Last reviewed 14 December 2015
Martin Hodgson, a consultant with a long history working in healthcare education, examines a new report from the National Audit Office which highlights “considerable variation” in access across different patient groups, and notes that a major challenge for general practice will be maintaining services in the face of overstretched budgets and increasing demand.
Rationale behind the report
The National Audit Office (NAO) — an independent body which scrutinises public spending and improves public services — state that the Stocktake of access to general practice in England report was written to “examine patient expectations” in relation to access to general practice, and to assess the capacity of general practice to meet growing demand.
The report recognises that most of the contact people have with the NHS is with general practice and that GPs and other primary care staff play “a crucial role” in healthcare.
Good access to general practice, the authors state, matters greatly both for patients themselves and for the health system as a whole. The NAO describe poor access as causing “stress and frustration” for patients at a time when they may already be worried by their health concerns, and express concern that this may potentially prolong discomfort or pain. Conversely, good levels of access improve patient outcomes and ensure patients have timely access to the healthcare they need.
In addition, the NAO state that good access to general practice “reduces pressure” on other parts of the NHS, particularly on hospital A&E departments.
The NAO report has been written at a time when there is much debate about demand and the relative pressures on general practice and the rest of the NHS, particularly those services that provide direct access to patients when they need it, such as A&E departments. In this regard it has been a long-term aim of the government to increase access to general practice in order to reduce pressure on emergency services. Part of this commitment is the high-profile government strategy of employing extra doctors in general practice and providing seven-days access to general practice.
The main findings
The report asks a number of questions about access to general practice, including:
can patients get appointments when required and within reasonable timeframes?
can patients access services that are close to their home?
can patients access GP practices at convenient times and in flexible ways?
can patients access the same professional each time if they need or want to?
The headline finding of the report, which uses data from 2014-15, is that people’s experience of accessing general practice services in England is overall a positive one, with three-quarters of patients saying that they got an appointment “within the timeframe they wanted” and only 12% of patients reported a poor experience of making an appointment.
Despite this positive picture, however, NAO state that patient satisfaction with access is “gradually and consistently declining”; figures have fallen from 91% in 2011-12.
Patient satisfaction with the process of making an appointment has also declined — 27% of patients reported difficulties in getting through to the GP practice on the telephone, compared with 19% in 2011-12. The percentage of patients who reported they were able to see their preferred GP has also fallen from 66% in 2011-12 to 60% in 2014���15.
The NAO reports considerable variation in access between different patient groups. It states that:
older patients are more likely than younger patients to report that they were able to access appointments
people from a white ethnic background reported better access than those from other ethnic groups.
The report notes that different patient groups have different expectations of access to general practice, with younger patients more likely to want an appointment quickly, whereas patients aged 75 and over are more likely to value continuity of care.
Regarding opening hours, the NAO quotes the latest GP Patient Survey as suggesting a fifth of patients report that opening hours are not convenient for them, increasing from 17% in 2011-12 to 20% in 2014-15. The report comments on government plans to give all patients access to general practice from 8am to 8pm, seven-days a week, by 2020. It describes evidence for this extension as “mixed”.
Demand and capacity
The NAO report concludes that demand for general practice is increasing as the population grows and people live longer, often with multiple medical conditions. It also notes that problems in recruiting and retaining GPs are increasing, with 12% of training places in 2014/15 remaining unfilled.
In addition, the NAO state that:
deprived areas tend to have a lower ratio of GPs and nurses to patients, and where the ratio is lower it is harder for patients to get appointments
the distribution of general practice staff across the country does not reflect need, meaning that inequalities exist despite NHS England allocation formulae
GPs make up only 29% of the general practice workforce, so increases in GP numbers alone are unlikely to be able to deal with the rising demand for services.
The lack of up-to-date Department of Health and NHS England data on the number of GP consultations is criticised in the report, which concludes that general practice is “under increasing pressure” with demand rising by more than capacity.
The NAO use an estimate of 372 million consultations in 2014-15 to suggest that activity has increased by 3.5% per year on average between 2004 and 2014. They compare this to a 2.0% increase in general practice staffing.
The NAO make the following recommendations:
NHS England should improve the data it collects on demand and supply in general practice, and research how different practices’ appointment-booking and other working arrangements drive variations in access
NHS England should research how different practices’ appointment-booking and other working arrangements drive variations in access
NHS England and clinical commissioning groups should influence people’s behaviour to help practices make best use of available capacity, including raising the awareness of people about different options
while making changes designed to improve access, NHS England should analyse the impact on different patient groups.
Referring to the need for better data, Amyas Morse, head of the NAO, concludes:
“Against the background of increasing demand and pressure on NHS resources, the challenge is how to maintain people’s positive experience of accessing general practice and reduce variation. The Department of Health and NHS England are working to improve access, but are making decisions without fully understanding either the demand for services or the capacity of the current system. Better data is needed so that decisions about how to use limited resources to best effect are well-informed.”
Response to the report
Commenting on the new report, Dr Maureen Baker, Chair of the Royal College of General Practitioners, said:
“The fact that so many patients are satisfied with the level of access they have to their GP practice is testament to the hard work and dedication of family doctors and their teams at a time when they are facing intense resource and workforce pressures.
But it cannot be ignored that as general practice strives to meet the increasing demand of a growing and ageing population, with consistently fewer resources, our patients’ ability to make a timely appointment is worsening. Recent analysis by the College based on the latest GP Patient Survey found that on 67m occasions this year, patients will wait more than a week for an appointment with their GP or nurse.
This is most worrying because when a patient can’t make an appointment with their GP, we don’t know where they go; they might get better on their own; they might visit A&E where care is far more expensive; or they may simply stay sick. It is also concerning that where people live is affecting their ability to access general practice services — something that should never be the case.
our patients should always be able to see a GP when they need to through the existing five day service and existing GP out of hours service – instead of looking into extending routine GP access, the first priority of politicians and decision makers should be to concentrate on making these services more accessible and better integrated.”
Dr Baker called for more resources for general practice so that access to services could be maintained and improved.
The NAO state that the impact of initiatives to improve access — such as increasing GP numbers and extended opening times — will be examined in a follow-up report on how effectively the Department of Health and NHS England oversee and support general practice.