Analysis: Why general practice is bracing itself for a fresh winter crisis
GPs are steeling themselves for a repeat of the pressures that saw avoidable emergency admissions and deaths last year, reports Nicola Merrifield
Alarm bells are yet again ringing as the NHS enters the winter period – but this year the pitch is sharper because hospitals have already been grappling with higher volumes of patients in the preceding months.
There has been no repeat of the extreme pressures that hit the NHS last winter – so far. But the signs are worrying.
Official NHS England figures show that during October, emergency admissions hit a record high and the number of patients waiting more than four hours in A&E was 10% higher than the same time last year.
In November, the BMA warned the Government the ‘rocketing demand’ had taken place ‘during a relatively mild autumn before the added pressure associated with much colder weather hits’.
Healthcare providers cannot afford to assume measures to reduce admissions will be enough
Dr Rob Harwood
Its consultants committee chair Dr Rob Harwood said: ‘We are no longer experiencing just a winter crisis in the NHS, it is now a truly year-round crisis.
‘Hospitals and healthcare providers cannot afford to assume measures to reduce admissions will be enough to beat this year’s winter pressures, when the figures show demand is increasing at a rate far higher than many had anticipated.’
A spell of cold weather could cause havoc, according to Dr Anu Rao, vice-chair of Leicester, Leicestershire and Rutland LMC: ‘If we were worried last year, we are three times more likely to be worried this year. In the summer our A&E appointments were up and they weren’t able to cope. The bed situation isn’t great in hospitals. Discharges are done early on so there is high risk and high prevalence of readmission.
‘We need to be highly concerned this year compared with any other – especially with the flu campaign being a bit out of control.’
The pressures on secondary care have huge implications for general practice. A Pulse survey last month revealed the extent of the problems caused by last year’s winter crisis.
More than half of GPs (52%) said it led to avoidable emergency admissions among their patients, with the same percentage saying their patients developed complications of their original illness. Around 46% said this led to escalation of treatment.
Most shockingly, 43 of the 750 respondents – almost 6% – said the pressures led to the avoidable death of a patient (see chart, below).
But there are also implications for practices themselves. Official NHS Improvement figures revealed GPs and nurses provided 345,000 more appointments than were commissioned by CCGs last winter, in what was the worst flu outbreak since 2010/11.
However, unlike secondary care – which has been given £145m of ‘bailout’ funding by NHS England– there is little support for practices. CCGs are making provisions for extra appointments, while NHS England has committed to retain its £10m winter indemnity fund, running from October to March, which means GPs will not have to cover the costs of professional indemnity for any extra sessions undertaken outside core hours.
CCGs hope the extended access scheme will help winter pressures – but we have massive problems recruiting GPs
Dr Anu Rao
But CCGs are being given no extra funding for primary care. When asked by Pulse what measures they are putting in place, most CCGs cited extended hours appointments, but some said they were instructing practices to stop routine appointments over the Christmas period, and introducing remote monitoring of care home patients (see box).
GPs say this won’t be enough in the event of an NHS crisis over the winter.
Dr Rao warns: ‘CCGs hope the extended access scheme will help winter pressures – but we have massive problems recruiting GPs to work in the scheme.’
BMA GP Committee chair Dr Richard Vautrey says: ‘Unlike hospitals, which make difficult decisions to manage extra demand during the winter, GPs don’t have the option of cancelling operations or other “routine” work – as most of what we do simply must continue.
‘Demand remains high all year long, meaning patients face frustratingly long waits for appointments, and GPs see no respite in traditionally quieter months.
‘Realistically, there is little or no spare capacity to respond to the upsurge in demand that winter could bring,’ he adds.
GPs responding to Pulse’s survey said their patients had come to harm as a result of pressures last winter. One recalled ‘a memorable case – a middle-aged man with young child, agonising renal stones, lithotripsy cancelled, delayed, leading to GP visit to beg me to contact hospital.’
Another respondent said: ‘A patient with a delayed total knee replacement had a fall that was mobility related. They had a neck of femur fracture, were still waiting for TKR. They were also waiting for a lap chole and had several A&E attendances.’
And while there has so far been no flu outbreak this year, the vaccination programme has been beset with delivery delays.
Dr Peter Scott, Birmingham GP and chair of Solihull LMC, says: ‘It’s fortunate we haven’t had an outbreak or epidemic. Logistical difficulties have meant rollout has been slow. Had there been an outbreak we would have been very much at risk.’
It may be that it will be a mild winter, with little flu. But if there is a serious outbreak, it is likely general practice – and the wider NHS – will struggle to cope, raising the spectre of a return to the crisis conditions seen last year.
What are commissioners doing to help GP practices?
• NHS Milton Keynes CCG: requesting that practices only offer urgent, on-the-day appointments between Christmas and New Year.
• NHS Rotherham CCG: implementing a new pilot for care homes and GP practices, which enables patient needs to be monitored remotely, reducing the need for a GP visit.
• NHS Herts Valleys CCG: providing an extra £1.10 per weighted patient to practices in the region to offer appointments after school hours, specifically for children, and care home visits in the morning.
• NHS Wigan Borough CCG: funding an additional 16,000 appointments between November and March, while also opening an urgent treatment service in its primary care centre at the local hospital.
• NHS Doncaster CCG: ensuring an extra 640 GP appointments are available each week, through extending access to surgeries. Offering a Choose Well app, offering signposting to services.
• Scottish Government: has provided £10m of winter funding to NHS health boards, although it is unclear how much of this has been spent on general practice.
• Welsh Government: has allocated £4m to ease winter pressures and part of this funding is to support two pilot schemes that are looking at extending GP access into evenings and weekends.
• Northern Ireland Government: investing additional £2.27m to cover 7,000 extra surgeries to help practices offer same-day urgent appointments, remain open at lunch time and ensure there are no half-day closures following the Christmas and New Year holidays.
Source: Pulse media request