Increases in general practice workload in England
Authors: Matthew Thompson, Fiona Walter
Journal: The Lancet (2016)

Primary care services form the backbone of health care in most high-income countries. Yet, there are growing concerns about the effects that numerous changes in the content and delivery of primary care have had on the workload of primary care practitioners. In a retrospective analysis in The Lancet, F D Richard Hobbs and colleagues1Hobbs FDR Bankhead C Mukhtar T et al.on behalf of the National Institute for Health Research School for Primary Care ResearchClinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007–14.Lancet. 2016; (published online April 5.)http://dx.doi.org/10.1016/S0140-6736(16)00620-6Summary Full Text Full Text PDF PubMed Scopus (364) Google Scholar investigated the direct clinical workload of general practitioners (GPs) and practice nurses in primary care in the UK, and present data from consultations of patients registered at 398 English general practices between April, 2007, and March, 2014. Hobbs and colleagues1Hobbs FDR Bankhead C Mukhtar T et al.on behalf of the National Institute for Health Research School for Primary Care ResearchClinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007–14.Lancet. 2016; (published online April 5.)http://dx.doi.org/10.1016/S0140-6736(16)00620-6Summary Full Text Full Text PDF PubMed Scopus (364) Google Scholar used data from electronic health records in the Clinical Practice Research Datalink, and linked these data to national datasets that included more than 100 million consultations and 20 626 297 person-years of observation. The study findings show that the overall workload of GPs in England rose by 16% in the 7 years up to 2014, with more frequent and longer GP consultations. Rates of GP consultations rose by 12·36% per 10 000 person-years, compared with 0·9% for practice nurses. Moderate rises in rates of GP face-to-face consultations (5·2%) were overshadowed by an almost 100% increase in the rate of GP telephone consultations. Additionally, the mean duration of GP face-to-face consultations rose by about half a minute, from 8·65 min (95% CI 8·64–8·65) in 2007–08 to 9·22 min (9·22–9·23) in 2013–14. This rising tide of workload is probably an underestimate, since an additional 40% of GP time is spent on tasks not measured in this study, such as arrangement of referrals or admissions, renewal of prescriptions, administrative and clinical meetings, and teaching.2Gibson J Checkland K Coleman A et al.Eight national GP worklife survey Manchester: University of Manchester.http://www.population-health.manchester.ac.uk/healtheconomics/research/Reports/EighthNationalGPWorklifeSurveyreport/EighthNationalGPWorklifeSurveyreport.pdfDate: 2015Google Scholar Moreover, although the dataset does not provide data about the number of GPs (which could account for the increase in consultations), the investigators point out that other data show there has been a 1% decline in full-time equivalent GPs over this time period. 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. A worrying amount of this work happens not just within consultations, but also afterwards, which can account for an estimated additional 8 h of work per week or more for an average GP.2Gibson J Checkland K Coleman A et al.Eight national GP worklife survey Manchester: University of Manchester.http://www.population-health.manchester.ac.uk/healtheconomics/research/Reports/EighthNationalGPWorklifeSurveyreport/EighthNationalGPWorklifeSurveyreport.pdfDate: 2015Google Scholar 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.3Hann M McDonald J Checkland K et al.Seventh national GP worklife survey. University of Manchester, Manchester2013http://www.population-health.manchester.ac.uk/healtheconomics/research/reports/FinalReportofthe7thNationalGPWorklifeSurvey.pdfGoogle Scholar, 4Dale J Potter R Owen K Parsons N Realpe A Leach J Retaining the general practitioner workforce in England: what matters to GPs? A cross-sectional study.BMC Fam Pract. 2015; 16: 140Crossref PubMed Scopus (53) Google Scholar When GPs who have left the UK's 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.5Doran N Fox R Rodham K Taylor G Harris M Lost to the NHS: a mixed methods study of why GPs leave practice early in England.Br J Gen Pract. 2016; 66: e128-e135Crossref PubMed Scopus (81) Google Scholar 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.2Gibson J Checkland K Coleman A et al.Eight national GP worklife survey Manchester: University of Manchester.http://www.population-health.manchester.ac.uk/healtheconomics/research/Reports/EighthNationalGPWorklifeSurveyreport/EighthNationalGPWorklifeSurveyreport.pdfDate: 2015Google Scholar Are GPs unique in the NHS in terms of their rising workload? Hobbs and colleagues focus on general practice, but rising workload has been documented in other areas of the NHS. For example, emergency admissions of children to hospital have risen by 28% in the past decade, with similar experiences in other parts of the health service.6Mahoney C 2013 was a horrible year for nursing—nurses are "burnt out," says chief.BMJ. 2014; 348: g126Crossref PubMed Scopus (7) Google Scholar, 7Gill P Goldacre M Mant D et al.Increase in emergency admissions to hospital for children aged under 15 in England, 1999–2010: national database analysis.Arch Dis Child. 2013; 98: 328-334Crossref PubMed Scopus (116) Google Scholar To some extent, the rise in GP workload parallels similar increases in overall health-care workload in the UK. Is rising GP workload an English NHS problem, or is it common to primary care in other countries? Surprisingly little information exists about consultation numbers and duration internationally, but other data suggest that English GPs are not alone. A 2008 survey of family doctors in 12 European countries found burnout was a common issue, with 43% of family doctors experiencing burnout from emotional exhaustion.8Soler JK Yaman H Esteva M et al.Burnout in European family doctors: the EGPRN study.Fam Pract. 2008; 25: 245-265Crossref PubMed Scopus (286) Google Scholar In the USA, almost half of primary care physicians have symptoms of burnout.9Shanafelt TD Boone S Tan L et al.Burnout and satisfaction with work-life balance among US physicians relative to the general US population.Arch Intern Med. 2012; 172: 1377-1385Crossref PubMed Scopus (1886) Google Scholar The reasons for this unhappiness internationally mirror those of English GPs—increasing administrative burdens, greater expectations placed on primary care, time pressures, longer working days, and fewer rewards. Even in countries with greater investment in health care, such as the USA, as Sinsky and colleagues have remarked, "joy is in short demand".10Sinsky CA Willard-Grace R Schutzbank AM Sinsky TA Margolius D Bodenheimer T In search of joy in practice: a report of 23 high-functioning primary care practices.Ann Fam Med. 2013; 11: 272-278Crossref PubMed Scopus (311) Google Scholar Roland and Everington have warned that "If general practice fails, the whole NHS fails".11Roland M Everington S Tackling the crisis in general practice.BMJ. 2016; 352: i942Crossref PubMed Scopus (66) Google Scholar With the NHS's budget under increasing financial pressure, what are practical solutions for achievement of a fully functioning and modern general practice? Increasing the supply of GP workforce is one solution, with 5000 more GPs cited as being needed in the UK by 2020.12NHS EnglandGeneral practice workforce action plan.https://www.england.nhs.uk/commissioning/primary-care-comm/gp-action-plan/Google Scholar However, with "GP training, recruitment, and retention in the UK fast approaching crisis point",5Doran N Fox R Rodham K Taylor G Harris M Lost to the NHS: a mixed methods study of why GPs leave practice early in England.Br J Gen Pract. 2016; 66: e128-e135Crossref PubMed Scopus (81) Google Scholar recruitment of more GPs is unlikely to fix the problem in time. So, what are other solutions? Roland and Everington gave sensible suggestions about what is needed to revive general practice, including substantial financial investment in general practice and in the NHS overall, novel ways of improving communication between GPs and specialists, and improving recruitment and retention of GPs.11Roland M Everington S Tackling the crisis in general practice.BMJ. 2016; 352: i942Crossref PubMed Scopus (66) Google Scholar We believe that a major shift is also needed in general practice, away from a doctor-centric model to one that is truly a shared care model, in which more and varied types of clinical support staff (eg, nurses, pharmacists, physician assistants) work in collaboration with GPs. However, Hobbs and colleagues' data show that English general practice is currently top heavy, with about three times more GP than nurse consultations.1Hobbs FDR Bankhead C Mukhtar T et al.on behalf of the National Institute for Health Research School for Primary Care ResearchClinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007–14.Lancet. 2016; (published online April 5.)http://dx.doi.org/10.1016/S0140-6736(16)00620-6Summary Full Text Full Text PDF PubMed Scopus (364) Google Scholar Expansion of the roles of different types of clinical support staff, rather than simply employing more GPs, is an underused approach in the UK, leaving GPs to bear the burden. Finally, what can be done to reduce demand for general practice consultations? Many GPs believe that however much capacity is provided (supply), whether by telephone, in person, and in some settings over the internet, this capacity is rapidly filled. Perhaps health-care services might never be able to fully match demand. For example, a random survey of 49 706 individuals, representative of the Danish adult population, found that some symptoms such as tiredness were reported in 49·4% of individuals.13Elnegaard S Andersen RS Pedersen AF et al.Self-reported symptoms and healthcare seeking in the general population—exploring "The Symptom Iceberg".BMC Public Health. 2015; 15: 685Crossref PubMed Scopus (70) Google Scholar GPs usually only see the tip of this so-called symptom iceberg, and might never be able to see (or should see) everyone with every symptom.13Elnegaard S Andersen RS Pedersen AF et al.Self-reported symptoms and healthcare seeking in the general population—exploring "The Symptom Iceberg".BMC Public Health. 2015; 15: 685Crossref PubMed Scopus (70) Google Scholar If general practice in England is to survive, new approaches are needed to address the expectations of patients and to provide advice and health care that does not always have to involve GP consultations, and with no additional health-care costs. This online publication has been corrected. The corrected version first appeared at thelancet.com on June 2, 2016 This online publication has been corrected. The corrected version first appeared at thelancet.com on June 2, 2016 We declare no competing interests. Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007–14Our findings show a substantial increase in practice consultation rates, average consultation duration, and total patient-facing clinical workload in English general practice. These results suggest that English primary care as currently delivered could be reaching saturation point. Notably, our data only explore direct clinical workload and not indirect activities and professional duties, which have probably also increased. This and additional research questions, including the outcomes of workload changes on other sectors of health care, need urgent answers for primary care provision internationally. Full-Text PDF Open AccessDepartment of ErrorThompson M, Walter F. Increases in general practice workload in England. Lancet 2016; 387: 2270–72—This Comment should have been published under a Creative Commons CC BY open access licence. This correction has been made as of June 2, 2016. Full-Text PDF Open Access