Much of the narrative around GP demand puts GPs and practices into the role of helpless victim, beaten down by the relentless growth in demand without the resources to meet it. But it is more helpful to focus on the practical actions practices can take to gain control over demand, and attempt to become the hero of their own story.

Demand on GP practices is growing. The King’s Fund 2016 study, Understanding pressures in general practice found,

“Our analysis of 30 million patient contacts from 177 practices found that consultations grew by more than 15 per cent between 2010/11 and 2014/15. The number of face-to-face consultations grew by 13 per cent and telephone consultations by 63 per cent. Over the same period, the GP workforce grew by 4.75 per cent and the practice nurse workforce by 2.85 per cent. Funding for primary care as a share of the NHS overall budget fell every year in our five-year study period, from 8.3 per cent to just over 7.9 per cent.”

Natasha Curry from the Nuffield Trust, in her article Fact or fiction? Demand for GP appointments is driving the crisis in general-practice, examined where the rise in demand for appointments was coming from, and found,

“While activity in general practice has increased, most of that increase is amongst staff groups other than GPs. Consultations with GPs rose by approximately 2 per cent, whereas consultations with nurses rose by 8 per cent and consultations with ‘other’ staff (a long list of professionals including pharmacists, physiotherapists, and speech therapists) grew by 18 per cent.”

Introducing new roles is clearly one mechanism practices have been using to manage the growth in demand. Introducing telephone appointments is another. Both have added to the complexity and challenge of the work the GPs actually do see face to face.

What else can practices do? The NHS Alliance considered “potentially avoidable” appointments in their report Making Time in General Practice. They found,

“Overall, 27% of GP appointments were judged by respondents to have been potentially avoidable, with changes to the system around them. The most common potentially avoidable consultations were amendable to action by the practice, often with the support of the CCG. The biggest three categories were where the patient would have been better served by being directed to someone else in the wider primary care team, either within the practice, in the pharmacy or a so-called ‘wellbeing worker’ (e.g. care navigator, peer coach, health trainer or befriender). Together, these three, which could be improved by more active signposting and new support services, accounted for 16% of GP appointments. An additional 1% were to inform a patient that their test result was normal and no further action was needed. A further 1% of appointments would not have been necessary if continuity of care or a clear management plan had been established.”

I recently discussed how “active signposting” works on a recent podcast. It is dependent on creating the alternative routes for patients to follow. Training receptionists will not help, unless at the same time places are established for patients to be signposted to.

Even with the same funding some practices cope well with the level of demand, and some do not. It is not only a function of ability to recruit GPs, or the ability to signpost. I have seen a number of examples where the ratio of GP sessions to patient population is the same or higher, but the ability to cope with the workload is significantly worse. When I have looked into why this is, a key factor appears to be GP generated demand.

GP generated demand are those appointments generated by the doctor (“come back in 4 weeks”) as opposed to those initiated by the patient themselves. While CCGs are working up and down the country to cajole practices into reviewing referral rates (in his paper, Does GP growth in referral link directly to growth in inpatient demand? Dr Rod Jones shows that the answer to his own question is no, and that it leads to a perceived need for higher levels of resource than is really the case), practices might be better focussing their attention on internal GP follow up rates. Rates between individual doctors vary, but the benefits of exploring and managing that variation fall directly to the practice.

Much emphasis, rightly, in general practice is given to continuity of care. Where GPs have their own lists, and know the patients better, they can be much more confident in only bringing those patients back when they know they need to be seen. Where patients simply see the next available Doctor the likelihood of follow-up appointments is higher. So the benefits of continuity of care fall to the practice as well as to the patient.

In practices with high levels of part time working the challenge of achieving this continuity can be higher. Practices in this situation that have managed it well have introduced “buddying” systems, whereby part time GPs work to manage a list together. Practices that have not are often drowning under the weight of the demand.

Use of telephone appointments, introducing new roles, active signposting and managing variation in internal follow-up rates are all actions open to all practices to take control of their own demand. When the status quo is unsustainable, becoming the hero is the only option.