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

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 longest time span of data comes from the QRESEARCH analysis. Between 1995/6 and 1999/00 GP consultations remained steady or even declined slightly, while practice nurse consultations increased, suggesting that nurse consultations may have substituted for GP consultations. From 1999/00 to 2008/9 both GP and nurse consultations increased at a steady rate. The nurse consultation rate rose faster than the GP rate, but from a lower baseline. The increase in the consultation rate did not seem to be influenced by the introduction of the Quality & Outcomes Framework (QOF) reimbursement system in 2004/5.

After 2009/10 the data become more difficult to interpret, perhaps because the three analyses used data from three different sets of practices. The CPRD study does suggest a continued increase in consultations by GPs but also suggests a plateauing out or even reduction in nurse consultations, as does the Nuffield study.

The consistency of the upward slopes in the consultation rate graphs might indicate that consultations are driven by demographic change, with a high birth rate driving up consultations with the under-fives while the ageing population (particularly the growth in the numbers of patients in their eighties and nineties) has also increased the need for consultations. What we cannot tell from the available data is what goes on in consultations, which may be becoming more complicated, especially as more of us live to an advanced age with multiple disorders.

Although it has not been explicitly discussed in the arguments around the crisis in general practice, supplier-induced demand needs to be considered here. The introduction in 2004/5 of QOF--a system of performance-related pay--encouraged practices to see patients with long term conditions more often to collect the clinical data about their condition needed to qualify for QOF payments. Whilst some of this data could be collected in the normal course of doctor- or nurse-patient contacts, some patients may 'need' additional appointments for data collection purposes. This form of doctor-initiated clinical activity could be seen as supplier-induced demand, similar to the doctor-led demand seen in specialist care in many other countries.

Supplier-induced demand in primary care is a contentious explanation for practice variations (15) that has been observed amongst GPs in the Netherlands (16) and Switzerland (17) but seemingly not studied in the UK. There are grounds for thinking that supplier-induced demand could occur in UK primary care, (18) and this needs further exploration.

Is the number of general practitioners declining?

The number of full-time equivalent GPs in England rose from around 30,000 in 2003 to 36,300 in 2013, equivalent to an increase of 12 per cent when taking population growth into account. The bulk of the rise occurred between 2004 and 2006. (19) However, a combination of reduced entry to general practice training programmes, rising levels of part-time working, migration (or drop out) of new GPs and intentions to retire expressed by older GPs point to a significant workforce undersupply, under a wide range of plausible future scenarios. The 2014 Centre for Workforce Intelligence report concluded that there was a clear risk of a major demand-supply imbalance emerging by 2020 unless there was a significant, sustained and immediate boost to GP training. (20)

The CfWI report suggests that the increase in GP training posts needed to balance demand and supply over the medium term (up to 2030) is likely to be around 20 per cent. However, given the significant lead-in time in training new GPs, an affordable and achievable 20 per cent increase in training posts would not fully meet expected medium-term demand for GP services. NHS England (together with Health Education England, the Royal College of General Practitioners and the British Medical Association) has acknowledged this problem and recruitment to GP training posts was higher in 2016/7 than in 2014/5. (21) Funding has been found to re-attract GPs who have dropped out ('returners') and to recruit from other countries; it remains to be seen how effective these measures will be, especially given the threat of Brexit to recruitment in Europe.

Is GP income falling?

Figure 2 shows the incomes of GPs with the commonest form of NHS contract, the General Medical Services contract. Total income per practitioner, practice expenses and individual earnings before tax are shown in real terms (as purchasing power, taking 2012/13 sums as 100 per cent). Gross income is determined by the NHS, using a complex formula. Expenses include premises, staff and equipment costs and are the investment the practitioner makes to keep the practice running.

The introduction of the QOF (a complex system of performance-related-pay designed to improve the care of patients with long term conditions) in 2004/5 increased gross income (by 58 per cent) and earnings (by 20 per cent) in that and the subsequent year, whilst expenses plateaued. Gross income and earnings started to decline after 2006/7, whilst expenses rose slightly. Even so, a full-time GP in 2012/3 still earned more (in purchasing power terms) than s/he did in 2003/4. Whilst gross income and expenditure continue to rise, by 2015/16 earnings seem to have plateaued. The overall pattern is still one of a steady rise in investment in practices.

The investment that occurred in the 1990s allowed GPs to maximise income from the QOF performance-related-pay because they had the staff and systems ready to undertake the work of collating patient-level data about disease management, identifying underperformance and documenting activity.

The introduction of QOF changed the internal organisation of practices. Decision-making became concentrated in the hands of a small group within each practice, which monitored and controlled staff behaviour for maximum performance to achieve targets. (22) It also focused energy on numbers not people, so that both GPs and practice nurses reported that the person-centredness of consultations and continuity of care were both harmed. Medical conditions that were not included in QOF received less attention, and this relative neglect worsened as time passed. Patient satisfaction with continuity of care began to decline. (23)

However, the introduction of QOF also led to a large increase in job satisfaction amongst GPs. A study using the GP Worklife Survey and QOF data returns (24) attributed this to the large increase in earnings that GPs experienced for a brief period after 2004/5. The study's authors concluded that GP job satisfaction was unlikely to be affected by changes in pay for performance as long as earnings remained constant. This did not happen and in 2012 job satisfaction fell to its lowest point for a decade. (25)

There is a sense that GPs are now trapped by performance-related pay. Declining gross income requires savings but these cannot be in expenses because expenses allow practices to maximise their performance-related income stream. Earnings had to fall, at least in the short term. Bold practitioners might cut their personal incomes even further to boost expenses (for example by hiring an extra doctor to meet the rising demand for consultations) but there is now no certainty that this investment will increase earnings in the future. The relative shortage of GPs means that a sellers' market may develop for doctors wanted for sessional work, and this may increase expenses and erode GP earnings as hard bargains are driven.

Alternative methods of increasing investment include merging back-office management functions in larger group practices, in creating 'federations' of practices, or in merging with hospital Trusts. A super-practice of nearly 200 partners was announced in August 2015, (26) and GPs and NHS England are following its development with interest. Federations allow GPs to lose some autonomy but gain efficiencies and some protection from commercial organisations trying to enter the primary care market. Nine hospitals were given the right to provide GPs services in the 2015 Vanguard programme. (27)

Crisis, what crisis?

Is there really a crisis in general practice, or is the talk of crisis just the way in which NHS practitioners express 'voice' (protest, complaint, demands) as an alternative to retiring or resigning ('exit')? (28) There is certainly a lot of noise, and Klein's 'linguistic excess and muddle' are widespread, but such dramatic rhetoric is a necessary and inescapable part of the clamour for resources within the NHS. GPs are independent contractors, making it almost impossible for them to take industrial action. In order to secure needed resources in competition with other parts of the Health Service, they must either use the tools of journalism and policy advocacy (or retire from practicing medicine).

The use of the word crisis is, moreover, objectively justifiable. We are facing a turning point in general practice. This could lead to retirement, emigration or career changes for individuals, and to super-practice and federation formation for existing practices. GPs have already been through a significant period of financial and organisational instability and emotional upheaval. And, judging by the tone of GPs' calls for their views to be heard and acted upon, the profession and the government are heading for a significant confrontation. Many GPs have experienced, or witnessed, major changes in their working environment and in their immediate health economies.

Demand for appointments has been rising, but this may in large part be a function of demographic change. It is strange that the NHS does not routinely collect data on consultations--general practice is a 'black box', we do not know what is going on inside it--but from what data we have we can perhaps see a plateau in the rising consultation figures.

Some of the 'demand' may be induced by the pay-for-performance elements of GP work, making it difficult for practitioners to control workloads without losing income. One way to reduce some workload pressure would be to end some pay-for-performance tasks--especially the ones with meagre scientific justification, like Health Checks or over 75 checks--and re-route the money attached to them into core funding. There was a precedent for this, when the Department of Health reduced the 2012/3 QOF targets without practices experiencing a loss of income.

At the moment it seems that the GP workforce is either stable or growing slowly, but there is a risk of a substantial mismatch in supply of and demand for GPs within a few years. This is probably the most certain and most serious element of the GP crisis. NHS England accepts that there is a crisis in general practice, and has launched multiple initiatives to encourage new entrants to the discipline, recruit from outside the UK, stave off early retirements and encourage 'returners' who have been out of clinical practice for a while but who want to restart their careers.

Gross practice income has been falling for some years, but appears to be increasing again following the publication of the General Practice Forward View in 2016 and the plans to increase the proportion of the NHS budget spent on the general practice workforce. (29) The General Practice Forward View goes further by supporting financially and organisationally vulnerable practices with a 'resilience' programme, thought to be potentially applicable to nearly i0 per cent of practices. It advocates a longer time interval between Care Quality Commission inspections (for 'good' or 'excellent' practices), a review of QOF given concerns that it undermines holistic assessments of individuals, and simplification of the oversight and payment systems. Significantly, the GP Forward View proposes a new but voluntary contract, for Multi-specialty Community Providers, which could bring about the formation of community services with general practitioners integrated within them--in effect, an end to independent contractor status.

Practice expenses--salaried doctors, nursing and other staff, equipment and premises--have held steady or risen because GPs have accepted a reduction in earnings. This has been unavoidable, because expenses need to be high to maintain practice income, especially the pay-for-performance funding streams. Not surprisingly, declining earnings lead to a decline in morale and job satisfaction, but this is not a problem confined to general practice--most employed people have experienced a reduction in real incomes since 2008. (30)

What should an incoming Labour government do?

Labour's 2017 manifesto said that a Labour government would 'increase funding to GP services to ensure patients can access the care they need'. The policy document produced before the 2015 General Election was much fuller. It promised 8,000 more GPs (without specifying how it would get them) but also guaranteed that people could get 'a GP appointment within 48 hours, or on the same day for those who needed it', plus "the right to book ahead with the GP of their choice'--a proposal with potential workload implications. Another promise of relevance to GP workload was to introduce 'safety checks' for vulnerable older people, 'to prevent problems before they occur'--a labour-intensive activity that contradicts the available evidence on either the clinical--or cost-effectiveness of such interventions.

Labour needs to catch up on policy for general practice. In general, Labour's public statements suggest that what the NHS needs is simply more money, rather than reform. But more money is merely one of the things a Labour government would need to do to really deliver an effective healthcare system for the twenty-first century. (31)

The recruitment and retention problem is arguably the most important one to solve, but is possibly the easiest given there are multiple methods for enlarging the medical workforce. All Labour needs to do about GP recruitment is to endorse the spirit of the General Practice Forward View, and commit to the spending plans within it.

Reducing the salience of QOF and other pay-for-performance funding streams, whilst transferring the budget allocated to them to core funding (gross income), would reduce some of the possible supplier-induced demand without loss of income. It is also likely to reduce box-ticking. There is a case for abandoning QOF on the grounds that it has lifted the quality of care provided by general practitioners, and so done its job. Whether GPs would invest the diverted income in their practice, or opt to increase personal earnings, remains to be seen.

Relaxing the payment system does not imply relaxing quality control. The NHS needs an information system for capturing GP activity in detail and on a large scale, to understand what is going on within consultations, to allow more sensitive workforce planning and to avoid political debates that are based on guesswork and highly selective data. Labour could be explicit about this need for scrutiny, rather than naively overvaluing investment in IT as a great leap forward for clinical care.

The sense of crisis should slowly abate given the actions now being taken to remedy some of the problems described in this article, and in these areas, all a Labour government will need do is support the policies already applied. Existential anxiety, on the other hand, will persist as general practitioners consider their future as sub-contractors to the NHS, with variable incomes and multiple organisational pressures. Some may be pleased to abandon their independent contractor status and become salaried employees of super-practices, GP Federations or hospital or community Trusts. The GP Forward View's promotion of Multi-specialty Community Providers is welcome, in that it imagines something that has long been desired but never achieved, an integrated system of primary care.

Labour should encourage experimentation in the ways that integrated primary care is developed and implemented. The time is right. Salaried status for GPs, once Labour policy but always a fringe idea in medicine, is now debated seriously in the British Medical Journal. (32) There is an opportunity to offer a new, salaried contract to GPs who will work within community or hospital Trusts, rather than work as isolated sub-contractors to the NHS. Labour needs to be bold, and let a hundred flowers bloom.

Steve Iliffe is Emeritus Professor of Primary Care for Older People at University College London, having been a general practitioner in inner London for 30 years.

Notes

(1.) B. Baird, 'Time to tackle the crisis in general practice', NHE, May/Jun 2016.

(2.) M. Roland & S. Everington, 'Tackling the crisis in general practice', BMJ, 2016.

(3.) BMA, General practice in the UK, London, July 2014.

(4.) BMA, 2016, www.bma.org.uk/news/media-centre/press-releases/2016/november/patient-safety-under-threat-from-pressures-in-general-practice, accessed 15.10.17.

(5.) R. Klein, 'Rhetoric and reality in the English National Health Service', Int. J. Health Policy & Management, 2015.

(6.) M. Dyan S. Arora, R. Rosen & N. Curry, Is general practice in crisis? Nuffield Trust, London, 2014.

(7.) N. Curry, 'Fact or fiction? Demand for GP appointments is driving the 'crisis' in general practice, Nuffield Trust blog, 3.3.15, http://www.nuffieldtrust.org.uk/blog/fact-or-fiction-demand-gp-appointments-driving-crisis-general-practice, accessed 14.1.17.

(8.) 'Person years' tells us how many years of contact with general practices each patient contributes to the datasets.

(9.) J. Hippisley-Cox, J. Fenty, M. Heaps, 'Trends in Consultation Rates in General Practice 1995 to 2006: Analysis of the QRESEARCH database. Final Report to the Information Centre and Department of Health', July 2007; Data.gov.uk, Trends in consultation rates in general practice 1995/6 to 2008/9, 2011, https://data.gov.uk/dataset/trends_in_consultation_rates_in_general_practice.

(10.) M.G. Dunnigan, Exaggerated estimates of GP consultation rates may discourage GP recruitment, BMJ, 2014.

(11.) Deloitte, Primary care: Today and tomorrow: Improving general practice by working differently, London, 2012.

(12.) F.D.R. Hobbs, C. Bankhead, T. Mukhtar, S. Stevens, R. Perera-Salazar, T. Holt, 'Clinical workload in UK primary care: a retrospective analysis of i00 million consultations in England, 2007-14', Lancet, 2016.

(13.) N. Curry, 'Fact or fiction? Demand for GP appointments is driving the 'crisis' in general practice', Nuffield Trust blog, 3.3.15, http://www.nuffieldtrust.org.uk/blog/fact-or-fiction-demand-gp-appointments-driving-crisis-general-practice, accessed 14.1.17.

(14.) B. Baird, 'Time to tackle the crisis in general practice', NHE, May/Jun 2016.

(15.) P. Davis, B. Gribben, A. Scott, R. Lay-Yee, 'The "supply hypothesis" and medical practice variation in primary care: testing economic and clinical models of inter-practitioner variation', Soc Sci Med, 2000.

(16.) M.J. van den Berg, D.H. de Bakker, G.P. Westery, J. van der Zee, P.P. Groenewegen, Do list size and remuneration affect GP's decisions about how they provide consultations? BMC Health Services Research, 2009; C.E. van Dijk, B. van den Berg, R.A.Verheij, P. Spreeuwenberg, P.P.Groenewegen, D.H. de Bakker, 'Moral hazard and supplier-induced demand: empirical evidence in general practice', Health Economics, 2013.

(17.) A. Busato, P. Matter, B.Kuenzi, Factors related to treatment intensity in Swiss primary care, BMC Health Services Research, 2009.

(18.) S. Peckham, K. Gousia, GP payment schemes review, PRUComm, Kent/London/Manchester, 2014.

(19.) J. Appleby, 'Is general practice in trouble?' BMJ, 2014.

(20.) Centre for Workforce Intelligence, In-depth review of the general practitioner workforce. Final report, London, 2014.

(21.) National Audit Office, Improving patient access to general practice, DoH/NHS England, 2017.

(22.) S. Grant, G. Huby, F. Watkins, K. Checkland, R. McDonald, H. Davies, B. Guthrie, 'The impact of pay-for-performance on professional boundaries in UK general practice: an ethnographic study', Sociology of Health & Illness, 2009.

(23.) S. Gillam, A.N. Siriwardena, N. Steel, 'Pay-for-performance in the United Kingdom: Impact of the Quality & Outcomes Framework--a systematic review' Ann Fam Med, 2012.

(24.) T. Allen, W. Whittaker, M. Sutton, 'Does the proportion of pay linked to performance affect the job satisfaction of general practitioners?' Social Science in Medicine, 2017.

(25.) M. Hann, J. McDonald, K. Checkland, A. Coleman, H. Gravelle, B. Sibbald, M. Sutton, Seventh National GP Worklife Survey, University of Manchester, 2013, Pulse Today, www.population-health.manchester.ac.uk/healtheconomics/research/FinalReportofthe7thNationalGPWorklifeSurvey.pdf.

(26.) A. Matthews-King, 'Largest GP partnership in the UK to launch with 'nearly 200' partners', Pulse Today http://www.pulsetoday.co.uk/your-practice/practice-topics/commissioning/largest-gp-partnership-in-the-uk-to-launch-with-nearly-200-partners/20010763.article.

(27.) J. Kaffash, 'Nine hospitals given green light to provide GP services', 2015, http://www.pulsetoday.co.uk/news/commissioning-news/nine-hospitals-given-green-light-to-provide-gp-services/20009414.article.

(28.) A.O. Hirschman, Exit, Voice, and Loyalty: Responses to Decline in Firms, Organizations, and States, Cambridge, MA, 1970.

(29.) S. Everington, M. Roland, 'NHS England's major boost for general practice', BMJ, 2016.

(30.) M. Dyan, S. Arora, R. Rosen, N. Curry, Is general practice in crisis? Nuffield Trust, London, 2014.

(31.) S. Hutchinson, 'Protecting the Legacy: Developing a Labour Vision for Health and Social Care', Renewal, 25/3-4, 2017, http://www.renewal.org.uk/articles/protecting-the-legacy-developing-a-labour-vision-for-health-and-social-care.

(32.) A. Majeed, L. Buckman, 'Should all GPs become NHS employees?', BMJ, 2016.
Table 1. Sources of data on consultation rates in general practice

Dataset            Source                 Time period

Q Research         Version 13 of the      1995/6-2008/9
                   database with 30
                   million person years
                   Of observation from
                   525 practices (8)
                   Dunnigan's analysis
                   used 10 million
                   patients from 602
                   practices
CPRD (Clinical     11.3 million patients  2007/8 to 2013/4
Practice Research  from 674 practices
datalink)          3.2 million patients   2010/11 to 2013/14
                   in 337 practices in
                   England
Research One       30 million individual  2010/11-2014/15
                   contacts with          Fund(2016) (14)
                   patients from 177
                   practices
Dataset            Analysed by
Q Research         Hippisley-Cox et al
                   (2007, 2009)
                   Data.Gov.uk(2011) (9)
                   Dunnigan (2014) (10)
                   DeLoitte (2012) (11)
CPRD (Clinical     Hobbsetal(2016) (12)
Practice Research
datalink)          Curry, Nuffield
                   Trust, (2015) (13)
Research One       Baird B et al, King's
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Title Annotation:UNDERSTANDING PUBLIC SERVICES
Author:Iliffe, Steve
Publication:Renewal
Geographic Code:4EUUK
Date:Jun 22, 2018
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