Dr Kamal R. Mahtani, an Oxfordshire based GP and deputy director of the Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, discusses the pressures on GPs and the factors affecting patient waiting times.
Over 50 million people in England are cared for by the NHS and at least 90% have their first NHS contact with a GP. However, getting to see a GP is increasingly becoming more of a challenge. The latest NHS patient survey showed that about one in five patients had to wait one week or more before they could see or speak to someone at their GP surgery. Ominously, the British Medical Association have added that patients should expect current waiting times to “rocket”. The Royal College of General Practitioners now estimate that by 2022 there will be over 100 million incidents of a patient waiting a week or more to see a GP or practice nurse.
This is bad news for patients. Longer waiting times mean that fewer patients will be seen and - for those that do get an appointment - severe constraints on the time that a GP can devote to each appointment.
So what is driving these pressures? One obvious reason is that patient demand has increased substantially. A recent analysis, published in The Lancet, and led by a team at the Nuffield Department of Primary Care Health Sciences, examined over 100 million NHS primary care consultations. The analysis showed that between 2007 and 2014 there were significant increases in both the numbers of consultations being requested by patients and the lengths of the consultations; the system, the researchers suggested, was reaching a “saturation point”.
Along with increasing demands to see GPs, the complexity of patients’ problems has also increased. A 10-year study of more than 15,000 people in England, aged over 50, showed a 10% rise in the number of patients who have two or more long-term conditions, so-called “multimorbidity”. NHS England has suggested that this is currently the greatest challenge facing the NHS, a challenge largely being managed by GPs. Patients who live longer, but with more health problems, also face the potential problem of polypharmacy, the use of multiple medications, sometimes justifiably, sometimes not. A 15-year study of over 300,000 patients in Scotland showed a doubling in the number of individuals who were taking five or more medicines. Avoiding the harms that medicines can cause, while maintaining their potential benefits by optimising their use, is a challenge faced by every GP every day, and one that can rarely be managed during a typical 10-minute consultation.
With rising demands and clinical complexity, the number of UK GPs continues to fall, a trend that, unless adequately addressed, appears likely to continue. A 2015 survey of over 1000 GPs showed that 82% intended to reduce direct clinical work within the next five years, citing work-related pressures, the changing nature of the job, and stress as contributing factors. A King’s Fund report has emphasised other problems contributing to the current pressures facing GPs: high levels of deprivation, a decline in self-management of minor illnesses, higher expectations, particularly of new services, and a fall in general practice funding.
If these pressures continue to mount, patients will suffer more than just longer waiting times. The Royal College of General Practitioners has suggested that the growing GP workload may affect patient safety. Empirical evidence suggests that this may already be happening. In a survey conducted by the British Medical Association, 93% of GP respondents reported that their workload had had negative effects on patient care.
Depending on what you read, the UK National Health Service is either one of the best health care systems in the world or one of the worst. Nevertheless, when the NHS was founded in 1948, “the most civilised achievement of modern Government” according to Nye Bevan, egalitarian implementation of the best standards of health care was expected to lead to reduced demands. The opposite has happened. The NHS has been hugely successful and is widely admired, but few will deny that it is suffering from its own success. For that success to be maintained, the factors that are harming it must be recognised and remedied. Given the number of patients served by general practice, this should be an obvious priority.