The future of general practice – Report Summary

This is a House of Commons Committee report, with recommendations to government. The Government has two months to respond.

Author: Health and Social Care Committee

Related inquiry: The future of General Practice

Date Published: 20 October 2022

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Summary

1. Every working day more than one million people attend an appointment at their local GP surgery: general practice is the beating heart of the NHS and when it fails the NHS fails. We know up to 90% of healthcare is delivered by primary care. Yet currently the profession is demoralised, GPs are leaving almost as fast as they can be recruited, and patients are increasingly dissatisfied with the level of access they receive.

2. The root cause of this is straightforward: there are not enough GPs to meet the ever-increasing demands on the service, coupled with increasing complexity of cases from an ageing population. In May this year there were an estimated 27.5 million appointments in general practice, more than two million more than in 2019. Yet over the same period, the number of qualified, full-time equivalent GPs working in the NHS has declined by nearly 500 from 28,094 to 27,627.1 This gap between demand and capacity leaves GPs working harder and facing more burnout as patients find it harder than ever to see them.

3. One result of this has been high reliance on the use of locum doctors, and the number of newly qualified GPs choosing to work in such roles rather than as salaried GPs or as partners. This is a symptom rather than the cause of the problem. Urgent work needs to be done to stop a bidding war for the services of locums and establish requirements for a minimum fair share of administrative duties.

4. Alongside worsening access to care, the decline of continuity of care in general practice is one of the most concerning impacts of the pressure on general practice. Since 2004 the majority of GPs have not had individual lists of patients even though there is clear international and UK research showing that seeing the same GP over a long period of time leads to fewer hospital visits, lower mortality and less cost for the NHS. Recent pressures have made it even less likely people will see the same doctor regularly and even more likely for patients to depend on overstretched emergency services. The fundamental division of labour between emergency and non-emergency care has broken down.

5. There can sometimes be a trade-off between access and continuity, and we believe that the balance has shifted too far towards access at the expense of continuity. Seeing your GP should not be like phoning a call centre or booking an Uber driver who you will never see again: relationship-based care is essential for patient safety and patient experience. It is also much more motivating for doctors.

6. Improving the accountability of care for individual patients through GP lists should not replace the team-based approach that is becoming increasingly important. It will not always be appropriate for GPs to provide care personally when, for example, it could be done so more efficiently by a practice nurse or a physician associate. But from the patient’s point of view it should always be clear where responsibility for their care lies, which outside hospital will normally be their GP.

7. The Government and NHS England have made several changes over recent years to help general practice become more sustainable and change the way patients receive care, such as the creation of Primary Care Networks and the introduction of a range of new professionals into general practice. However, our inquiry has found that these developments, while welcome, are not yet making a meaningful impact on the future sustainability of general practice. Instead, we heard that patients can become confused over who they are signposted to and why, leaving GPs dealing with multiple complex cases one after another and as a result, contributing to clinician burnout and concerns by the clinicians they might make mistakes or not be able to practise safely. This combination of intensely complex cases, done at speed, with fear over reprisals on the individual clinician is driving a systemically toxic environment in primary care.

8. Instead, the Government and the NHS should be bolder. We recommend abolishing the Quality and Outcomes Framework (QOF) and Impact and Investment Framework (IIF) which have become tools of micromanagement and risk turning patients into numbers. GPs should be treated like professionals and incentivised to provide relationship-based care for all patients by restoring individual patient lists. The Government’s decision to introduce an additional two-week wait target for GP appointments, while well-intentioned, does not address the fundamental capacity problem causing poor GP access.

9. To help achieve this the Government should examine the possibility of limiting the list size of patients to, for example, 2500 on a list, which would slowly reduce to a figure of around 1850 over five years as more GPs are recruited as planned. These numbers should reflect varying levels of need in local populations. This would draw us closer in line with our European counterparts, and help improve access and continuity. It should only be implemented in a way that does not undermine the fundamental rights of patients to access a GP.

10. Continuity of care is beneficial for all patient interactions even if it cannot always be offered. It should not therefore be available only for patients with complex needs, because part of the purpose of a long-term relationship between a doctor and patient is to prevent chronic or long-term illness before it happens.

11. Historically one of the key drivers of innovation and improvement in general practice has been the GP partnership model, which gives GPs the flexibility to innovate with a focus on the needs of their local population. We know there are significant pressures on GP partners at the moment but the evidence we received was clear that the partnership remains an efficient and effective model for general practice if properly funded and supported. It is important that the model of general practice can vary according to local needs, so other models of delivery should also continue to be explored where this works for local communities. Whether or not in a partnership model, the professional status of GPs should not be undermined by the inappropriate refusal of GP referral decisions.

12. Rather than hinting it may scrap the partnership model, the Government should strengthen it. For GP partners at the end of their careers, one of the biggest barriers to staying on longer is the huge pensions tax bills that many face. We continue to call for the Government to take specific action to allow senior doctors, including GPs, to carry on working without facing these tax bills. We welcome the focus on this issue in the Government’s Plan for Patients but the Government must provide further detail on what changes it will introduce. Partnerships as entities also need support with complex issues around premises they own which may not be fit for purpose. The Government should consider adopting the approach taken on this issue in Scotland which allows a route for GP partners to remove the property risk from their businesses.

13. As part of a broader overhaul of primary care, the NHS should dramatically simplify the patient interface. Currently patients with urgent care needs are left wondering whether to call their surgery, the out of hours service, 111 or to go to A&E. Many people are not clear about the difference between such services and the most appropriate option, further adding to the pressures on general practice.

14. We also heard very clearly that the issues facing general practice are not equal everywhere in the country. In some parts of the country challenges such as workforce shortages are significantly more acute, and these are often areas where there are already higher levels of ill-health and deprivation. The Government and NHS England must develop a better mechanism to award funding to more deprived areas to replace the Carr-Hill formula which is insufficiently weighted for deprivation at present. This funding change should be used to support further work to ensure equal access to general practice across the country.

15. Finally, it is time to recognise the need to make the job not just manageable but once again fulfilling and enjoyable. General practice really should be the jewel in the crown of the NHS, one of the services most valued by its patients. For doctors it should allow a cradle to grave relationship with patients not possible for other specialties but for many infinitely more rewarding. To do that general practice needs to have its professional status restored with a decisive move away from micromanagement and short staffing to a win-win environment in which investment in general practice reduces pressure on hospitals and saves resources for the NHS.