Access to GP care

Page last updated: 21 October 2022

This is the 2020/21 edition of State of Care

Like all health and care services, GPs and their teams have had a crucial role to play in supporting the health needs of their communities throughout the pandemic, as well as keeping people safe.

GP practices, following national directives and drivers from government, have had to accelerate innovation, such as moving rapidly to remote consultations, to respond to the pandemic.

A remarkable achievement since December 2020 has been the rollout of the COVID-19 vaccination programme, with GP practices and primary care networks at the forefront of this critical task. Many different local services have worked together at speed on a programme that has shown the NHS at its most versatile and patient-centred. Across the UK, more than 92 million vaccinations had been given by mid-September 2021 – in a nine-month period, almost 90% of people aged 16 and over had received their first dose and over 80% had received both doses.

Data from NHS Digital up to the end of May 2021 shows that, after dropping considerably in April 2020, the total number of GP appointments started to pick up from June 2020 with the end of the first national lockdown, and by September 2020 was broadly in line with figures for the previous year. This data does not show the totality of GP workload such as COVID-19 vaccination activity, and there are known issues with data quality that are likely to have been exacerbated by the pandemic.

The pandemic had an impact on patient behaviour. Findings from the 2021 GP patient survey (based on responses from January to March 2021) showed that the proportion of respondents spending more than a year without attending a GP appointment more than doubled to 27% in 2021 compared with the previous years (figure 7).

When asked whether, at any time in the last 12 months, they had avoided making a GP appointment for any reason, 42% of respondents confirmed that they had. The top two reasons were because people were worried about the burden on the NHS (20%), and because people were worried about the risk of catching COVID-19 (17%).

This was reflected in a Healthwatch report from March 2021, which found that people were worried about “overloading” services and not speaking to their GP practice unless they felt their health issue was of extreme importance. This was especially prevalent in feedback from older people.

People need to feel confident in seeking advice and treatment from their GP if they have health concerns, as these can deteriorate and have an impact on their long-term health, and place greater demands on the health and care system in future.

The GP workforce will need to be able to cope with the potential backlog of patients, once people feel more confident to return to practices. However, workforce data from NHS Digital shows some areas of concern. Although the total number of full-time equivalent GPs from September 2020 onwards is higher than it has been previously, the number of qualified permanent GPs, which excludes GPs in training grade and locums, has been falling, with figures in June 2021 nearly 3% lower than they were in June 2017 (the earliest point at which data for June is available).

Furthermore, the total number of full-time equivalent (FTE) GPs per 100,000 patients reduced from 58 per 100,000 in June 2017 to 55 per 100,000 in June 2020. While figures for June 2021 show an increase there are still fewer FTE GPs in total per 100,000 patients than there were in 2017. Over the pandemic, the number of qualified permanent FTE GPs per 100,000 patients has been at its lowest level in recent years.

To help mitigate workforce issues in general practice, the Additional Roles Reimbursement Scheme (ARRS) provides funding for primary care networks to recruit 26,000 additional roles to create bespoke multidisciplinary teams to support people where it is most needed. It is important that local systems, including GP practices, have the capacity to make sure that these new roles are supervised and supported to meet the ambitions of the scheme.

Getting a GP appointment

We carried out 58 risk-based inspections from mid-May to end of June 2021, as well as holding conversations with several GP ‘at scale’ providers (providers who are working collaboratively to offer services from more than one practice), to better understand how GP practices have been working to ensure access to services during the pandemic. We found that, in line with guidance, practices had moved to a triage model for everyone seeking an appointment, to help to keep people safe from infection and to avoid vulnerable people coming into contact with people who were COVID-positive.

Most commonly the triage process took place by telephone, either involving a member of reception staff or by a clinician (usually a nurse, advanced nurse practitioner or GP). Some practices had more than one layer of triage, with an initial screen by reception staff being followed up by a clinician.

Sometimes, the triage process took place through an online service. Our inspectors raised concerns about this in a few practices, such as describing staff who were “unsupported by their technological systems to provide a fully effective service”, or noting that “patient satisfaction with this [triage] approach was mixed”. Some practices, which were unable to provide online triage, had removed online appointment booking facilities in order to triage patients by telephone.

In the 2021 GP patient survey, in answer to the question, “Generally, how easy is it to get through to someone at your GP practice on the phone?”, 68% said ‘easy’ in 2021, compared with 65% last year. Nearly 71% of respondents described their experience of making a GP appointment as ‘good’ in the 2021 survey, compared with 65% in 2020.

However, these survey results do not reflect everyone’s experience. In our analysis of feedback received via our Give Feedback on Care service, phone calls and social media between April and December 2020, we found that many people who contacted CQC about access to GP services told us about their inability to make an appointment. People described finding it difficult to figure out the best or ‘correct’ way to contact practices. When calling by phone, people told us they were often on hold or in a queue for a long time. Some people found that, when they did make a telephone appointment, the doctor did not call them during the allotted time or at all, and they had to go through the booking process again.

In March 2021, Healthwatch reported that, despite a reduction in complaints about contacting a GP practice by telephone in the initial part of the lockdown, by September 2020 complaints had increased to pre-pandemic levels. These included complaints about long queues, lines consistently being engaged, people having to try to make contact several days in a row, and some who were unable to remain on hold for long due to the cost of the calls.

Trying to get a GP appointment

Terry has diagnosed Bipolar. The pandemic made him feel anxious, which for him was a warning sign, so he wanted to speak to a GP for reassurance.

He made a considerable number of calls to his surgery trying to get through to make an appointment, which added to his stress – “If you’re not the first person on the line at 8am you will not get an appointment”. There were also no online consultation slots available. He understands there is a country-wide problem and he is sympathetic, but at the same time felt it wasn’t acceptable.

When he eventually got through to the surgery, Terry was given an approximate time when the doctor would call him back. The GP was very good and put him at ease by talking him through the vaccine options that were soon to be rolled out. It was exactly what he needed.

Now that the pandemic has calmed down it still takes quite a number of calls to get through, which Terry feels is still not acceptable and will put off some people from calling.

Online prescriptions have worked well for him. He feels that the pharmacy staff keep him safe when he goes to collect his prescription.

Interview with a member of the public

Findings from our inspections have noted issues with telephone systems, resulting in long hold times, people being cut off while waiting, and repeated engaged tones causing frustration for people trying to get through.

Other practices have tried to address this by increasing their phone line capacity or upgrading their telephone systems to meet need. Some have used newer telephone systems to actively monitor their telephone waiting times. A practice in London, for example, had live telephone performance information displayed on a screen in the waiting area. The manager of this practice was also able to review the performance from a dashboard.

How appointments were delivered

Results from the 2021 GP patient survey show that remote appointments as a whole increased substantially since the onset of the pandemic. The majority of those were telephone appointments. The last time people booked an appointment 47% were carried out over the phone, compared with only 10% in the previous year’s survey (figure 8). Although online consultations, such as video calls, are still relatively low at 3%, their increase is considerable compared with the negligible levels in previous years.

As noted in the Royal College of General Practitioners’ August 2021 statement, face-to-face appointments have continued to be offered wherever safe and appropriate throughout the pandemic, and this is supported by the 2021 GP survey data, which shows that 48% of respondents said their last appointment was to see someone at their GP practice (compared with 85% the previous year).

In May 2021, the Royal College of General Practitioners (RCGP) published a report that noted that remote or digital consultations (which are not in-person but carried out by telephone, video or online) offered a variety of benefits to patients, but only when supported by effective technologies, and where individual patients’ needs are met.

Improved GP practice prioritises the needs of its patients

When we inspected Rishton and Great Harwood Surgery in October 2020 – about six months into the pandemic – to follow up on previous concerns, we rated the GP practice as good, a huge improvement from its previous rating of inadequate. With a new practice manager in place, the practice developed and implemented a comprehensive improvement plan. They were supported in this by the Royal College of General Practitioners.

In responding to the pandemic, the practice kept up-to-date with the advice and guidance from NHS England to make sure it was COVID secure. It carried out regular reviews and spot checks to ensure staff were distancing safely, washing hands and wearing appropriate personal protective equipment. The practice was granted funding to change the reception and waiting areas at the Rishton surgery so that risks from cross infection could be reduced further.

The practice adapted how it offered appointments in line with guidance to maintain the safety and welfare of patients and staff. Telephone appointments were offered in the first instance, all triaged by the GP. All patients who needed it were offered a telephone appointment on the day and, if required, a face-to-face appointment. Pre-bookable appointments in the evening until 8pm and at weekends were also available at local hub sites. If a face-to-face appointment was needed, patients were offered a choice of three surgery sites.

All patients assessed as vulnerable or advised to shield received a welfare check from the practice. These calls ensured they had the right support for both their healthcare and social care needs. In addition, the practice called all patients with a positive COVID-19 result to make sure they knew what to do if their symptoms got worse, and how to get additional support if they needed it.

The practice used a clinical tool to identify older patients who were living with moderate or severe frailty – these people received a full assessment of their physical, mental and social needs. The practice also followed up on older patients discharged from hospital.

Patients with long-term conditions were offered a structured annual review to check their health and medicines needs were being met. Nurses explained they were mostly able to carry out reviews over the phone for stable patients, and updated care plans were sent out in the post. Those patients with acute symptoms were offered a face-to-face appointment with a clinician.

The practice shared their staff availability every day with their clinical commissioning group (CCG). This enabled the CCG to maintain an overview of GP services in the local community and direct additional support to practices that were short of staff.

In our provider collaboration review of services for people with a learning disability, we heard that remote consultations were more accessible for some people with a learning disability and their families and carers, as they removed the barriers imposed by travelling to appointments, particularly cost and time. In our provider collaboration review looking at cancer care, we heard that, since many people with cancer are immunosuppressed due to their treatments, remote interaction helped ensure their safety and alleviate anxiety.

However, all the local systems we spoke to recognised that there are significant challenges using remote consultations, including digital poverty, poor access to internet, English not being a first language, and variation in digital literacy. Other issues raised included concerns about confidentiality, and difficulties in building a relationship with a person using the service or identifying signs of deterioration in health and wellbeing when not being able to examine a them.

The pandemic has created a steep learning curve for some GP practices in terms of remote access. We support the RCGP’s call for an evaluation of what ‘good’ looks like for digital triage systems, co-designed with patients and clinicians, to ensure that they do not exacerbate health inequalities.

One of the principles in Healthwatch’s report on digitally excluded people’s experiences of remote GP appointments calls for traditional models of care to be maintained alongside remote methods and support.

The sector needs to think about the future impact of remote or digital appointments, to make sure everyone gets the appropriate access to meet their needs safely.

Access to dental care

Adult social care fragility