General practice in England nearing 'saturation point'

The researchers, from the Universities of Oxford and Bristol, reporting their findings in The Lancet today, warn the increases are unsustainable, and that general practice in England could be reaching saturation point.

"For many years, doctors and nurses have reported increasing workloads, but for the first time, we are able to provide objective data that this is indeed the case," says Professor Richard Hobbs, lead author from the Nuffield Department of Primary Care and Health Sciences at the University of Oxford.

"The demands on general practice have increased substantially over the past seven years. Recruitment of new GPs and nurses remains low while the population in England steadily increases. As currently delivered, the system seems to be approaching saturation point."

Overall, the authors found that the workload in general practice (GP and nurses combined) has increased by 16 per cent. The study was based on an analysis of more than 100 million GP and nurse consultations at 398 general practices in England between 2007 and 2014 -- equivalent to 4.5 per cent of all GP practices in England.

The researchers used data from the Clinical Practice Research Datalink -- a database where GPs and nurses record all face-to-face and telephone consultations with patients and home visits.

Between 2007 and 2014, the average number of annual consultations (face-to-face, telephone and home visits) per patient rose by 13.67 per cent for doctors (from 3.35 to 3.80 consultations per patient per year), and 2.76 per cent for nurses (1.32 to 1.36). Consultation rates were highest for children aged less than four years and adults over 85 years old.

The average number of annual face-to-face GP consultations increased by 6.38 per cent (2.99 to 3.18 per person per year), but the greatest increase was in GP telephone consultations, which have nearly doubled since 2007 (0.27-0.45 per person per year).

Telephone consulting was widely introduced to help cope with rising workloads, but because of the time involved (60 per cent of the time a face-to-face consultation would take) and the proportion of calls (about a third) resulting in a face-to-face consultation, the researchers question whether the strategy will help to manage demand, and are concerned that relying on calls may lead to missed opportunities for disease prevention.

Average consultation times in general practice in England have also increased by five per cent from 8.45 minutes in 2007 to 8.86 minutes in 2014. The authors warn that as consultation times gradually approach the 10 minute allocated slot, doctors and nurses have very little time in between seeing patients to fulfil other duties.

Although the total number of GPs has increased over the study period (30,936 in 2007 to 32628 in 2014), this actually represents a one per cent decrease in the number of GPs per patient (from 60.9 GPs per 100,000 patients in 2007; to 60.6 in 2014).

Finally, the study only included consultations involving direct patient contact, which is estimated to make up 60 per cent of GP work time. The study does not include other activities such as arranging hospital referrals, teaching, auditing or professional development. Since these aspects of GP workload are likely to also have substantially increased since 2007, the true extent of workload increases is likely to be even higher than that reported.

Co-author Professor Chris Salisbury, a GP and head of the Centre for Academic Primary Care at the University of Bristol, said: "Because consultations are happening more often and taking longer, the combined effect is that overall workload of doctors and nurses in general practice has increased by 16 per cent over the seven years, while time spent by GPs with patients has increased by 18 per cent. This increased workload for GPs is equivalent to almost an extra working day each week. These findings may explain why people are finding it increasingly difficult to get an appointment."

Professor Hobbs added: "Current trends in population growth, low levels of recruitment and the demands of an ageing population with more complex needs will mean consultation rates will continue to rise. In 2015, GPs in England reported having the lowest job satisfaction rates since records began in 2001. NHS plans to recruit an additional 5,000 GPs will take some time and, crucially, depend on an improved appeal of general practice as a career choice.

"There are few short term solutions, but reducing the time doctors need to spend on non-clinical duties may help ease the workload temporarily. More research is urgently needed to fully estimate the knock-on effects of increased workloads in general practice on other sectors of the health system."