GP practices consider cutting lists to improve access

Many practices are at capacity, and are unable to provide the levels of access they would like – with some considering cutting their lists. Jaimie Kaffash reports on the latest in our Access All Areas series

Practices would like to offer more appointments, cater to patients’ preferences and make it easier to contact the practice. But a number of factors influence their ability to do so; none more so than workload. Many GP practices consider themselves to be working at capacity – or even beyond it.

Not only are the numbers of patients increasing; they are having more appointments a year on average at the same time as GP full-time-equivalent numbers are decreasing.

At the same time, GP appointments are becoming more complex. The DHSC’s 10-year plan says: ‘More than a quarter of the population have a long-term health condition, and they now account for 65% of NHS spending. The NHS today is no longer just a safety net to help people in crisis – it must provide a continuous service for those who have a chronic illness.’ The plan was quoting a 2014 report, but there is little doubt people are living with more health conditions.

Meanwhile, long-term conditions and multimorbidity are on the rise – anything from 19%-40% of people are estimated to be living with multimorbidity – and people are living longer.

‘Advice and Guidance’ (A&G) formalises the idea of more complex patients being managed in primary care, but there are other, even less appropriate ways that GPs are being left to manage patients who may previously have been seen in secondary care. One GP in the north west of England says: ‘Other health and social care services requesting access or workload dumping has increased. Some local services don’t seem to exist or our patients don’t meet their recently revised entry criteria. Hospital waiting times are so long that referral is not a realistic option. More and more conditions are being managed in primary care and prevalence of many conditions increasing.’

Alongside increasing complexity, GPs are seeing less-demanding work taken way through schemes like ARRS and Pharmacy First. While the aim of these schemes is, in part, to take over simpler work, this in itself causes problems. Stafford GP Dr Lee Sanders-Cook says: ‘Pharmacy First has effectively sieved out straightforward cases, leaving a void that has simply been filled by the remaining more complex caseload. On paper this seems not an issue – 15 x 10 minute appointments with no change, and more patients now seeing the pharmacists for basic ailments.

‘But all GPs would probably agree that not all cases are equal. The undiagnosed dementia patient in denial, the suicidal teacher trapped in her menopause, the elderly growing older and accruing drugs, diagnoses and test results with mixed understanding. These patients bring problems and concerns that cannot be managed in 10 minutes. And so their 10 minutes last longer, as clinical necessity dictates.’

Previously, GPs were taught that an essential skill for time management was to make up lost time with the ‘easier’ appointments, which could be around a quarter of cases, Dr Sanders-Cook says. ‘But as these cases have been diverted, all that remains are the increasingly complex – except now with less flexibility to juggle time, and claw it back.’

Cutting list sizes and rationing

Due to this increase in appointment numbers and complexity, practices’ main avenue to reducing appointments is to cut lists. One South Yorkshire GP says: ‘We need more time with our patients – both at the time of a consultation and greater frequency of consultation. This cannot be accommodated with the current demand for appointments. The only way to reduce the demand and allow the individual time needed is either to re-size lists or to take away areas of work – whether this be all acute illness, metal health or benefits.’

Demand in the NHS is effectively limitless, while the service is rationed, says one GP in Greater Manchester. ‘Traditionally, rationing has taken the form of long waits on phone lines, or delays in securing appointments. We have already implemented as many technological and process improvements as possible, and primary care is working at full stretch trying to keep pace with ever-increasing demand. That leaves us with three broad options: accept a compromise on access; increase the capacity of already efficient GP surgeries to meet rising demand –something that can only be achieved with appropriate funding and support; or cut list sizes to cap demand in order to maintain or improve access that patients currently receive in primary care.’

Our recent survey asked distinct practices (see methodology) whether they would need to cut their lists in order to provide the required levels of access. Around 40% said they would, with 30% of all responding practices stating they would need to cut lists by more than 10%.

Some practices are having to proactively cut their lists in response to rising demand. One GP partner in Surrey says his practice had to cleanse its list in order to provide the access it deemed necessary. He says: ‘It’s still an ongoing process. We are writing to patients who are out of area and outside of our designated catchment. It’s an issue we’ve avoided for years because it could be quite emotive for patients and some GPs alike. But our hands have been forced by the demands of managing access for our list size with the limited resources we have.’

While this is helping the practice get on top of access, the GP warns: ‘What have we created? Can we sustain this level of access in the long run? Will we be victims of our own success in terms of patients now expecting very quick access and quick responses to their problems? Are we sacrificing continuity of care on the altar of access? Are we still running family practices or small urgent treatment centres? I think these are valid concerns.’

Cutting list sizes doesn’t solve the problem of access, of course. It moves it elsewhere. As one practice manager puts it: ‘We wouldn’t want to cut our list size, where would the patients go?’

Practices are struggling with access, often through no fault of their own but due to systemic issues. In the next feature in our series, we will see what measures ministers and NHS managers have implemented to support practices, and how successful they have they been.

You can find all the data and the methodology in the full report. Click here to download the full report. GPs can download it for free.

Commercial partner of this white paper: General Practice Solutions