There are not enough GPs to tackle the burden of non-communicable diseases
The current state of primary healthcare is ill-equipped to handle the increase of non-communicable diseases (NCDs), with the shortage of GPs and the 9-minute consultation model putting patients at risk. Social prescribing has been suggested as a solution, but it requires funding for services outside of the NHS...
General Practitioners are the gate-keepers to primary healthcare. In the dawn of the NHS this model worked. You called the doctor, scheduled an in-person appointment, and your course of treatment was prescribed. We are now in a very different medical landscape. The demands of an increasingly sick population exceed the capacity of a shrinking pool of GPs to safely visit, assess, treat, and refer patients. Getting an appointment is a challenge, with waiting times typically weeks not days. To the disappointment of many, the appointment often will be online, raising the problem of diagnosis-at-a-distance. We are asking GPs to make professional medical judgements via webcam versus physical evidence. The UK has the shortest GP consultations in Europe. If you make it into the surgery, you will likely be rushed through a 9-minute-long appointment1. In its current state it is impossible to envisage a healthcare system able to prioritise patient-centred care.
Today’s patients are increasingly complex
Patients today are presenting with increasingly complex concerns, predominantly non-communicable diseases (NCDs). The underlying risk factors of which include smoking, body mass index, alcohol consumption, physical activity, by age, sex, socioeconomic status and ethnicity. Such is the escalation of chronic diet and lifestyle-induced disorders, patients cannot necessarily be diagnosed with one singular condition. They may be in a state of pre-disease and evaluated against measures, such as years lived with disability (YLD). The top 3 risk factors for YLD are high body mass index (overweight, obesity), smoking and high fasting plasma glucose (blood glucose dysregulation leading to insulin resistance and Type 2 Diabetes Mellitus (T2DM)). Two out of three of these risk factors are heavily influenced by diet.
Patient care is dependent on the nature of the care needed.
There is no singular treatment for high body mass index and high fasting plasma glucose with both requiring a multi-factorial therapeutic approach. However, diet and lifestyle recommendations are essential elements which cannot be effectively communicated in a standard GP visit.
Helen Stokes-Lampard, chair of the Royal College of General Practitioners, was quoted back in 2017 as saying “Increasingly, patients are living with multiple, long-term chronic conditions, both physical and psychological — and at the same time GPs are being asked to do more checks, ask more questions and give more advice as standard during consultations. The standard ten-minute appointment is simply inadequate to deal with this.”2
GPs are already stretched to capacity
The average number of patients per GP practice increased to 9.4 thousand in January 2022, up from 7.7 thousand in 20162. The average number of patients each GP is responsible for has increased by 335 – 17% – since 2015, and now stands at 2,2733. Patients, GPs, and secondary care doctors all agree that there is a problem with access to healthcare. Not the fault of GPs, but a sign of a system stretched beyond capacity.
Workload statistics show that practices in England delivered 26.9 million appointments in June 2021 which was 3.1 million more than in June 20194,5. It is widely acknowledged that there is a shortage of GPs in the NHS, and that GP work is increasingly stressful6.
Despite the growing demands on GPs, the British Medical Journal (BMJ) reported in 2021 that ‘GPs are being blamed for government failures in primary care’, accused by the media of ‘hiding behind zoom screens’ and more seriously ‘virtual GP visits are costing lives’7,8,9,10,11.
Considering the continuing rise in number of patients per GP it is therefore unrealistic to expect GPs to deal directly with all of today’s patient’s needs. They need a clear road map to refer on to qualified practitioners across a broad range of disciplines supporting mental and physical health and wellbeing – notably nutrition.
Where does social prescribing fit into healthcare policy?
There has been much dialogue about social prescribing over the past few years with national NHS bodies committing resources to rolling it out across England. However, it’s not a new concept, and dates to the 1990’s when it was more commonly known as ‘community referral’12. It was conceived to enable health professionals to refer people to a range of local services, recognising that people’s health and wellbeing are determined by a range of social, economic, and environmental factors. It was also intended to encourage individuals to take greater control of their own health.
In 2019 a five-year GP contract framework was agreed to help stabilise general practice and create more structure to social prescribing, with increased funding for social prescribing roles13. The challenge for social prescribing remains one of funding for referrals to professions that currently sit outside of the NHS. Many of the currently used services do not include the services most pertinent to patient care and the need to support those with non-communicable disease profile.
Alongside this, the contract also set out to provide additional funding for Primary Care Networks (PCNs) through the creation of Additional Roles Reimbursement Scheme (ARRS). This scheme has the scope to enable a greater provision of proactive, personalised and more integrated health and social care by bringing new roles into general practice to build multi-disciplinary teams. Included are pharmacy technicians, care co-ordinators, occupational therapists, dieticians, podiatrists, nursing associates, and health and wellbeing coaches all of whom, it should be noted, are employed by the NHS.
Registered Nutritional Therapy Practitioners (RNTPs) are not mentioned in the listing currently, which Sarah Green, acting Chair for the British Association for Nutrition and Lifestyle Medicine claims is an “intentional failure to address the needs of patients by omitting practitioners qualified to deal with diet and lifestyle related illness”. However, GPs can already refer to any practitioner who is on the Voluntary Accredited Register held by the Professional Standards Authority for Health and Social Care (PSA). These services have historically been chargeable to the patient, exacerbating health inequalities, but GPs can and should use the ARRS funding to engage RNTPs, particularly due to the shortage of dietitians available to work with them. RNTPs are specialised in personalised nutrition thus bridging the gap between the acute-care nutrition qualifications of dietitians, and health coaches who lack any formal training in nutrition. RNTPs better align with the NHS Health Check program ambition ‘preventing illness and improving health for all”14 and can provide nutrition and lifestyle expertise in both one-to-one and group settings.
Creating PCN bespoke multi-disciplinary teams with nutrition at their core
Returning to the challenge facing GPs; the number of patients per capita, and the rise in patients presenting with NCDs – where high body mass index and blood glucose dysregulation are two of the most prolific factors - the need for multi-disciplinary teams with an RNTP at the core has never been greater.
It’s akin to solving a maths problem; GPs divided by number of clients equals shortfall.
Add in the specifics of the problem, namely that diet-induced NCDs are the cause of 74% of global deaths annually15, and closer to home account for 88.8% of deaths in England16 there is clear evidence that personalised nutrition must form part of the solution.
Prevention is the only strategy that will get to the root cause of the problem and deal with NCDs. We must tackle the cause and not only the consequence. Only then can we ease the burden on the NHS.
RNTPs are a workforce asset that is not currently being tapped into by GPs with regularity across PCNs and yet there is budget available. The solution is in the NHS hands.
For more on RNTPs ways-of-working and how they can support general practice
REFERENCES:
1International variations in primary care physician consultation time: a systematic review of 67 countries. https://bmjopen.bmj.com/content/7/10/e017902
2UK has shortest GP consultations in Europe, study finds - https://pharmaceutical-journal.com/article/news/uk-has-shortest-gp-consultations-in-europe-study-finds
3https://www.statista.com/statistics/996727/number-of-patients-per-gp-practice-in-england/
4https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice-data-analysis#:~:text=There%20are%20now%20just%200.44,and%20now%20stands%20at%202%2C273.
5NHS Digital. Appointments in general practice. Jun 2021. https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice/june-2021
6Shortage of general practitioners in the NHS. BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3191 (Published 10 July 2017)
7NHS Digital. Appointments in general practice. Jun 2019. https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice/june-2021
8BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n2234 (Published 13 September 2021) https://www.bmj.com/content/374/bmj.n2234
9Virtual GP visits are “costing lives.” Times https://www.thetimes.co.uk/article/virtual-gp-visits-costing-lives-covid-vtkrv7rth
10Pearce C. Doctors’ union reports Telegraph to media regulator over ‘misleading’ GP coverage. Pulse. Sep 2021. https://www.pulsetoday.co.uk/news/workload/doctors-union-reports-telegraph-to-media-regulator-over-misleading-gp-coverage
11https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice-data-analysis
12What is social prescribing - https://www.kingsfund.org.uk/publications/social-prescribing?gclid=CjwKCAiA9NGfBhBvEiwAq5vSyyubnQLlFwlPI3jgxlcztrVIKTKQwIfigzu__7KYQ97BqBkQLp2eeBoC-HEQAvD_BwE
1320/2021 update to the GP Contract - https://www.kingsfund.org.uk/publications/202021-update-gp-contract-explained
14NHS Health Check Program - https://www.gov.uk/government/publications/nhs-health-check-programme-review/annex-c-data-on-the-distribution-determinants-and-burden-of-non-communicable-diseases-in-england
15WHO report: 74% of Global Deaths are due to non-communicable diseases - Read more at: https://economictimes.indiatimes.com/news/international/us/who-report-74-of-global-deaths-are-due-to-non-communicable-diseases/articleshow/94359603.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst
1688.8% of deaths in England were attributable to NCDs https://www.gov.uk/government/publications/nhs-health-check-programme-review/annex-c-data-on-the-distribution-determinants-and-burden-of-non-communicable-diseases-in-england
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