Pressures and Constraints in General Practices

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01 December, 2021

Leonie Millard

In recent times there has been a rise in problems in GP surgeries, and these problems have been exacerbated because of the COVID-19 pandemic. These problems arise as a consequence of all-around pressures. These current pressures lead to GPs missing red flags when examining patients due to various reasons which we will look at in this article in further detail.

Downward pressures

Clinical Commissioning Groups

GPs are part of the Clinical Commissioning Groups (CCGs), which commission most of the hospital and community NHS services in the local areas for which they are responsible. CCGs involve deciding what services are needed for diverse local populations and ensuring that they are provided. This involves the continual process of planning, agreeing, and monitoring services.

All GP practices now belong to a CCG and have been part of a similar commission previously. This puts pressure on GPs. There are certain budgetary constraints for GPs to purchase drugs/issue prescriptions, meaning that there is a constraint on the number of drugs that GPs are supposed to provide. If this is exceeded, the budget gets reduced the following year.

Audit of Referrals

There is also an audit of referral rates that takes place at GP surgeries. This monitors how many referrals are made to other departments, with specific reference to each GP. Therefore, GPs want to keep their referral rates low to try to demonstrate that they are competent at dealing with the issue themselves. Unfortunately, this results in certain people not being referred to other specialist departments when they should be.

Peer Comparison

GPs are also more aware of the comparison to their peers. The budget is reviewed against their peers in the same way that the referral rate is measured and audited, which gets produced to the rest of their peers to show where each person ranks in terms of the lowest referrals and sticking within the budget.

Other Additional Measures

Department of Health directives and National Guidelines (NICE) are additional measures that GPs have to comply with, compounded by the added pressure of COVID-19 restrictions.

Upward Pressures

Increased Appointments

There is increased pressure on GPs from the patients that they are seeing. The government publicity/media message most of the time is to go and see your GP with almost any issue you have.


The use of technology and the ability to use google search to investigate the issues that you have yourself based on your symptoms often results in patients 'self-diagnosing'. This increases public expectation when individuals go to see a GP afterwards and effectively try to inform the GP of what they are diagnosed with. Therefore, there is added pressure on the GP to somewhat agree with the patient, which naturally results in decreased public patience.

Financial pressures

The particular way that GPs are paid their salary is in itself a pressure. Quality and Outcome Framework (WOF) is the framework used for the way GP's get paid. GP's can get an extra payment if they have certain advice rates, the higher the advice rate the greater payment. This can result in a patient going to see their GP about one issue, but the GP only focusing on another, to provide a particular line of advice to suit meeting the advice rates.

There is added pressure on GPs to participate in Directed Enhanced Service (DES) work, which is government-based project work, and LES which is a local based project work. GP's receive extra money for doing this extra work, which can take them away from focusing on their GP day to day duties.

Many GPs have now left the NHS organisation and work in non-NHS work, resulting in fewer qualified GPs in the NHS and further exacerbating understaffed pressures.

Consequences of COVID-19

Naturally, the pandemic has resulted in an increased number of consultations at GP surgeries and an increased requirement of what GP's should do in each consultation.

GPs have various solutions that they have implemented because of this:

Cutting corners

As doctors are busy dealing with the overwhelming number of patients, this results in the delegation to inadequately trained staff, which seems to be happening more and more recently. There are not enough qualified GP's and too much work to do, so they delegate. Those that are being delegated are promoted to the position of incompetence as they are being given jobs that they are not qualified to do.

Telephone consultations

GP surgeries have still not resumed to a face-to-face consultation, despite COVID-19 restrictions being relaxed.

Telephone consultations are being used for symptoms/problems that a telephone consultation is simply inadequate for. This fails to examine the patient, which is the biggest source of clinical negligence.

The overwhelming number of patients and reduction in GPs results in patients being redirected to other agencies i.e. A&E when they do not necessarily need to be sent to A&E, but they simply do not have enough time to see them.

The rush of trying to get through as many patients as possible in a day means that GPs are not examining the problem widely enough, and not giving the patient enough time, to work with the patient to establish and fully understand their problem/needs.

Incorrect/unsuitable referrals to non-audited departments - i.e., physio. These types of referrals are not audited, so GPs won't get criticised for being the one GP with the most referrals to other departments and again, seeming like they are incompetent.

Cost-effective prescribing to patients has resulted in the inadequate and ineffective treatment being prescribed. GPs are prescribing a cheaper drug that may not be effective as they feel pressured to adhere to their cost budget.

This all leads to potential breaches of Duty of Care in clinical negligence.


COVID-19 has exacerbated all these problems stated above. There is still the approach that GPs should see as few patients in person as possible, so this is an ongoing issue. During the lockdown periods, patients were encouraged not to attend A&E or even leave their homes. This will inevitably result in undiagnosed serious illnesses because people haven't gone to GPs in the times of COVID. There is still the 'see as few patients as possible' policy in place. Patients should be seen face to face and these things will only get worse whilst there is still this type of policy in place.

Case Example

Joanna Georgiou has tumours next to her heart, in her lungs and one in her knee, and is still battling stage 4 cancer. NHS doctors missed her cancer as they were focused on COVID patients in the pandemic and non-COVID patients were effectively put on hold.

Joanna repeatedly went to NHS doctors because of a small lump on her knee that they failed to recognise as a tumour. The problem was exacerbated in the pandemic as she was forced to use e-consultations rather than in-person consultations. When Joanna went to a private clinic after being repeatedly dismissed by doctors in the NHS, it was confirmed by the private clinic that she has a tumour the size of a satsuma next to her heart, six small tumours in her lungs, and a huge tumour in her knee. She is now undergoing intensive chemotherapy and contemplating having her leg removed to save her life.

This demonstrates the huge impact that the NHS struggles can have on individual lives, and with the huge NHS backlog and waiting lists that are still apparent, this may be a struggle for some time yet.

For more information contact Leonie Millard in our Clinical Negligence department via email or phone on 01254 770517. Alternatively send any question through to Forbes Solicitors via our online Contact Form.

Learn more about our Clinical Negligence department here

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