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How are GP services commissioned and regulated?

Primary medical services in England are provided by general practitioners (GPs) under contracts with NHS England and NHS Improvement (NHSEI). These functions can also be delegated to clinical commissioning groups (CCGs), under co-commissioning arrangements, although NHSEI maintain overall responsibility for ensuring the quality of services. Further information on primary care can be found on the NHS England website.  Information on GP access is provided on the NHS website.

Under the Health and Care Bill responsibility for making the necessary arrangements to secure the provision of primary medical services will transfer from NHSEI (and CCGs) to Integrated Care Systems (ICSs) although NHS England (and the Secretary of State) will maintain some powers of direction. Further information on plans to put ICSs on a statutory footing can be found in the Library briefing paper on the Health and Care Bill, prepared ahead of the Bill’s second reading.0F0F0F[1]

GP practices have also begun working together with community, mental health, social care, pharmacy, hospital and voluntary services in their local areas in primary care networks (PCNs). PCNs typically serve communities of around 30,000 to 50,000.

The Care Quality Commission (CQC) is responsible for the registration, inspection and monitoring of health and adult social care providers, including independent providers, under the Health and Social Care Act 2008. Information on how the CQC regulates primary care services can be found on the CQC website (see for example, CQC, How we monitor GP practices).

GP services during the coronavirus pandemic

While there have been longstanding pressures on GP services, and concerns about access to appointments predated the pandemic, social distancing and infection control requirements have limited the capacity to offer face-to-face GP services. GPs have also been heavily involved in the roll-out of the Covid-19 vaccination programme. The pandemic has accelerated the move to online bookings and video and phone consultations. Previous research from Healthwatch England has highlighted that remote consultations have made getting care quicker and easier for many people. However, the media has reported some patients experiencing poor access, and difficulties contacting practices. There are particular concerns that vulnerable groups (such as older people, disabled people, people affected by homelessness and on low incomes, and those whose first language isn’t English) have greater problems accessing remote appointments.

NHSEI guidance throughout the coronavirus pandemic has been that face-to-face appointments should be available if clinically necessary. On 13 May 2021 NHS England published a letter on Access to GP practices which confirmed that the previous guidance on providing access to surgeries was being updated. It emphasised that:

  • “GP practices must all ensure they are offering face to face appointments.”
  • “Patients and clinicians have a choice of consultation mode. Patients’ input into this choice should be sought and practices should respect preferences for face to face care unless there are good clinical reasons to the contrary.”
  • “All practice receptions should be open to patients, adhering to social distancing and IPC [Infection Protection and Control] guidance. This is important for ensuring that patients who do not have easy access to phones or other devices are not disadvantaged in their ability to access care.”

On 14 October 2021 NHSEI, working with the Department of Health and Social Care (DHSC) published a plan for improving access to GP appointments. Measures to make it easier for patients to see or speak to GPs and their teams include a £250 million access fund for the five months from November 2021 to March 2022. It also set out plans for NHSEI will increase its oversight of practices with the most acute issues in relation to access, and to publish more detailed GP appointment data by spring 2022. Other measures are intended to increase and optimise capacity, address variation and encourage good practice, and improve communication with the public, including tackling abuse and violence against NHS staff.

The GP access plan notes that there are limited evidence-based professional standards or guidance to help show what constitutes good practice or what is likely to be an unacceptable standard of care around the availability of appointments. It highlighted that a minority of practices are now offering wholly inappropriate access, with very low levels of face-to-face care. In August 2021 over 15% of practices recorded less than 20% of their GP appointments being held face-to-face. The plan said that this “…is likely to be contrary to good clinical practice, even if it were to reflect the preferences of their patients.”1F1F1F[2]

The Royal College of General Practitioners (RCGP) has said the plan’s focus on access ignores other challenges in general practice. Professor Martin Marshall, Chair of the RCGP, said:

Additional financial support for patient care in general practice is always welcome, and shows the pressures facing general practice are being recognised. But a focus purely on access ignores the other challenges we face in providing high-quality, personalised care. Crucially, there is also nothing here to address the long-standing workforce pressures facing general practice. We need the Government to make good on its manifesto pledge of an additional 6,000 GPs, and 26,000 other primary care professionals, to enter the workforce by 2024.

The British Medical Association’s GP Committee (GPC) has called on the Government to work with them to introduce a new contract “which ensures general practice is properly funded, with safer workload and reduced bureaucracy, and ultimately provides better care and services for patients and vastly improved working conditions for doctors and their teams.” The GPC has encouraged GPs to not comply with what it describes as the “worst aspects” of the plan and has said it intends to ballot the profession on industrial action.2F2F2F[3]

Statistics on GP appointments (England)

NHS Digital publishes monthly statistics on Appointments in General Practice.

The data shows that there were 23.9 million general practice appointments recorded in August 2021, compared with 23.4 million in August 2019. In addition, 1.5 million COVID-19 vaccination appointments were delivered by general practice or primary care networks in August 2021.

13.7 million appointments were recorded as being face-to-face – 59% of those where an appointment mode was recorded. This compares with 84% of appointments recorded as being face-to-face in August 2019.

However, NHS Digital provides the following context on the quality of GP appointments data:

The GP appointment book systems from which this data is taken are not primarily designed for data analysis purposes. Guidance has recently been issued to increase the standardisation of data entry in these systems however substantial variation and data quality issues remain. These quality issues impose limitations on what can be inferred from this data and as such they should continue to be considered as experimental statistics. The outbreak of Coronavirus (COVID-19) has led to unprecedented changes in the work and behaviour of General Practices and subsequently the GP appointments data within this publication. The variation in approach to appointment management between practices is likely to be greater than usual during the Coronavirus outbreak and this may result in long term changes. As a result, methods of data recording have been impacted and users should therefore exhibit appropriate caution in drawing conclusions from comparing current appointment volumes with those recorded before the pandemic.

This means that you should exercise caution when interpreting the figures, and particularly when looking at variation between areas.

[1]   Further information can be found in paras 289-293 of the Explanatory Notes to the Bill. For a general introduction to local and national NHS organisations please refer to the Library briefing paper, The structure of the NHS in England (June 2020).

[2]   NHSEI, Our plan for improving access for patients and supporting general practice, 14 October 2021, page 5

[3]   BMA, BMA’s England GP committee rejects Government’s rescue package and moves towards a ballot on industrial action, 21 October 2021

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