We don’t really understand demand in general practice.  The big message from the Kings Fund report earlier in the year, Understanding Pressures in General Practice, was the need to create the ability to measure this demand.  The West of England AHSN published Measuring Demand in General Practice which found,

“A lack of research in this area and a lack of continuity in national projects aimed at supporting GP practices to understand demand… Work with GP practices revealed no definitive or widespread approach to measuring demand in primary care. However, it confirmed that practices and CCGs were struggling to cope with apparently increasing demand and were very keen to engage in further activities that might help understand and manage it better.” p3

We do, however, know some things.  We know the population is growing.  We know people are living longer and morbidity is increasing.  We know people are becoming more demanding.  We know there is a GP recruitment crisis.  We know 71% of GPs identify workload as the top factor negatively impacting on a career in general practice.  We know waiting times for an appointment are going up.

Clearly there are no straightforward answers to the challenge growing demand presents, but is there anything that can help?  In the past we had ‘advanced access’ (you can find the evaluation of this here), then came telephone appointments, and more recently based web-based systems, Skype and e-consultations.

I always find starting with the answer to be a mistake.  Better to understand the problem as best we can, and develop solutions from there.  There is a limited capacity (and shortage) of GPs, which cannot meet the totality of the demand.  Demand is rising faster than the population or its underlying morbidity, which means demand is presenting now that previously patients would have managed themselves.  There is a growing cohort of patients with complex multimorbidity.  Continuity of care is needed for some patients but not for all, but is particularly important for this complex group.  All this suggests efforts to access additional or different capacity to meet the less complex demand, and free up GP time to focus on the more complex demand, are those most likely to be successful.

The other place to look is to see what others are doing.  The practices I have seen that are dealing with the pressures best all seem to split demand into two.  They split the demand that presents on the day (on the day demand) from the demand that comes from the management of patients with ongoing chronic conditions, some of whom are highly complex (ongoing demand).  They find demand for the former constitutes a large proportion of the demand on a practice, and they have found different ways of creating capacity to meet this demand.

Some have introduced new roles in to practices specifically to help meet this demand.  Some have gone as far as creating a multidisciplinary team, led by a GP, for this specific purpose.  Some have used joint working with other practices to enable a collective approach.  They have set up ‘urgent care hubs’ or the like to manage on the day demand across multiple practices in one place, with an extended team and a range of roles.  Some have used partnerships with the local community trust, ambulance service or acute trust to access the additional skills and capacity they need to help meet this demand.

Many of these sites have found by making these changes they have been able to free up more GP time for the ongoing demand, for the more complex patients, and some have been able to increase appointment times for these patients to 15 minutes, or even longer.

Changing how on the day demand is dealt with can do two really important things.  It can ease the overall pressure on the practice, and it can create more capacity for GPs to focus on the ongoing demand and provide continuity of care where it is most needed.  The specific changes individual practices choose to make will always need to be tailored to the individual local circumstances.  But the principles behind the changes remain the same: consider on the day demand and ongoing demand separately, find new ways of creating capacity to meet the on the day demand, and this in turn will free up more expert GP capacity to meet the ongoing demand.