Primary care Contents

1The experience of primary care

Meeting patient expectations

1.Primary care is the bedrock of Britain’s National Health Service, accounting for nine out of ten patient contacts within the NHS.1 Our system is admired around the world for the quality and continuity of care it provides, and for its role in preventing ill health and reducing the pressure on more expensive acute and secondary care.

2.Primary care has, however, come under unprecedented pressure. In many areas patients are finding it increasingly difficult to access services and we heard evidence of an unacceptable level of variation in the care provided.

3.Healthcare professionals report growing and unsustainable pressure, exacerbated by a lack of resources. In spite of Government recognition of the importance of primary care and the need to move more care from acute settings into the community, the service has received a falling proportion of overall NHS funding since 2006.2

4.Primary care will need to adapt if it is to meet the rapidly rising and changing demands of patients living with increasingly complex health problems. In the course of this inquiry we have heard many examples of innovative practice which give cause for optimism that this change can be achieved. Our report does not seek to replicate other more detailed inquiries such as the Primary Care Workforce Commission (PCWC), which described a new model of care based on practices collaborating via networks and federations and primary care health professionals working in multi-disciplinary teams. Instead, we seek to address the barriers which may stand in the way of developing new models of care and to encourage the provision of the best primary care services for patients now and in the future.

5.Don Redding, Policy Director at National Voices, a coalition of national health and social care organisations including charities which support patients, succinctly set out why a new model of care is required:

Two thirds of consultations are for people with long-term conditions and a third of consultations are for people with multiple conditions. The core customer has changed but the model has not. The model remains reactive, in that it waits for people to turn up with an exacerbation or a symptom. It is episodic. Although GPs try their best to provide continuity, the way that they work is not geared to providing continuous support. It deals with one issue or symptom per consultation.3

Candace Imison of the Nuffield Trust starkly explained the challenge that this presents to the NHS:

We want and need general practice to do things it has not historically done, so there is a need to think very strongly about population health management, proactively manage chronic disease, support people to do selfcare and relate very differently to patients and local communities. Those are all things that move general practice away from its traditional model, and that is going to require significant investment and change.4

Patient satisfaction

6.Despite the pressures facing general practice, feedback from many patient groups remains resolutely positive. A number of local organisations endorsed the overall quality of care available to patients in their areas. Healthwatch Brighton and Hove noted that “Doctors (85%) and nurses (87%) were rated positively with regards to listening to patients properly and making them feel heard.”5 Healthwatch Richmond described “a relatively high level of overall patient satisfaction with the quality and standards of care in the borough”6 and, similarly, Healthwatch Suffolk reported the outcome of their GP survey which found that “of 604 survey respondents, 486 (82%) said that they were happy with the overall service provided by their GP Surgery.”7 In Cambridgeshire, Healthwatch found that “89% of people are positive about their surgery and their Doctors.”8

7.From the national perspective, Healthwatch England said they “found that, overall, people spoke positively about their interactions with their GP.”9 This perspective supported the argument made by the Government in its evidence. The Government emphasised the outcomes of the GP Patient Survey:

The latest results, published in July 2015, show that 85.2% of patients reported a good overall experience of their GP surgery.

In addition to the GP Patient Survey from December 2014 it became a contractual requirement for GP practices to offer the “Friends and Family test” (FFT). [..] The latest publication of results for May 2015 shows that 88% of patients would recommend their GP practice to their friends and family.10

8.Anna Bradley, Chair of Healthwatch England, told us that high levels of reported patient satisfaction can mask wider concerns:

You will be very well aware that, if you ask patients [and] the public about the quality of primary care, you get very high levels of satisfaction. That is undoubtedly the way most people talk about primary care. It has been our experience very clearly that, if you scratch the surface and have a bit more of a conversation with people about perhaps their latest episode of care or their experience most recently, it is very varied.

Ms Bradley said that, in part, this is because patients value services provided by the NHS and are reluctant to voice complaints, however informal:

people are ultimately truly grateful for the national health service and see it as a treasure that they want to protect, and throwing brickbats at it for not doing quite what they want is not, in their view, necessarily the right way to behave. There is something about the quality of conversation that you have with people and the fact that people feel safe to have that conversation.

One thing that has emerged in all the research we have done is that people feel quite vulnerable when they are using health and care services and are quite fearful to say if their experience has not been that good because they think it may have ramifications for their future service, and there have been occasions where indeed it has. Although that is not the general picture, it is something that makes people quite fearful and perhaps slightly less than honest.11

9.Anna Bradley’s insight is vital to understanding the real experience of patients. It would be easy for policy makers to become complacent by relying on the headline figures and ignore serious underlying concerns. General practice does manage to provide good quality care that is highly valued by patients, but sometimes in spite of the system rather than because of it and due to the skill and dedication of the health professionals in primary care. Sir Bruce Keogh, Medical Director of NHS England, outlined the challenge of providing care as a member of a general practice team and paid tribute to the skills of the workforce—a tribute which we endorse:

Both general practitioners and their associated staff are having to deal with tricky issues of increasing demand and rising expectations, and in particular in the face of increasing complexity of the patient workload that they have to see. In my view, it is a really hard job. They have to be clinically, intellectually and emotionally strong. I can say this as a cardiac surgeon, where all our patients come to us kind of worked up. [ … ] But day in, day out, general practitioners are having to sort out the wheat from the chaff, to identify major clinical problems masquerading as minor ailments, and it is utterly relentless. It requires quite a lot of intellectual flexibility and people have to be very tolerant individuals. It is one of the hardest jobs in medicine. It is important to say that at a time when general practice is going through quite a lot of turmoil.12

Improving access to primary care

10.Difficulty in accessing general practice is a core concern and one which can determine the extent to which patients are satisfied with the service they receive. Much of the evidence from the patient organisations that submitted evidence to this inquiry examined questions of access, both in terms of the availability of appointments when requested and wider concerns related to extended hours and routine weekend appointments. The Patients Association summarised their overarching national view in their evidence:

Through our National Helpline and our research we have received consistently poor reports from patients about the ease and time it takes to book a GP appointment. Issues of waiting times, inability to obtain same day appointments or appointments in advance remain an ongoing problem. Callers to our Helpline constantly tell us of waiting long periods simply to get through by phone to their GP surgery. Often when they eventually get through there are no appointments available and are asked to call the following morning [ … ] These recent results are also largely consistent with our larger report, Access Denied, published in 2013, which revealed that:

11.The headline finding from the National Audit Office’s (NAO) stocktake of access to primary care, published in November 2015, appeared to contradict the evidence supplied by the Patients Association:

Overall, the vast majority of patients report a positive experience of access to general practice, with 89% reporting in 2014–15 that they could get an appointment. Three-quarters of patients got an appointment within the timeframe they wanted. Only 12% of patients reported a poor experience of making the appointment.14

12.Behind this figure, however, the NAO reported significant variation between practices, which can shape the widely differing experiences of patients:

The availability of appointments varies significantly between different practices–the proportion of patients unable to get an appointment ranged from 0% to 52% in 2014–15. We found that much of this variation could not be explained by demographic factors, practice characteristics or supply of general practice staff.

Significantly the NAO found that variation in access means that some groups are less able to access care:

13.The public has consistently rated the service provided by general practice even more highly than the NHS as a whole.16 Trust in doctors is higher than for any other profession and faith in GPs exceeds that of other medical professionals.17,18 However, high patient satisfaction rates have recently fallen, declining by 3 points from 2013 to 2014 according to the British Social Attitudes Survey.19 The public and patients’ groups report increasing dissatisfaction with their ability to get to see a GP, either when they need to or at a time that is convenient for them. In response to these concerns the Government made a commitment to deliver a seven day service by enabling the provision of routine GP appointments at weekends.

Weekend appointments

14.The Government’s 2015 general election manifesto contained a commitment to “ensure you can see a GP and receive the hospital care you need, 7 days a week by 2020, with a guarantee that everyone over 75 will get a same-day appointment if they need one”.20 The introduction of weekend primary care services, however, pre-dated the 2015 manifesto commitment and by April 2014 twenty pilot sites had already been selected to test the provision of weekend appointments in general practice.

15.In January, the Secretary of State for Health, Rt Hon Jeremy Hunt MP, reiterated the Government’s position regarding the delivery of seven day services:

As part of our commitment to a seven-day NHS, we want all patients to be able to make routine appointments at their GP surgeries in the evenings and at weekends.21

16.When asked to set out how the Government will evaluate evidence emanating from seven day primary care pilot schemes, Alistair Burt reflected that the evidence from the pilots was not yet clear but said that he “would look at the evidence individually from each area and make a decision based upon that.”22 Mr Burt added that if the operation of routine seven day services represented “a complete waste of resource”23 then that would be “a material fact I would take into consideration.”24

17.There has been some confusion about the intention of the Government’s policy. When Simon Stevens, Chief Executive of NHS England was asked at a meeting of the Committee of Public Accounts whether he was “wedded to the idea of every general practice providing an 8-till-8, seven-day-a-week service”25 Mr Stevens simply answered “No”.26 Mr Stevens explained that he does not believe that this is what the Government wants and, in any case, workforce constraints would not allow for this type of service.27

18.Dr Maureen Baker, Chair of the Royal College of General Practitioners Council, outlined concerns that there is insufficient capacity within the existing general practice workforce to provide seven day services and extended weekday hours:

We are struggling with medical, nursing and other workforce in general practice to provide the service Mondays to Fridays, and to provide extended access in the evenings, which we do know that patients want, and Saturday mornings as well.28

Demand for weekend appointments

19.The NAO reported that the “percentage of patients reporting that opening times are not convenient increased from 17% in 2011–12 to 20% in 2014–15.”29 The report noted, however, that the majority of the evidence gathered from analysis of the Prime Minister’s GP Access Fund called into question demand for services at weekends, especially on Sundays:

A survey commissioned by Monitor in 2014 found that 14% of respondents said evening and weekend opening was one of the top 5 things they look for in a general practice.

Research in 2015 found that weekend opening is much less important than evening opening during the week when people are choosing a GP practice. However, respondents to our survey in September 2015 said it was just as important to be able to see or consult with someone on a Saturday or Sunday as it was to consult with someone after 6.30 in the evening.

The Prime Minister’s GP Access Fund evaluation, also in 2015, found high take-up of extended hours appointments in the week and on Saturday mornings, but very low take-up on Sundays.30

The independent evaluation of the GP Access Fund (also known as the Prime Minister’s Challenge Fund) concluded that additional hours are necessary but the case has not yet been made for seven day routine services:

Given reported low utilisation on Sundays in most locations, additional hours are most likely to be well utilised if provided during the week or on Saturdays (particularly Saturday mornings). Furthermore, where pilots do choose to make some appointment hours available at the weekend, evidence to date suggests that these might best be reserved for urgent care rather than pre-bookable slots.31

We note that the first independent evaluation of the Prime Minister’s Challenge Fund pilot schemes reported that a number of the pilots reduced or discontinued their weekend services. Whilst in some cases this was due to low attendance this was not exclusively the case.32

20.These findings are in line with evidence produced by organisations which have examined the take up of weekend primary care services in local areas. The Centre for Health Innovation Leadership and Learning, Nottingham University Business School evaluated the take-up of Prime Minister’s Challenge Fund (PMC) supported additional hours projects in the East Midlands. They found that there was little demand for weekend services:

Patient preferences are revealed by the take-up of weekend appointments in PMCF initiatives. Utilisation rates for the weekend hub pilot in Rushcliffe CCG for the period 1st January to 31st June 2015 is 38% on Saturday mornings and 29% on Sunday mornings. A similar weekend hub located in Ilkeston (Erewash CCG) had utilisation rates of 31% on both Saturday and Sunday mornings during the period 1st January to 31st July 2015.

We know that in other weekend PMCF initiatives around the country, that Sunday utilisation rates can be as low as 10%.33

The researchers who undertook the evaluation concluded that:

If evidence such as this had been available, ex ante, to local practices and CCGs, it is very unlikely they would have undertaken initiatives to offer additional weekend appointments.34

21.It is notable that criticism of the Government’s policy extended to local commissioners of health services. Sheffield CCG said in their evidence that:

7 day access always has been available when out of hours is considered. The question is should 7 day a week ‘routine’ care be available? We do not see much evidence to support the view that patients want, let alone need, access to routine GP services seven days a week.35

22.Chris Ham, Chief Executive of the King’s Fund, was enthusiastic about the concept of 7 day services, but he argued that it would require significant additional resource to deliver.36 This argument is reinforced by analysis undertaken by the RCGP that attempted to cost the delivery of routine care on Saturdays and Sundays. They reported:

That extending GP hours so that one in four surgeries open late and at weekends would cost at least £749m per year–rising to £1.2bn if one in two practices were to take part.37

23.The Patients Association is a keen advocate of seven day services and said that routine care should be provided across the working week and weekends. Their Chief Executive, Katherine Murphy, argued that lack of demand in the pilot schemes was attributable to poor public awareness, telling us “[the] public are quite used to having a primary care service from Monday to Friday. If they do not know that the services are available, it is difficult for them to access them.”38

24.It should, of course, be acknowledged that any patient registered with a practice offering weekend services who seeks an appointment will be made aware of weekend availability once they contact their surgery. This point was partly addressed by the first evaluation of PMCF projects which questioned the relationship between advertising and demand:

there is general agreement that the lack of success with certain weekend extended hours slots is not necessarily attributable to the delivery and design of projects or an ineffective communications strategy; rather it is a result of entrenched patient behaviours.39

The implication of Katherine Murphy’s statement is that there is a population of patients that do not ever seek to make routine appointments as they assume that they could only be seen between Monday and Friday during working hours. This is the group of patients that needs to be reached.

Improving access to primary care: conclusions

25.We believe that it is vital that patients have timely access to primary care services. This includes both access to urgent appointments and the ability to book routine appointments in advance.

26.Evidence from the National Audit Office shows that people who work during the week would like to make use of extended hours at weekends.40 We welcome the principle of improving access for people whose working lives make it very difficult to obtain appointments during the week and recognise that this was one of the Government’s manifesto commitments. The Government should, however, bear in mind evidence that there may be more demand for access to GPs in the evenings or on Saturdays than on Sundays.

27.There should be a full evaluation of the pilot programmes testing the provision of routine weekend appointments before any new system is rolled out around the country. The Government’s approach should be evidence based, learn from best practice and avoid unintended consequences such as damaging weekday services, continuity of care or existing urgent out-of-hours primary care services.

28.Patient understanding of the services available to them would be enhanced by the Government and NHS England providing more detail as to the type of service the Government would like primary care to offer. The Secretary of State and the Prime Minister have stated that patients can expect to have 7 day access to a GP surgery for routine appointments, but comments from Alistair Burt and Simon Stevens suggest a more nuanced approach.41 A more consistent message which clarifies the type of service that patients can expect would help the public to better understand how primary care is evolving. We note that virtually all practices involved in PMCF initiatives have also taken the opportunity to remodel their workforce.42 In promoting improved access the Government should also emphasise that patients will not only be able to consult a GP but can have access to a broader multi-disciplinary team. It would be helpful for the Government to provide more clarity about how certain aspects of the policy will function, for example:

29.We are concerned that insufficient advertising and promotion of routine weekend appointments may have artificially limited latent demand for weekend appointments by failing to reach those who would benefit the most from these services. An essential component of extending primary care services to weekends should be making those patients currently disenfranchised by the existing model of care aware of improved access. Ongoing evaluation of Prime Minister’s Challenge Fund backed projects should, at a local level, incorporate an analysis of patient awareness of weekend services.

Continuity of care

30.The RCGP has cautioned that seven day services would disrupt the continuity of care that patients with multiple long-term conditions require:

We are concerned that the proposal to provide seven day GP access to routine care could jeopardise continuity of care, which is of key importance to tackling the problems currently facing the NHS, especially in the management of long-term conditions.43

Without additional workforce numbers the requirement to provide weekend services could diminish the availability of extended weekday appointments and diminish continuity of care, which we know is valued by patients.44

31.An inability to communicate patient information also risks compromising continuity of care. The Government and NHS England told us that investment is in place to ensure that interoperability of IT systems allows for the transfer of electronic patient records between practices that are parts of federations.45 At present, however, systems are not in place to make this standard practice and, for the time being, practices are using “temporary solutions.”46

32.Continuity of care demands continuity of record keeping. Patient safety is compromised by inadequate access to patient records. There is greater risk of medical errors as well as the unnecessary costs of increased bureaucracy where patient records cannot be accessed and electronically updated at every point of contact. Routine appointments, especially for complex patients, without access to patient records give rise to an avoidable risk.

33.It is essential, both for patient safety and to reduce bureaucracy, for patient records, accessed with their consent, to be directly accessible by all the health professionals seeing patients registered with any practice within a federation, network or out-of-hours provider. The response to this report should lay out a clear timetable for these arrangements to be in place including for shared access between primary and secondary care. Efforts should be made to ensure that such arrangements apply UK wide.

Interaction with out-of-hours care

34.In oral evidence Dr Maureen Baker argued that operating weekend services could make existing out-of-hours provision untenable:

One concern we have is that by focusing on provision of routine services seven days a week we could be running down the essential out-of-hours service. Even if you did provide routine general practice eight to eight, Monday to Friday, 12 hours a day still need to be covered by an out-of-hours service. At the moment, where schemes are providing extended access in the evenings and weekends, the doctors that they bring in to do those are doctors who would otherwise work in the out-of-hours service. So some out-of-hours services are finding they are becoming extremely unstable in being able to provide doctors for that service.47

35.Dr Baker observed that extended hours can be more attractive to GPs because such a system is better remunerated and carries less risk,48 a point reinforced by evidence from the Medical & Dental Defence Union of Scotland.49 During our visit to Sheffield the GPs working at Page Hall Medical Centre said that the extended hours hubs they work through offered GPs better remuneration but were not meeting patient demand.50 The net result of these concerns was illustrated by the Lancashire Cumbria Consortium of LMCs:

There are only so many GPs to go round and we are already seeing the impact of initiatives such as the Prime Minister’s Challenge Fund where locum GPs are attracted to do shifts for these services at the expense of being available to man out of hours services or fill sickness and holiday absences in practices. Furthermore the market is being distorted as GPs see the advantages of doing shifts to suit their personal circumstances at attractive payment rates without any ongoing worries or commitments to their practice.51

36.The RCGP has called for the policy emphasis to be on locating GP out-of-hours services where patients can physically access them. Dr Baker said the RCGP had:

recently produced a joint statement with the Royal College of Emergency Medicine to say that co-location of GP out-of-hours services with A&E services, where there is suitable opportunity to do so—it does not work everywhere—is, in general, helpful, useful for patients and leads to better use of resource.52

37.The relationship with out-of-hours services is particularly pertinent in the context of providing weekend appointments in rural areas. Giving evidence to us in September 2015, the Secretary of State said that weekend GP services could be offered by one practice as part of a network or federation.53 During our visit to Sheffield this concept was addressed by one GP who said that offering services through federations in rural areas (such as his) would not be satisfactory as patients would not be willing to travel ten miles or more for a routine appointment if only one practice in a federation was offering the weekend services.54 Analysis by the NAO found that “only 1% of people in urban areas do not have a GP surgery within 2 kilometres, compared with 37% in rural areas.”55 Where rural federations operate across even wider areas, the distances patients need to travel will be even greater.

38.There is a risk that an unsophisticated approach to the introduction of 7 day GP services in rural areas delivered by federations or networks may not achieve the ambition of facilitating better patient access. The availability of primary care services will not be improved if patients are expected to travel to inaccessible locations. Weekend urgent primary care is already available via out of hours providers and this should be taken into account when assessing the most effective method of delivering weekend services, especially in rural areas. We recommend that clinical commissioning groups, federations and networks be given the flexibility to develop local solutions for weekend access to meet the needs of those who cannot attend routine services between Monday and Friday. Clear and consistent statements affirming the Government’s commitment to local flexibility are required to assist both implementation and public comprehension of the policy. Implementation of new weekend routine services must also take account of the impact on local provision of existing out of hours services for urgent primary care. We recommend that locally led design underpinned by adequate funding and resource from the centre should form the basis of the Government’s implementation of its manifesto commitment to 7-day primary care services.

39.In 2013 our predecessor committee recommended in its report on urgent and emergency services that urgent care centres providing out of hours GP services should be co-located on hospital sites where appropriate for the local population.56 The future location of extended primary care provision should take this recommendation into account as part of a process of simplifying and concentrating the confusing array of urgent primary care services.57 Local demographics and the location of hospitals will not always make this possible, therefore local input is vital to determine the optimum locations for patient access.

Utilising information technology

40.A key conclusion of the Primary Care Workforce Commission emphasised the importance of better applying technology in primary care. The Commission said they:

anticipate that video-conferencing consultations will become a common extension of the telephone consultations that are already widespread in general practice.58

The number and profile of patients who will want to take up online consultations or other services has not been established, and trends relating to patient demand are not well understood. Patient expectations regarding the use of IT can, however, range from a desire to use new technology to access consultations or advice to far more prosaic concerns such as being able to easily communicate with their practices. Causes of frustration for patients can include being unable to speak to practice staff when necessary and it not being possible or straightforward to book appointments online.59

Contacting practices

41.The views of many local Healthwatch bodies focused on improving the use of IT to improve and simplify basic elements of general practice such as booking appointments. Healthwatch Brighton reported that the majority of patients they surveyed had never attempted to book appointments online.60 Healthwatch Worcestershire identified that existing call-back booking services are difficult to use for teenagers in school or at college and that this group would prefer to book online or by text message.61

42.NHS England data from January 2015 showed that 91 per cent of patients are registered with practices “that offer the ability to book or cancel appointments online.”62 The GP Patient survey reported that patient awareness of online services is improving with 29.3% of patients now aware that appointments can be booked online, but only 6.3% of patients actually book appointments this way.63 Healthwatch Gloucestershire’s evidence, however, highlighted the problems of local variation—27% of practice websites they examined still did not offer online appointments.64 Overall they found a lack of consistency in the information available from practice websites in their area and almost half those reviewed contained out of date information.65

43.The GP patient survey has reported that the proportion of patients who find it easy to contact their practice by telephone is in consistent decline from 76.6% in December 2012 to 70.4% in January 2016.66 Over a quarter of patients now report that it is not easy to speak to someone in their practice by telephone.67 Katherine Murphy described the experience of many patients when they attempt to contact their practice by telephone:

very often people are on the phone at half past eight in the morning, phoning for an hour, only to be told that there are no appointments left for that day or to phone back in the afternoon, and when they phone back in the afternoon the appointment has gone. This occurs day after day.68

Remote consultations

44.Examining alternative ways for patients to consult health professionals, Healthwatch England called for the use of email to replace posted letters “as a bare minimum”. Facilitating direct communication between clinicians and patients by email was explored by the PCWC. The Commission suggested that this idea should be progressed with some caution:

Email correspondence between primary care clinicians and their patients should be piloted prior to becoming a routine part of NHS care. The impact of introducing emails from patients on the primary care workload should be evaluated, bearing in mind its potential to reduce face-to-face consultations.69

45.Healthwatch Sutton reported findings from a survey that said:

Respondents were asked to identify which methods they would be happy to use to hold a consultation with a GP. If commonly available methods are removed from the equation (i.e. face-to-face appointments), 58% of respondents advised that they would be happy to hold a consultation over the phone, 16% by email and 12% via video call (Skype).70

46.Healthwatch Coventry identified a reluctance on the part of patients to engage with remote consultations. In circumstances where a face to face consultation was not available most patients “would prefer to have a phone consultation with their GP; or alternatively see a practice nurse.”71 We found no sense in any of the evidence from patient groups that telephone consultations or various methods of consulting online were regarded as preferable to face-to-face consultations.

47.Understanding patient willingness to use online and remote services is a particularly complex problem. Professor Steve Field, Chief Inspector of General Practice at the Care Quality Commission (CQC), said that he expected young people to be enthusiastic about utilising new technology:

Younger people—the millennial generation—have a different idea of access to general practice from my parents. It is not going to be just in a surgery seeing somebody. It will be via mobile phone and Skype.72

But Anna Bradley warned that Healthwatch England’s research shows that this may not necessarily be the case:

The work we have done gave us a very interesting finding—slightly counterintuitive, on the first take—which was that younger people were, on the whole, less content to use Skype and other means to engage with GPs than older people. [ … ] It emerged when we explored that a bit further that that was because these young people did not think that GPs were going to listen to them because they were young. Their experience of GPs was that they were dismissed. There was a lack of trust and confidence for these young people in their GP service. They felt that they had to sit and look at the whites of their eyes to get an honest response from their doctor. There is an important lesson in there, which is that technology can do great things for us, but unless the fundamentals of the relationships are right and the trust and confidence is there it won’t help.

48.Healthwatch England noted that older people may not be concerned about this aspect of the patient / doctor relationship because they were “more familiar with dealing with the Health Service”.73 Nevertheless, they observed that there is demand for services such as consultations by Skype,74 and Katherine Murphy said there are patients who “find it really useful and very reassuring, especially mothers of young children who use Skype and telephone consultations a lot”.75

Improving access with IT: conclusions

49.The frustration of not being able see a GP quickly or at a convenient time is exacerbated by difficulty in contacting practices to make an appointment or a routine query. Some patients have no difficulty in communicating with their GP practice, including making appointments online and communicating with practice staff by e-mail. This should be the norm. The primary care system should enable all patients to get to see a GP urgently when they need to and to book a non-urgent appointment ahead with ease.

50.Enabling direct email contact between GPs and patients would inevitably add to the clinical and administrative workload faced by primary care staff. Piloting and evaluation needs to produce a clear understanding of the patient benefits and avoid creating an additional burden which detracts from clinical care. There should not be an assumption that email contact will reduce demand.

51.We firmly believe that harnessing the opportunities presented by IT could improve access and quality of care. Patients expect to be able to book appointments online and practice websites should facilitate that. Whilst many patients will prefer or require a face to face consultation, for those who do not, primary care providers should facilitate telephone and eventually online consultations.

52.NHS England must offer support by sharing and promoting best practice on the use of IT to facilitate remote consultations. Practice partners and managers would benefit from clear guidance and support in helping them to understand how technology can be harnessed to improve access and clinical standards of care in the most cost effective manner. We recommend that NHS England undertake research to support this objective with the aim of formally assessing demand, risk and potential benefits.

Struggling workforce

53.General practice has been forced to contend with increased demand without a consequential growth in resources. The Centre for Workforce Intelligence reported “a slowly growing GP workforce unable to keep up with increasing patient demand”76 and added that “Demand pressures have been compounded by a decline in real funding levels and in the number of GPs per capita in recent years.”77 Their written evidence highlighted Health Education England data which showed that “NHS England estimated demand for GP services equivalent to around 35,500 FTE for 2014–almost 3,000 FTE more than the recorded level.”78

Workload

54.It was evident from the submissions sent to us by individual GPs that much of the general practice workforce regards their workload as unmanageable. This concern was best expressed by the NHS Alliance, who described an “undoable workload” as being the “underlying problem” facing general practice.79 The Local Government Association and ADASS submission looked specifically at the clinical workload that primary care is required to deal with and reported that “Between 1995 and 2009 the number of general practice consultations has risen by 75 per cent, resulting in an increased clinical workload of over 40 per cent.”80

55.More detailed analysis was provided by the Nuffield Trust, but they emphasised the difficulty in accurately measuring the work undertaken by GPs and questioned the extent to which it is an increased clinical workload that has created the difficult circumstances within general practice. Their analysis pointed to the complexity of patient conditions and lack of overall care coordination for patients as being central problems:

To try and address the lack of reliable evidence on GP workloads, the Nuffield Trust last year acquired data held on a private basis by the Clinical Practice Research Datalink, which recorded consultation trends across a sample of 337 practices (Curry, 2015). [ … ]

From 2010/11 to 2013/14, consultations in total rose around 11 per cent. The number of consultations per person per year registered on a practice list also rose–from 7.6 to 8.3. However, it is noteworthy that consultations with GPs themselves only rose by around 2%, in the context of a workforce which also grew by around 2% in the same period. We speculate that if pressure on GPs has sharply increased, it might be more related to an increase in other tasks. Anecdotally, GPs may be spending more time than they used to co-ordinating the care their patients receive with hospitals and local authorities.81

56.This strikes at the heart of the challenge faced by GPs in particular and the problem with the existing model of care. Anna Bradley told us that people with long-term conditions often understand what services they require and “they do not want to have to keep going back to their GP”82 to manage every single element of their care. Ms Bradley said that patients do not want their GP to be the sole coordinator of care and “they wanted someone whom they described as a care navigator, someone who could help them to find their way through the system.”83 The problem faced by GPs is that without professionals in place to undertake this role the GP will inevitably become the de-facto care navigator.

57.The feeling that the provision of general practice has become unsustainable is a consequence of caring for so many more patients with complex needs and long term conditions. As the BMA observed:

The factors increasing GPs’ workloads include a growing population of older people with more complex health needs and the movement of care out of hospitals into the community. The number and complexity of patients in residential and nursing homes has added to the increase in doctors’ workloads.84

Giving oral evidence on behalf of the BMA, Dr Chaand Nagpaul said that the challenge GPs face is that demand for their services is unlimited.85 The King’s Fund also agreed that the overall workload has become more complex.86 Don Redding said that patients with multiple long-term conditions “will likely have 10 or 12 GP appointments in the year, see eight specialists, and have 11 or 12 medications to manage, three episodes of urgent care, and so on.”87

58.We heard that this pressured environment has created a “haemorrhage”88 of GPs and that a retirement crisis is looming. Dr Nagpaul said that of GPs aged 50–54:

the University of Manchester says that 38% of GPs are likely to retire in the next five years. [ … ] Our own statistic in the BMA was 36%, so it is even worse through independent analysis. We know that is happening. We see it in front of our own eyes when we meet colleagues who are retiring early.89

We heard anecdotal evidence from GPs that changes to pension arrangements and seniority payments were also encouraging GPs to leave the profession.90

59.Beyond the risk posed by GPs planning to retire, we also heard warnings that as a consequence of what is felt to be an unmanageable workload in general practice, young GPs are planning for careers away from the NHS and outside England:

younger GPs are more amenable to considering working abroad in places like Dubai, Australia, and New Zealand where working conditions are perceived to offer a more attractive work life balance.91

60.A survey of 1,001 GPs working across the UK published by the Health Foundation in February 2016 underlined just how fragile morale is amongst GPs:

GPs in the UK report higher levels of stress and lower satisfaction with practising medicine compared to primary care doctors in other countries. 67% of UK GPs report being satisfied, compared to an average of 79% across the other 10 countries featured in the survey. 59% of GPs in the UK describe their job as extremely or very stressful, higher than anywhere else.92

61.The findings reported by the Health Foundation are consistent with the general tone of discussion around general practice. Professor Martin Roland, Chair of the Primary Care Workforce Commission, said that at present “morale is poor”93 and this was reflected in the comments from the GPs we met in Sheffield.94 It was evident that whilst their commitment to providing the best possible patient care had not wavered, their genuine concern for the future of general practice and their own profession had contributed to low morale.95

Funding

62.The challenges facing primary care are compounded by particularly constrained funding for primary care. Even the Department of Health’s evidence conceded that “there has been a decrease in investment in general practice of around 0.8% per cent in real terms since 2008/09”96. The King’s Fund added that:

Relative to other health services (eg, the acute hospital sector), general practice’s share of NHS funding has been declining: between 2005/6 and 2013/14, total investment in general practice fell by 6 per cent–equivalent to nearly £560 million. This is in contrast to a real rise in total NHS spending of 4.4 per cent since 2010/11.97

63.The RCGP acknowledged that this pattern is the unintended consequence of the overall NHS funding system:

real terms spending on general practice fell by 3.0% between 2009/10 and 2013/14. This drop seems to have not been the result of a deliberate policy, but reflects the fact that NHS funding mechanisms tend to channel money towards secondary care.98

64.As real terms spending on primary care has declined so have practice incomes. The Government’s evidence showed that “between 2004/05 and 2012/13 there has been an annual average percentage decrease of 2.1 per cent per year” in practice income.99 The BMA summarised some of the additional financial burdens that practices have had to manage which, they argued, have compounded the problem of constrained funding. The BMA said that rising national insurance contributions, a 9% increase in Care Quality Commission (CQC) fees for 2015–16 and growing indemnity costs were particularly pressing concerns for GP partners.100

65.Beyond these challenges, practices have had to contend with the phasing out of minimum practice income guarantee (MPIG) payments and the equalisation process stemming from the review of Personal Medical Services (PMS) contracts. Practices contracted through PMS contracts can expect a reduction in the premium received as NHS England seeks to equalise core general practice funding across all types of contracts.101 Dr Kate Bellingham, a partner at Page Hall Medical Centre in Sheffield, which serves a population with high levels of need, outlined the impact of the equalisation process for her practice:

We will be losing £258,000 in income (21% of our total budget) over the next 3 years through the equalisation process, and will not be viable unless extra resources are found.102

66.Pulse, the magazine for general practitioners, highlighted the relationship between funding changes and practice closures:

Shrinking funding is a major factor in rising numbers of practices nearing closure. Figures obtained by Pulse show more than 160,000 patients across the UK having to register with another practice as a result of their practice closing over the past two years. There has been a 500% jump in the number of practices seeking advice from NHS managers about closure or merging. 103

Variable quality

67.A lack of consistency in the quality of primary care was highlighted by local Healthwatch organisations. The essence of their concern related to the variation in standards that they have observed across relatively small local areas. The organisations that have highlighted this concern are located in different regions of England, which indicates that problems are not exclusive to any one part of the country.

68.Healthwatch Cambridgeshire’s evidence noted that whilst the majority of the complaints they hear relate to primary care they too “hear many stories of excellent care and staff going way beyond their job to help patients”.104 Nevertheless they remain concerned at the level of ‘inconsistency’105 in the quality of primary care. Healthwatch in Coventry described variation not only in quality but also in access and linked this variation to the health inequalities experienced in an inner city area:

For a number of years in Coventry there has been an issue regarding variation in quality of service/care from different GP practices, evidenced by different health and patient experience outcomes depending on where people live and which GP practice they are registered with. Pressure on inner city practices serving ethnically diverse and deprived populations is apparent within Coventry. Coventry also experiences a number of health inequalities which may contribute to the variation issues regarding GP services.106

In addition, Healthwatch Coventry’s observation that “Patients find it confusing when they hear from friends or relatives who seem to be getting a more comprehensive service from another GP practice”107 captured the fundamental frustration experienced by patients.

69.From the national perspective, variation in the quality of care was a key theme identified by Professor Steve Field from the CQC’s inspection of general practice services. He said that “85% of practices are good or outstanding”108 but the worst 4% rated inadequate were “generally worse than I thought they would be before I started.”109

70.The BMA and the RCGP vociferously argued that the CQC inspection regime is not effective and that the data measured by the CQC does not allow for an accurate assessment of quality.110 Dr Nagpaul questioned the value of attaching ratings to individual providers:

Practices vary at the moment in funding per head by twofold. You cannot compare two and say one is great and one is not without understanding that. Practices that are being inspected may have, as I said earlier, recruitment problems; they may be trying to run a practice three partners down and no one is there to fill those spaces. Ranking them without understanding the context does not help.111

71.Dr Maureen Baker said that GPs should not be burdened with “a very heavy bureaucratic, onerous process with many areas that people do not feel are valid in terms of quality and safety” simply because a small minority of practices have provided unsafe care.112 Professor Field, however, said that many failing practices had been known about for years and there has been “a failure of my colleagues and the systems that have been in place to identify and do things about it”113 Professor Field added that he is “doing this job on behalf of patients and the public”114 and the practices that were of greatest concern were those with “poor or absent leadership, no vision, [and] poor systems”.115 The CQC’s evidence outlined the overall figures for practices that had been rated following inspection:116

Measure

Outstanding

Good

Requires improvement

Inadequate

Number of locations

122

2443

311

112

% of locations

4%

82%

10%

4%

72.The CQC’s written evidence provided examples of the type of poor care which would attract enforcement action against a practice once they had been rated as inadequate. In one case, the CQC described a practice which had its registration removed after it was discovered that:

During the inspection CQC identified one locum staff member who had treated patients but could not provide evidence that they were medically qualified to do so. The management of medicines was found to be unsafe and placed patients at serious risk of harm. Medicines were found to be out-of-date which rendered them unsafe, and requests for prescriptions had not been processed in a timely manner to ensure patients had access to their medicines.117

In addition, the CQC has reported other cases where emergency medicines have been inaccessible or unavailable and where no employment checks have been undertaken to ensure that staff can practice safely.118

Variable quality: conclusions

73.We welcome Care Quality Commission (CQC) inspection of GP practices and the benefit which it has brought for patients. Independent regulation supported by robust inspection is a useful tool in driving improvement, ensuring quality and giving the public confidence in the services they pay for. Since the CQC’s remit was extended to primary care it has played an important role in identifying failing and underperforming practices, closing some down and ensuring others improve.

74.We reject the calls from the British Medical Association and the Royal College of General Practitioners to scrap the current regulatory regime. We urge them to work constructively with the Care Quality Commission to protect the public from the small minority of dangerous practitioners and to help to turn around underperforming practices.

75.Professor Field told us that the CQC is starting to collaborate with NHS England and the GMC “to try and reduce the data load, the workload, for general practice so that we collect data once and it is used for many different reasons.”119

76.We heard evidence of duplication of data requests resulting from the Care Quality Commission’s (CQC) primary care inspection methodology. Like all good regulators the CQC should constantly examine its procedures and methods to avoid or minimise unnecessary burdens or duplication. NHS England, the CQC, the General Medical Council and Local Education and Training Boards must work together to agree a common framework and data set to reduce bureaucracy and unnecessary duplication. It is essential that time which should be devoted to patient care is not eroded by an excessive bureaucratic burden.

77.We were encouraged by Professor Field’s evidence that the CQC’s “role is to encourage improvement”120 and that “93% of the 100-plus practices we have re-inspected have improved.”121 He added that once the CQC can:

sort out the very poor practices, that means we can all focus on how we improve care and move to a much more efficient integrated health and social care system.122

We believe that this is the correct approach. To build faith amongst both the public and clinicians and the CQC’s inspection regime must be seen to be relevant for improving patient care as well as identifying poor practice.

The experience of primary care: conclusion

78.Primary care has been described as the “jewel in the crown” of NHS services123 but it is under unprecedented strain after several years of funding decline relative to other services. There are growing concerns from patients about access to primary care services, quality varies from the excellent to the dangerously bad and the system of care is unsustainable. These circumstances have undermined the morale of the workforce and disenchanted GPs and other primary care professionals. Patient satisfaction remains high but patient concerns are growing: good headline figures can mask the poor experience some patients can have of primary care. The difficulties experienced by patients underline just how important it has become to develop a new model of care.


1 Royal College of General Practitioners (PRI 174) para 1

2 The King’s Fund (PRI 191) para 16

3 Q185

4 Q151

5 Healthwatch Brighton and Hove (PRI 41) para 2

6 Healthwatch Richmond (PRI 77) p 2

7 Healthwatch Suffolk (PRI 167) p 4

8 Healthwatch Cambridgeshire (PRI 74) p 4

9 Healthwatch England (PRI 228) para 21

10 Department of Health, NHS England and Health Education England (PRI 200) paras 21–22

11 Q186 (Ms Bradley)

12 Q267

13 The Patients Association (PRI 196), p 4

16 National Centre for Social Research, British Social Attitudes 32 - Health (2015)

17 General Pharmaceutical Council, Public perceptions of pharmacy (January 2015)

18 Ipsos Mori Social Research Institute, Veracity Index 2015 (January 2016)

19 National Centre for Social Research, British Social Attitudes 32 - Health (2015)

20 The Conservative Party, The Conservative Party Manifesto 2015 (April 2015), p 37

21 HC Deb, 5 January 2016, col 4 [Commons Chamber]

22 Q360

23 Q369

24 Q369

25 Oral evidence taken before the Committee of Public Accounts on 11 December 2015, HC (2015–16) 673, Q 46 [Ms Flint]

26 Ibid, Q46

27 Ibid, Qq47–48

28 RCGP (PRI 174) para 23

29 C&AG’s Report, para 14

30 C&AG’s Report, para 5.6

32 Ibid, GP seven-day pilot schemes, Pulse, 7 May 2015

33 Centre for Health Innovation Leadership and Learning, Nottingham University Business School (PRI 122) para 21–22

34 Ibid, para 20

35 Sheffield Clinical Commissioning Group (PRI 127) para 3.2

36 Q152

38 Q220

40 C&AG’s Report, para 12

41PM on plans for a seven-day NHS”, Prime Minister’s Office, 10 Downing Street, 18 May 2015

42 Q 248

43 The Royal College of General Practitioners (PRI 174) para 24

44 The Nuffield Trust (PRI 175) para 2.2

45 Q377

46 Q378

47 Q310

48 Q311

49 Medical and Dental Defence Union of Scotland (PRI 185) para 2.1

50 Note of Committee visit to Halifax and Sheffield

51 PRI 87, p 3

52 Q312

53 Oral evidence taken on 15 September 2016 HC (2015–16) 446, Qq 24–27

54 Note of Committee visit to Halifax and Sheffield

55 C&AG’s Report, para 18

56 Health Committee, Second Report of Session 2013–14, Urgent and Emergency Services, HC 171, para 114

57 Ibid, para 112 – 113

59 The Patients Association (PRI 196) p 4

60 Healthwatch Brighton and Hove (PRI 41) para 2

61 Healthwatch Worcestershire (PRI 194) p 4

62 NHS England, Board Paper (January 2015)

63 Ipsos Mori Social Research Institute, The GP Patient Survey (January 2016) p 7

64 Ibid, p 5

65 Healthwatch Gloucestershire (PRI 14), p 6

66 Ipsos Mori Social Research Institute, The GP Patient Survey (January 2016) p 6

67 Ibid

68 Q207

70 Healthwatch Sutton, GP Access Report (December 2014), p 4

71 Healthwatch Coventry (PRI 71) para 1.2.2

72 Q344

73 Healthwatch England (PRI 228) para 41

74 Ibid, para 22

75 Q225

76 Centre for Workforce Intelligence (PRI 183) p 1

77 Ibid, p 1

78 Ibid, p 1

79 NHS Alliance (PRI 90) para 3.2

80 Local Government Association and Association of Directors of Adult Social Services (PRI 70) para 5.1

81 The Nuffield Trust (PRI 175) pp 9–10

82 Q205 (Ms Bradley)

83 Q219 (Ms Bradley)

84 British Medical Association (PRI 49) para 37

85 Q288

86 The King’s Fund (PRI 191) para 15

87 Q217

88 Q326

89 Q325

90 Note of Committee visit to Halifax & Sheffield

91 Londonwide LMCs (PRI 172) para 23

93 Q73

94 Note of Committee visit to Halifax & Sheffield

95 Note of Committee visit to Halifax & Sheffield

96 Department of Health, NHS England and Health Education England (PRI 200) para 45

97 The King’s Fund (PRI 191) para 16

98 RCGP (PRI 174) para 5

99 Department of Health, NHS England and Health Education England (PRI 200) para 53–54

100 British Medical Association (PRI 232) para 19

101 NHS England, Reviews of Personal Medical Services, (February 2014)

102 Dr Kate Bellingham (PRI 152) para 2b

103 Pulse (PRI 165) p 4

104 Healthwatch Cambridgeshire (PRI 74) para 2.1

106 Healthwatch Coventry (PRI 71) para 1.2

107 Ibid, para 1.2.2

108 Q268

109 Q270

110 Q280

111 Q280, Dr Nagpaul

112 Q282

113 Q275

114 Q284

115 Q272

116 Care Quality Commission (PRI 244)

118 Ibid, para 29

119 Q273

120 Q276

121 Q278

122 Q278




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20 April 2016