Not for the first time in living memory, the GP media is full of headlines on demand taking practices to “breaking point”. It seems to me important that we bring the best data we can to bear on this question. It’s only good scientific discipline to diagnose the problem before attempting to apply a cure.
There are real world issues which could be driving some level of increased demand. Patients may have saved up issues during the pandemic for which now they want help. Long waiting lists for secondary care may increase the primary care burden. Concerns about covid, and long covid, may be part of the load. Complexity may have risen, with mental health issues more common. While all these are possible, I’ve seen no data to quantify the effects and we don’t know the detail of patient requests.
We can say that overall patient demand is at a new peak, compared with winter 2019 pre-pandemic, numbers up by around 5%. At this time of year demand usually flattens by a few % with spring weather so the relative change may be slightly higher. There is a much bigger change compared with April 2020, because demand fell by around 30% during the first lockdown.
How to measure?
While headlines can be made by choosing a suitable baseline, I think it’s vital to use consistent measures. Even though they are imperfect, the same measure year after year gives us a much clearer view than introducing different measures, imperfect in new ways. This is a key reason why we start from patient demand, driven by patients from outside the system it’s less subject to internal system changes.
How could system changes contribute to the headlines on demand? There’s public speculation that making access easier, particularly online access, could increase demand. No one can say that it’s never true, but pre-pandemic we found that overall clinical demand stayed predictable and constant around 6.5% of patient list per week, and was not affected by faster service. It is true that if supply was previously constrained then the true level of demand would become apparent, but this is not strictly new or increased demand.
English practices are being asked to provide new data, relating to appointments. Changing the measure to “activity” may seem a fine point, but if one patient request generates two activities (eg telephone call plus separate face to face) the activity appears to double, cf one pre-booked appointment. This could be misinterpreted as demand and on a large scale, very misleading numbers will follow.
So what to do?
There are calls to go back to the time before. I can understand that, at a human level we are acutely aware of loss of good times remembered. But thinking back, there were huge stresses, and patients who’d waited weeks to see the GP were suffering. Another form of double counting was the “just in case demand” – patients booking ahead speculatively, knowing that it’s hard to get an appointment.
Now there are calls to limit online access. We’ve always believed that practices should have control over their access channels, so they can programme times to accept new requests into askmyGP. The data shows that turning off out of hours has little effect on overall demand, and is only fair within the GMS contract, although we do have practices who accept requests at all times (and respond in hours).
However, if access is turned off too early, or after a fixed count is reached, unintended effects can follow. Once patients lose faith in the online channel being available, they return to the phone, taking up reception time in answering and more GP time as a phone call is needed in return, and the beauty of asynchronous messaging is lost. A downwards spiral results, where online demand falls, workload increases and waiting times increase, as does stress for all parties. Access becomes a lottery, and the very thing we want to avoid, digital inequity, returns. Those advocating the blunt instrument of limiting supply have not come up with a way to make it fair or based on clinical need.
Don’t give up!
Primary care has made huge and positive changes through the pandemic and we must not lose sight of the gains. I’m hearing of lengthening waits even for a phone call, queues of online forms awaiting triage, and many practices with very little incoming online or a token bolt on tool.
It has been striking to see askmyGP data show the proportion of requests resolved same day stay close to 83%, with half under four hours, even as demand has increased and face to face has ticked up to 10%. We’ve never said it’s easy, never said we’ve reached the destination, and our users are feeling the same real world pressures as all GPs. But I think we’re on the right track:
online access for the large majority who can use it,
digital triage in one click,
a rapid, appropriate clinical response.
When times are hard, we can celebrate having in the UK one of the least worst primary care systems in the world. Given the ups and downs, let’s go forward rather than back.
“So much better service this is definitely the way forward thankyou.” Lincolnshire patient 8 minutes ago.
What’s happening to GP demand?
Not for the first time in living memory, the GP media is full of headlines on demand taking practices to “breaking point”. It seems to me important that we bring the best data we can to bear on this question. It’s only good scientific discipline to diagnose the problem before attempting to apply a cure.
There are real world issues which could be driving some level of increased demand. Patients may have saved up issues during the pandemic for which now they want help. Long waiting lists for secondary care may increase the primary care burden. Concerns about covid, and long covid, may be part of the load. Complexity may have risen, with mental health issues more common. While all these are possible, I’ve seen no data to quantify the effects and we don’t know the detail of patient requests.
We can say that overall patient demand is at a new peak, compared with winter 2019 pre-pandemic, numbers up by around 5%. At this time of year demand usually flattens by a few % with spring weather so the relative change may be slightly higher. There is a much bigger change compared with April 2020, because demand fell by around 30% during the first lockdown.
How to measure?
While headlines can be made by choosing a suitable baseline, I think it’s vital to use consistent measures. Even though they are imperfect, the same measure year after year gives us a much clearer view than introducing different measures, imperfect in new ways. This is a key reason why we start from patient demand, driven by patients from outside the system it’s less subject to internal system changes.
How could system changes contribute to the headlines on demand? There’s public speculation that making access easier, particularly online access, could increase demand. No one can say that it’s never true, but pre-pandemic we found that overall clinical demand stayed predictable and constant around 6.5% of patient list per week, and was not affected by faster service. It is true that if supply was previously constrained then the true level of demand would become apparent, but this is not strictly new or increased demand.
English practices are being asked to provide new data, relating to appointments. Changing the measure to “activity” may seem a fine point, but if one patient request generates two activities (eg telephone call plus separate face to face) the activity appears to double, cf one pre-booked appointment. This could be misinterpreted as demand and on a large scale, very misleading numbers will follow.
So what to do?
There are calls to go back to the time before. I can understand that, at a human level we are acutely aware of loss of good times remembered. But thinking back, there were huge stresses, and patients who’d waited weeks to see the GP were suffering. Another form of double counting was the “just in case demand” – patients booking ahead speculatively, knowing that it’s hard to get an appointment.
Now there are calls to limit online access. We’ve always believed that practices should have control over their access channels, so they can programme times to accept new requests into askmyGP. The data shows that turning off out of hours has little effect on overall demand, and is only fair within the GMS contract, although we do have practices who accept requests at all times (and respond in hours).
However, if access is turned off too early, or after a fixed count is reached, unintended effects can follow. Once patients lose faith in the online channel being available, they return to the phone, taking up reception time in answering and more GP time as a phone call is needed in return, and the beauty of asynchronous messaging is lost. A downwards spiral results, where online demand falls, workload increases and waiting times increase, as does stress for all parties. Access becomes a lottery, and the very thing we want to avoid, digital inequity, returns. Those advocating the blunt instrument of limiting supply have not come up with a way to make it fair or based on clinical need.
Don’t give up!
Primary care has made huge and positive changes through the pandemic and we must not lose sight of the gains. I’m hearing of lengthening waits even for a phone call, queues of online forms awaiting triage, and many practices with very little incoming online or a token bolt on tool.
It has been striking to see askmyGP data show the proportion of requests resolved same day stay close to 83%, with half under four hours, even as demand has increased and face to face has ticked up to 10%. We’ve never said it’s easy, never said we’ve reached the destination, and our users are feeling the same real world pressures as all GPs. But I think we’re on the right track:
When times are hard, we can celebrate having in the UK one of the least worst primary care systems in the world. Given the ups and downs, let’s go forward rather than back.
“So much better service this is definitely the way forward thankyou.” Lincolnshire patient 8 minutes ago.
Harry Longman
What you can read next
The NHS App and the toenail test
GP at hand. General practice in very big trouble.
Babylon are getting speed and convenience right