Healthcare on the brink? Assessing the crisis in General Practice.

AuthorIliffe, Steve
PositionUNDERSTANDING PUBLIC SERVICES

Since at least 2014 England's NHS has been under visible strain. Ambulances are queuing outside Accident & Emergency departments, patients waiting on trolleys, and hospital beds are being occupied by people medically fit for discharge. Waiting time targets have slipped, staff vacancies remain unfilled, and managers agitate for more resources. Local campaigns rally against NHS cuts, political groups oppose privatisation, and the word 'crisis' is widely used. In the public mind, the focus of this 'crisis'--like that of the Health Service itself--is to be found in hospitals. But behind the hospital drama there is a second crisis, in general practice. This article explores this under-appreciated crisis, and the possible policy responses a Labour government might pursue.

GPs under strain

The crisis in general practice is both predictable and unexpected. Whilst 90 per cent of the footfall in the NHS is outside hospitals, 75 per cent of the NHS budget goes to hospitals. This imbalance makes stresses in general practice seem inevitable, especially when the hospital sector itself is short of funds and agitating for more funding. On the other hand, general practice in the 2000s had never had it so good, with a dramatic rise in incomes following New Labour's GP contract changes of 2004. The new GP contract introduced performance-related pay using the Quality and Outcomes Framework, a mechanism designed to reward good quality clinical care and competent practice management. It also removed GP responsibility for out-of-hours work, making general practice an office-hours job. The positive mood created by the reforms did not last long. GP incomes peaked, then began to fall, while the demand for appointments continued to increase. By 2014/15 average real GP earnings had returned to the level of 2003/4 (see Figure 2 below).

The strain that stagnant wages and increasing workload has placed on GPs has been widely observed in both the media and the health policy community. In November 2014 the Observer newspaper quoted the President of the Royal College of General Practitioners as saying:

... doctors are routinely having to work ii hour days and are making between 40-60 patient contacts a day. We now make 340 million patient consultations a year--40 million more than five years ago. In 2016, a King's Fund commentator argued that: 'The pressures on general practice are now so great that it is at risk of imploding without rapid and radical action'. (1) Professor Martin Roland and Dr. Sam Everington, writing in the British Medical Journal in 2016, warned that 'If general practice fails, the whole NHS fails'. (2)

The British Medical Association blames bureaucracy, 'box ticking' and target chasing for reducing contact time with patients. It also highlighted the worsening economic situation in general practice, claiming that earnings had dropped by 11 per cent between 2008 and 2014, whilst the cost of running practices had risen by 2 per cent. (3)

Funding and workload challenges are contributing to a crisis in the recruitment and retention of GPs. This, in turn, puts even more pressure on practitioners to work longer hours and see more patients. Dr Mark Porter, BMA chair of the Council of the British Medical Association, said (in January 2017): 'GPs are conducting millions more consultations every year while also facing a recruitment crisis. A recent BMA survey of GPs found that 84 per cent said that workloads are now so unmanageable it is affecting the delivery of safe patient care'. (1)

However, despite the range and volume of complaints about the state of general practice, we should be ready and willing to interrogate narratives of crisis.

Policy analyst Rudolph Klein notes the apocalyptic prophecies and premature obituaries that are part of the political rhetoric about the NHS, and asks: ' What is it about the NHS that prompts linguistic excess and muddle?' (5) In Klein's view 'crises' are normal parts of the bidding and bargaining processes that determine resource allocation within the NHS.

Is crisis discourse about general practice just another example of this theatricality or does it herald the potential implosion of the NHS? To try and answer this question this article examines the evidence underpinning the crisis narrative in general practice. It explores whether GPs are having more consultations, if the number of GPs is going down, if GP earnings are declining and if these changes do indeed add up to something we might regard as a 'crisis'.

Is workload in general practice increasing?

The 2014 Nuffield Trust report 'Is general practice in crisis?' concluded that the absence of up-to-date and comprehensive activity data in general practice reduces planning to guesswork and the debate on pressures within general practice to exchanges of anecdotes. (6) In contrast to NHS hospitals, which report monthly on how many people are treated, for what conditions, and for how long, levels of activity in general practice remain something of a 'black box'. There is no national repository or routine public reporting of GP activity data. (7) It is difficult to know, therefore, if workload is really increasing.

However, there are large datasets derived from anonymised GP electronic medical records which give an impression of practice activity, and allow some analysis of trends in consultations with GPs and practice nurses. Six analyses have been published to date using three different data sets; 'QRESEARCH', 'CPRD' and 'ResearchOne'. Table 1 shows the characteristics of these datasets.

Figure 1 combines the data from the Hippisley-Cox analysis, the Hobbs et al study and the Nuffield Trust report. Data from the King's Fund analysis are not included here because in their published form they do not consistently provide raw consultation data, only percentage changes. Data obtained by Dunnigan and Deloitte have been reported selectively and so are mentioned in the text (see below) but not included in the graph. The Royal College of General Practitioners' statements about GP workload have relied on data from the DeLoitte analysis.

The...

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