General practice in England nearing 'saturation point' as study reveals extent of GP workload increase

The largest analysis of GP and nurse consultations to date shows that workloads in general practice have increased by 16% over the past 7 years, with more frequent and longer consultations. The authors, reporting their findings in The Lancet, warn that 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, University of Oxford, UK. "The demands on general practice have increased substantially over the past 7 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."¹

Overall, the authors find that the workload in general practice (GP and nurses combined) has increased by 16% (1095 days per 10000 patient years in 2007 to 1270.3 days in 2014). The study is based on an analysis of over 100 million GP and nurse consultations at 398 general practices in England between 2007 and 2014 - equivalent to 4.5% of all GP practices in England.

The researchers from the University of Oxford 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% for doctors (from 3.35 to 3.80 consultations per patient per year), and 2.76% for nurses (1.32 to 1.36). Consultation rates were highest for children aged less than 4 years and adults more than 85 years old.

The average number of annual face-to-face GP consultations increased by 6.38% (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% 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 authors 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 5% 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 (30936 in 2007 to 32628 in 2014), the authors point out that this actually represents a 1% decrease in the number of GPs per patient (from 60.9 GPs per 100000 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% 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 authors say that the true extent of workload increases is likely to be even higher than that reported.

Professor Hobbs adds: "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 5000 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."

Writing in a linked Comment, Dr Matthew Thompson, former NHS GP, now Professor at the University of Washington, Seattle, USA, suggests that increasing workloads are not only a problem for GPs in the NHS, but that other services in the UK and internationally are also experiencing burnout. "These startling results reflect what we and many of our GP colleagues have experienced - a seemingly endless demand for consultations, coupled with more complex patient care, escalating administrative tasks, pressures to meet quality performance targets, and rising documentation requirements... This struggle to provide the quality of care GPs would like to offer in the face of competing demands on time, is contributing to alarming rates of burnout. 54% of UK GPs older than 50 years report a considerable or high likelihood of quitting direct patient care within 5 years, with 82% intending to leave or reduce their clinical work within the next 5 years. When GPs who have left the UK National Health Service (NHS) are asked why, they cite the negative impacts of administrative tasks and overall workload, and limited ability to provide patient-centred care. The lowest level of job satisfaction among GPs since 2001 is deeply concerning, and presumably reflects, among other things, the various changes to organisation of general practice in England under successive governments."