that a permanent shift towards largely remote consulting may adversely affect people with lower levels of technology literacy, disability, or a lack of English language confidence.

Much like the consultations themselves, the initial point of contact for access to GP-led primary care is evolving. Currently, the majority of patient contact with primary care remains a telephone call at 8am, hoping to be granted an appointment with a GP that day. However, some patients may be able to book appointments via apps or an online portal. In recognition of the additional workloads and case complexities described above, the UK government is changing policy to encourage redirection of patients towards other forms of primary care. The change reflects Dr Fuller’s comment that:

Whichever route people choose to say, “I need help”—whether that is through an e-consultation, a phone call or walking in—we can direct them to the people that are available to provide that care. It is not up to the patient to get it right; it is up to us as professionals working together in teams to make better use of community pharmacy, better use of the optometrists, better use of the dentists, better use of sexual health.

For practices, it is going to require a combination of efforts to meet these new requirements. It will involve significant upskilling of reception staff into trained care navigators as first points of contact for patients. Properly understanding and assessing a patient’s health needs and the available primary care providers in that area will be key and the competencies to do this should not be underestimated. This can be better facilitated with supportive technologies in place. These technologies will need to cope with the physical stream of patient contact, particularly during early mornings, while having necessary patient information readily retrievable and interoperable with systems used by other care providers within PCNs.


 

Part II: Are GP access requirements fit for purpose?

 

Regulatory requirements for patient access to GPs have been evolving over time. The overarching theme has been towards greater opening hours of general practice. In 2006, under the “advanced access” requirements, practices had to provide patients with the ability to book an appointment via telephone more than two days ahead with their preferred GP. A salient message from this is, despite significant investment in improving access, there is a danger of leaving a damaging, unintended consequence of exacerbating GP departure rates.

In 2016, the “extended access” arrangements opened the path to appointments being provided in evenings and at weekends. Changes in 2022 then further extended the requirements for PCNs to provide services longer into evenings and weekends. However, these arrangements have not been enough to meet the ongoing higher levels of demand and have possibly exacerbated GP staff departures and reductions in working g hours, as discussed in Part I.

The quantitative nature of demand for GP access has been well established as discussed above. Usefully though, the qualitative aspects to patient demand are becoming increasingly better understood and were articulated in the Fuller stocktake. This report recognises that people who want to see a GP will do so for a wide range of different reasons. Some will need to see a doctor with an urgent matter straight away, while others with minor issues might be happy to wait. Those with chronic conditions may want to prioritise doctor continuity for consistency in their care, while others with episodic needs may be comfortable with the first available clinician. The way a patient attends their appointment has also changed, ranging from face-to-face to virtual or telephone options.

The report goes on to discuss the evolution in practices and PCNs that has occurred in response to these quantitative and qualitative changes in patient demands. Forming single multidisciplinary teams that manage and direct patients to the most appropriate care at first contact has produced service efficiencies in practices that have taken up this approach. But these service improvements and efficiencies can only be achieved when there are dedicated resources, including workforce, made available.

The NHS Long Term Workforce Plan puts large emphasis on ensuring that expanding and optimising multidisciplinary teams is prioritised, particularly in primary care.32 It includes the ambition to expand the Additional Roles Reimbursement Scheme (ARRS) to provide more non-GP direct patient care staff, and train 1300 physician associates in 2023/24, increasing to more than 1500 per year by 2031/32. However, both of these methods to increase staffing in primary care have come under intense scrutiny in the last year. The ARRS scheme has been criticised for exacerbating workforce shortages in other areas of primary care, particularly community pharmacy, and there has been extensive debate around the regulation of the physician associate role.

Prior to the release of the Long Term Workforce Plan, it appears the government had formed the view that at the very least, patient access to GP primary care was not meeting public expectations. This expectation gap perhaps emerged from the three-way intersection between increased public demand for primary care services, a limited GP workforce, and the evolution in available access technologies. To address access for patients to primary care, the March 2023/24 GP contract changes were made to partially address this perceived deficit. In a letter to GPs and PCNs that articulated the contract changes, Dr Amanda Doyle, NHS England National Director for Primary Care and Community Services made clear that:

Patients should be offered an assessment of need, or signposted to an appropriate service, at first contact with the practice. Practices will therefore no longer be able to request that patients contact the practice at a later time.

The statutory instrument which came into force on 15 May 2023, sets out the “appropriate response” a practice is expected to provide to a patient upon their first contact with the practice. The term “appropriate response” is defined in the instrument as follows:

  • invite the patient for an appointment, either to attend the contractor’s practice premises or to participate in a telephone or video consultation, at a time which is appropriate and reasonable having regard to all the circumstances;

  • provide appropriate advice or care to the patient by another method;

  • invite the patient to make use of, or direct the patient towards, appropriate services which are available to the patient, including services which the patient may access themselves; or

  • communicate with the patient— to request further information; or as to when and how the patient will receive further information on the services that may be provided to them, having regard to the urgency of their clinical needs and other relevant circumstances.

In practice, the requirements for an “appropriate response” will impact patients, practices and PCNs in different ways. For a practice and PCN, it’s important to havetriage systems and procedures in place that are capable of flexing to meet the demands for the catchment area. That will initially require a thorough review and consolidation of the data available and identifying the gaps in required information.

The data sets will likely include call rates over time at various times of year, call dropouts (those unable or unwilling to hold the line in wait), up-to-date information for triage on the available services that patients can be directed to and, capacities of non-GP provided primary care to meet the needs of patients being redirected towards them. Reviewing appointment data that is available via General Practice Appointment Data may provide valuable insights of the quantitative and qualitative nature of appointments being held in GP practices.

The arrangements to take effect in the 2024/25 GP contract have built upon 2023/24 contract requirements for practices entering digital telephone contracts to additionally review the data that digital telephony systems are generating. This is to take place ahead of a national extraction of this data, with the aim of better understanding the overall demand on general practice in advance of the winter period. The data will be used by integrated care boards (ICBs) and NHS England to better understand patterns of patient demand and surge in activity to support improving the patient experience of access. The requirement will come into effect from October 2024 to allow practices time to review and understand their own data before it is shared.

For staff administering patient requests for appointments in a practice or wider PCN, the training and education required to allocate the right time and carer to the needs of the patient may be extensive and wide-ranging. The large investment put behind the recruitment of additional personnel resources as part of the workforce plan should go some way to meet the demands of the required longer initial consultations. However, perhaps pooling and centralising first contact centres in a PCN, so that resources are more efficiently used, will also need to be considered.

For patients, it will require accepting a sensitive but more thorough review of the person’s request at first point of contact. This might include discussing symptoms, circumstances, and perceived requirements in more detail with a variety of appropriate personnel and perhaps most difficult for some, accepting that their care is best provided and able to be met by someone other than a GP.

Clearly the mandated changes from government are going to require dedicated time and effort to implement by the current deadlines. However, the government has expanded upon the policy rationale and support available to practices meeting these evolutionary reforms.


 

Part III: Planning to implement “Modern General Practice Access”

 

In 2023, the Department of Health and Social Care along with NHS England released the Delivery Plan for Recovering Access to Primary Care as its policy implementation response to the demands and regulatory changes discussed above. It brings together a theme developed in the earlier Fuller stocktake report, and the changes made to the GP contract with an implementation proposal. The Fuller Stocktake was orientated around three themes of: streamlining access to care and advice; providing more proactive, personalised care from a multidisciplinary team of professionals; and helping people stay well for longer. Picking-up and developing on the first theme, the plan states an ambition to ease contact with practices for patients and to ensure that patients have a clinically appropriate care pathway set out for them after contacting the practice.

The Delivery Plan’s intent to address the ease of contact is expanded upon in the programme entitled “Modern General Practice Access”. As part of this, the government is re-targeting £240 million of existing funds toward the programme. PCNs and individual practices are eligible to apply for up to £60,000 each to implement the programme through buying new online tools and digital telephony, expanding training for the care navigation teams, and other transformation support. NHS England has indicated that more than 1,000 practices so far have applied for digital upgrades, with the remaining practices to have done so by the end of the financial year. It is essential for PCNs and practices to procure the necessary IT infrastructure by 2025 and get their workforce prepared for the new triaging requirements.

The first component of the Modern General Practice Access programme relates to the procurement of new digital telephony products. The stated intention behind the move from analogue to digital is to better deal with the morning peak hour appointment rush using greater call management capabilities. Given the analogue telephone network is due to be switched off at the end of 2025, the move to digital working is required regardless of its intention.

The requirements imposed by the 2023/24 GP contract indicate that new digital telephone contracts must be procured through the Better Purchasing Framework, produced by the NHS England National Commercial and Procurement Hub. The framework provides practices with a list of suppliers who have been through early assurance and offers an additional wrap-around support offer from the procurement hub. Significant progress has been achieved so far, with an announcement in September 2023 indicating that 100 per cent of practices still on analogue telephone lines have signed up to move to cloud based digital telephony. Further, those practices on digital telephony with lower functionality than the national standards are receiving additional support. However, this is prioritised based on available funding depending on demand.

Clearly there will be benefits for patient experience and satisfaction with better call management systems in-place. However, these benefits will only materialise when interoperability between systems occurs across a PCN. This will ensure that patients are not only easily transferred to the appropriate care point within the PCN, but the care provider has access to all relevant patient information. Therefore, PCNs and ICBs should be encouraged to procure from a single provider and train staff consistently across the PCN.

The second part of the programme focuses on the development of online engagement. Practices are currently required to allow patients to make contact via online means as mandated by the 2023/24 GP contract. Since the publishing of the delivery plan, ICBs are now able to select digital tools from the Digital Pathway Framework

Much like the improvements for patients that should come with the transition to digital telephone systems, improving the online engagement experience for patients should be a positive development. In effect, these changes mean primary care is starting to catch up with the way society has generally reorientated itself towards online engagement with consumer services. Engaging with a practice online will replicate the convenience factor of using online tools for a patient and give a greater sense of control of information regarding their care. For practices it should divert some workload away from reception staff and gather better information from the patient so that their needs are more appropriately addressed more quickly by the most suitable care provider. Despite mandating the rollout of the online engagement, whether these goals can be achieved will be dependent on the policies and procurement options that NHS England are yet to develop and share with the primary care community.

The third and final part of the programme addresses patient care navigation, assessment, and response. This is effectively the landing-point of the contact reforms proposed in the first two parts of the programme. Following contact, a patient can now expect to have a response to their care request assessed and navigated towards the most appropriate service. Whether that be a GP appointment or direction to another staff member within the wider practice team or other forms of service within the PCN. Key to the successful implementation of care navigation is the upskilling of staff, which is being supported by the National Association of Primary Care to rollout the new National Care Navigation Training programme between July 2023 and March 2024. However, whether the allocated funding of £13,500 per practice and £11,500 per PCN will adequately cover the costs associated with this transformation is yet to be seen.

Ultimately, the focus on greater care navigation to the most appropriate form of primary care is a welcome development and the progress made so far is positive. Freeing GPs to focus on the growing caseload of complex care that has developed since the Covid-19 pandemic as discussed earlier may go some way to alleviating the stresses and strains that GPs say are contributing to the decline in their own health and career satisfaction. Helping patients appropriately access other primary care providers may well reduce pressures on GPs as one component of maturing the PCN. It remains to be seen if those additional health and care roles within a PCN, now charged with delivering that care, have the capabilities, capacity, and infrastructure in place to do so.

Just as importantly but currently missing from this programme and the report generally, is a public educational component that reassures the public that their health will be equally managed and that each care provider is talking to each other. There may well be a forthcoming debate about just how well that is or is not occurring.


 

Conclusion

 

This examination of the present and future state of GP access and GPs’ future role in primary care has sought to highlight some of the very real and current challenges facing primary care in England today. The figures show that the diminishing number of GPs is coinciding with an increase in demand for their services and an increase in case complexity that requires even greater time and exercise of skill than before. Serious consideration will need to be given to prioritising allocations of funding in the NHS, which currently mainly give preference to hospital-based services, especially given that well-resourced primary care provides many solutions to the ills of the hospital sector.

The ambition to recruit and train more GPs alongside other primary care, mental health and community care roles, as outlined by the Long Term Workforce Plan, will begin to address the workforce shortages discussed, thereby increasing capacity and freeing up available appointments. However, the latest changes to GP primary care access place them in the continuum of changes to the GP contract that attempts to increase the supply of appointment availability. In this instance, rather than simply widening operational hours, patients are being directed to alternative primary care providers thereby freeing-up GPs to attend to more complex cases and those that benefit from continuity of care. Overall, the Delivery Plan sets out a series of operational ideas to alleviate pressures.

Although the Delivery Plan does make significant progress to address an ever-increasing demand upon the health care system, the aim of achieving the vision of a health and care service focused on communities over the acute sector, as set out by successive governments, is still far from being achieved. Despite the majority of health care taking place in settings other than acute hospitals, a recent report points out that there has still been larger financial and workforce growth in the acute hospital sector compared to compared to primary and community care. The same report suggests that implementing a few changes is insufficient, and that a wholesale shift is required to realise this vision.

As such, what would be welcome is a transformative Primary Care Strategy. This should set out an agreed list of aims and objectives for primary care, with plans for how, going into the next two decades, the evolving health needs of the community will be met by the NHS. At PPP, we will continue to engage with this critical public conversation with leading experts in their fields so that the policy challenges in primary care are surfaced, debated, and a path to meet those challenges is laid out.

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