Conclusions and recommendations
1.Problems with recruitment and retention means there are not enough GPs to meet demand. For the last decade, demand in general practice has risen faster than capacity. The best available estimates for 2004–05 to 2014–15 indicate that each year the number of consultations grew by 3.5% on average, compared with 2% average annual growth in general practice staffing. The Government has committed to providing 5,000 additional doctors working in general practice by 2020. NHS England, together with Health Education England, the Royal College of General Practitioners and the British Medical Association, published a 10-point workforce action plan in January 2015 to increase staffing by: making it more attractive for staff to remain in general practice; supporting those who wish to return after time away; and increasing recruitment. However, the Department and NHS England acknowledge that faster action is needed if they are to have 5,000 more doctors working in general practice.
- More GPs are leaving the profession, particularly older staff with more experience. Between 2005 and 2014 the proportion of GPs aged between 55 and 64 that left approximately doubled, and the proportion of younger GPs leaving has also increased. Declining job satisfaction among GPs caused by increasing workloads and a feeling of being undervalued appear to be contributing to this trend. NHS England and the Royal College of General Practitioners are interviewing older GPs to find out what might encourage them to stay in general practice.
- It is too difficult for GPs who have left to return to practice. The number of GPs leaving means there is a large pool of people not currently practising in England who could potentially be attracted back. The Royal College of General Practitioners referred to GPs in Scotland who wanted to practise in England. However, it told us that it is unnecessarily difficult and takes a long time for GPs to return after an extended period away, even if they have been working in the meantime as GPs in other countries. Efforts have been made to improve the process, but the Royal College considers it is still too bureaucratic.
- NHS England and Health Education England are struggling to attract new doctors to become GPs. Recently, the number of trainees recruited each year has remained at approximately 2,700, although the number of training places has increased. This meant that 12% of training places were unfilled in 2014–15. We heard that negative perceptions about general practice and the heavy workload were making it more difficult to attract trainees. For 2015–16 Health Education England carried out a marketing campaign and regional roadshows to promote general practice to foundation-year doctors who were coming to the point of having to make a career choice, and 100 more people took up GP training places than in the previous year.
Recommendation: Building on the workforce action plan, the Department, NHS England and Health Education England should:
a)set out how they plan to reduce the number of GPs leaving the profession early, informed by analysis of the interviews with older GPs;
b)set out how they plan to attract more GPs to return to practice, and how they will monitor progress;
c)establish which incentives work best in attracting new recruits to general practice; and
d)report back to us by December 2016 on the three points above and on progress towards having 5,000 more doctors working in general practice.
2.Having good access to general practice is too dependent on where patients live because of variations in staffing levels. Staffing varies significantly across the country—after adjusting for patient needs, the most deprived areas had on average nearly five fewer GPs and nurses per 100,000 people than the least deprived areas in 2014, although the gap has narrowed since 2010 when the most deprived areas had 19 fewer GPs and nurses per 100,000 people. In areas where there are fewer staff it is harder for patients to get appointments. In the third of clinical commissioning groups with the lowest ratio of GPs and nurses to patients, 13% of patients could not get an appointment, compared with 10% in the third of clinical commissioning groups with the highest ratio. In addition, a higher proportion of older GPs work in more urban and deprived areas so there is a risk that the inequality between areas may increase when these GPs come to retire. There is no mechanism to ensure that doctors and nurses are distributed equitably around the country, and places for new GPs are much easier to fill in London than in some other parts of the country. Through its workforce action plan NHS England has been using incentives, such as extra financial support, to attract trainee GPs to work in areas of greatest need. However, it is not clear what progress has been made.
Recommendation: By December 2016 NHS England should review the effectiveness of its incentives to attract staff to areas which have relatively few general practice staff, and set out the action it will take in light of its findings.
3.There is unacceptable variation in patients’ experiences of getting and making appointments. Patients who are older, white or in a more affluent urban area get better access than anyone else. Conversely, patients who are younger, work full-time or from a minority ethnic group are more likely to report problems in getting a convenient appointment and in seeing their preferred member of staff. For example, in 2014–15 19% of Asian patients were unable to get an appointment, compared with 11% of white patients. The proportion of patients at each practice unable to get an appointment varied significantly, from 0% to 52% in 2014–15. Most of this variation appears to be due to the way practices are managed rather than underlying demographic factors. Through the Prime Minister’s GP Access Fund and other initiatives, NHS England is exploring how practices can improve access for their patients, for example through better use of technology, staffing and wider community-based services. It is also doing some work to share learning and good practice more generally, but it is still not easy enough for individual practices to find out what is working well elsewhere.
Recommendation: NHS England should develop a strategy for identifying and sharing best practice on access to general practice, including on how to improve access for patients from minority ethnic groups, and report back to us by December 2016.
4.We are concerned that it appears it is not always easy for people to find the information they need to access the right medical care. To help them choose their general practice and get appointments when needed, people need clear information on the services practices provide and when they are open. Without this information, they may go to A&E instead or do nothing at all. However, it can be difficult to find out even basic information such as practice opening hours. Research by Healthwatch has highlighted examples of practices having no website and, in one county, more than a quarter of answer-machine messages gave the wrong out-of-hours telephone number, which puts patients at risk if they do not know how to get help when their general practice is closed. Good information may also help to reduce the number of avoidable GP appointments by letting patients know where they can find more appropriate organisations to help them with non-medical issues such as benefits or housing.
Recommendation: NHS England should set out the minimum level of information that all general practices should provide to the public to help them access services easily, and it should monitor practices’ compliance annually.
5.The Department and NHS England do not have enough information on demand, activity or capacity to support their decisions on general practice. The National Audit Office’s report highlighted a large number of important gaps in the data on general practice. For example, the Department has not collected data on the number of consultations since 2008–09, and no data are collected on staff vacancies within practices. The Royal College of General Practitioners told us that individual practices do collect detailed data on activity, but these data are not extracted, analysed or used. The General Practice Extraction System aimed to provide this information but, as we reported in January 2016, this project is late and still does not deliver all that was intended. The Department told us that it and NHS England use existing data from the GP Patient Survey as an indicator of pressure in the system, and that they have work underway to improve data on activity levels and staffing. However, the existing data gaps mean that the Department and NHS England cannot be making well-informed decisions on how to improve access to general practice or where to direct their limited resources.
Recommendation: By September 2016 the Department and NHS England should publish a plan for improving the information they have on demand, activity and capacity in general practice, including the minimum dataset they need and how and when they plan to collect this dataset.
© Parliamentary copyright 2015
Prepared 3 March 2016