Use of primary care during the COVID-19 pandemic Patient-level data analysis of the impact of COVID-19 on primary care activity in England

Graphic showing a stethoscope

Key points

  • The reduction in GP consultations since the start of the pandemic has been widely reported. This has led to concerns about the care of non-COVID patients, people with long-term health conditions, and the potential for delayed diagnoses.
  • This analysis uses patient-level primary care data up to end of June 2020 to explore how different activities and patient pathways were affected around the peak of COVID-19 in England, and how these effects varied by age, sex and for patients with pre-existing illness. This is a significant advance on what is possible using NHS Digital data.

Consultations

  • Primary care consultations per person fell from an average of 4.1 before mid-March in 2020 to 3 consultations per person per year (around a 30% reduction) the week after the introduction of lockdown at the end of March. Rates were still at that level in the most recent data (end of June).
  • The reduction in consultations masks a more fundamental shift in how consultations are taking place. The number of face-to-face consultations has fallen by 2.3 per person per year, which was partially – but not completely – offset by the increase in remote consultations of 1 per person per year.
  • After lockdown 50–60% of consultations in these data were conducted remotely, allowing vulnerable patients the chance to keep in touch with their GPs without the need to visit a practice and risk contraction or spreading of the disease. This is consistent with messaging at the timefrom NHS England that patients should be seen remotely first then face-to-face if necessary.
  • It is not clear exactly what is driving this reduction. We don't know whether patients were worried about accessing services, making use of NHS 111 services or whether access was restricted because of capacity.

Primary care pathway

  • Over the same period there was a fall in the number of referrals, medical tests, new prescriptions and immunisations.
  • GPs were advised to hold off on routine referrals to free up capacity for hospitals to deal with the large number of expected severe cases of COVID-19. Routine referrals were 74% lower between the weeks commencing 15 March–21 June when compared with the same weeks in 2019. Routine referrals had not recovered towards the end of June, remaining at a 50% reduction in rates.
  • The reduction in referrals overall occurred before lockdown had started. The drop in referrals was not solely driven by a fall in consultations, as the rates of referrals made per consultation also fell.
  • 2-week wait referrals are used by GPs to urgently refer patients who have symptoms which may indicate cancer. Advice to GPs and secondary care was to maintain the normal cancer service throughout lockdown. However, from the middle of March to the end of June there were 43% fewer 2-week wait referrals than in the same weeks in 2019. There appears to be a quicker recovery for 2-week wait referrals than other types. Throughout June they had recovered to a fall of between 10–30%.
  • Repeat prescriptions spiked the week before lockdown was introduced as patients and GPs attempted to maintain continuity of access to medicine for pre-existing conditions. New prescriptions reduced after lockdown at the same rate as consultations.
  • Health testing that occurs in primary care (such as blood tests) fell by 80%. Childhood immunisations appear to have held their pre-lockdown levels, in line with advice to GPs to protect them. While adult immunisations fell, their normal rate throughout early summer is typically very low. It is worth noting that social distancing and reduced travel may have reduced the risk (and demand) of vaccine preventable diseases.

Introduction

Health care in England has undergone monumental changes in response to the COVID-19 pandemic. In the early months of the pandemic, some aspects of hospital activity stopped, and staff and resources were redirected to care for acutely ill COVID-19 patients. Outpatient activity was either postponed or took place remotely. Planned non-urgent treatment, including diagnostic care, was also postponed and sometimes closed to new referrals.

Changes outside of hospitals have been equally large. Face-to-face care was mostly suspended in the community, unless it was urgent. For services such as general practice, the public were told to phone their GP surgery in the first instance, as practices began total triage and adapted their services to protect patients and staff from infection.

NHS data reveal stark shifts in service use over the last 6 months. Some shifts are a direct result of the crisis response: more patients waiting much longer for planned hospital treatment and for diagnostic tests, alongside sharp falls in referrals to outpatients. Other shifts were less predictable as they were patient-led, including large reductions in people attending A&E and a reduction in desire to seek care. Fears about contracting COVID-19 have played a part in keeping some people away from NHS services, prompting a national campaign in April to encourage the public to use GP and hospital services if they had urgent care needs.

Primary care plays a pivotal role within the NHS – it is responsible for the majority of patient contact with the health system, and it affects both planned and unplanned flows into the rest of the system. NHS Digital publishes data that can give a rough picture of the volume and type of overall GP appointments in England, but do not contain data on referrals and tests, or any information about patients, for example their age, or whether they have non-communicable diseases (NCDs).

The policy goals surrounding the recovery are designed to help patients and practitioners recover from this monumental shock and to get back to business as usual. Knowing how primary care has changed since lockdown, and for whom, will help direct the focus to those with the greatest need.

There has been profound disruption and changes to primary care as a result of the pandemic.

Key milestones include:

  • 2 February: NHS branded COVID-19 public information launched in the UK. This included advice to people who had returned from Wuhan, China with symptoms to isolate and call NHS 111 rather than visit their GP.
  • 26 February: NHS 111 launched a new service with funding for extra capacity to deal with increased demand due to COVID-19.
  • 17 March: NHS England advised GPs to roll out remote consultations to elderly and vulnerable patients as a matter of urgency, stating that 'face to face appointments should only happen when absolutely necessary'.
  • 19 March: Advice followed that GPs should move to a total online or phone triage system, prepare for more home visits and prioritise high-risk patients. Shortly after, steps were taken to free up GP capacity, including the suspension of Quality and Outcomes Framework (QOF) and CQC inspections, as well as appraisals and revalidations for GP licences. There was also advice relating to prescriptions: to maintain repeat prescriptions, encourage patients to use online services for repeat prescriptions, and not to increase duration of prescriptions.
  • 21 March: 2 days before the national lockdown, GPs received initial guidance on which of their patients were to be shielded and how to continue their care.

The current picture

In July, NHS England made clear that most non-COVID NHS services, including general practice, should return to normal levels of activity in what it described as the 'third phase' of the NHS response to COVID-19.

As part of this process, general practice is required to develop priority lists of patients needing preventative services and management of NCDs, reflecting how 'health needs and care may have been exacerbated during the COVID-19 pandemic'.

Using patient-level data to understand primary care activity

We have used a patient-level primary care data set, the Clinical Practice Research Datalink (CPRD), to explore primary care activity and outcomes from a subset of practices. Unlike the high level NHS Digital appointment data, this patient-level data allows us to match consultations to patients by age, sex and whether they have been diagnosed with non-communicable diseases (NCDs). The data provide the most detailed view that we can access of the changes that the COVID-19 pandemic and accompanying lockdown has brought about.

This analysis is based on a sample of 500,000 patients registered at 84 practices in England. This modest sample of practices brings limitations. However, it allows for a much deeper understanding of primary care than is currently available. We make the aggregated trend data available for analysis in the hope it will be used to improve policy decisions in the UK recovery from COVID-19. Our data analysis is placed in the context of NHS England advice for primary care practitioners throughout the crisis response. A full description of the data and our analysis can be downloaded here:

Consultations

Consultation rates per person dropped by around 30% the week following lockdown (week commencing 29 March): from over 4 consultations per person per year to less than 3. Figures 1.1–1.6 show the reduction in consultations for the whole population, by sex, by age and for people with NCDs. Percentage change graphs (1.4 & 1.6) show the difference between the weeks of 2020 and the average of the same weeks during 2016–19.

We don't observe an overall drop in GP consultations until the second week of lockdown (commencing 29 March). Appointments fell for younger patients, while consultation rates for older patients and patients with NCDs increased in the first week of lockdown. These data indicate that NCDs were the major determinant of whether a patient had a consultation at the start of lockdown. These data don't tell us whether the consultation was a result of GPs reaching out, or patient led.

Modes of consultation

In line with guidance, the share of consultations which were remote (through phone or video call) grew dramatically the week before lockdown, from 15–20% of consultations to 50–60%. It has remained higher than pre-COVID. This allowed for vulnerable patients to contact their GPs at a time when they were advised to remain in their homes.

Prescriptions

Repeat prescriptions

Repeat prescriptions are series of prescriptions for the same drugs issued to patients by GPs. They are usually issued without the patient revisiting the GP and are typically for the treatment of pre-existing conditions. For example, inhalers for asthma sufferers. GPs were encouraged to continue these and to move to electronic repeat prescribing if possible.

Repeat prescribing didn't fall through lockdown as much as other areas of care. Before lockdown started we observe a spike similar to that experienced around the winter holidays, with only a minor reduction in rates after a few weeks of lockdown.

New prescriptions

New prescriptions, unlike repeat prescriptions, are issued following a consultation in primary care, whether remote or face-to-face.

The reduction in new prescribing rates can be explained almost completely by the reduction in consultations. The rate of new prescriptions administered per consultation has not changed since lockdown. Although there is little unexplained change, the composition of patients may have changed. Social distancing may have contributed to a fall in other infectious diseases, such as gastroenteritis, and patients who would have otherwise attended A&E may have chosen to use primary care instead.

Referrals and tests

Referrals to secondary care and health tests administered in primary care are part of the care pathway into further treatment or monitoring.

These primary care outcomes have fallen more than can be explained by the reduction in consultations. This is because the rates of testing and referrals per consultation have also fallen. We do not yet know to what extent this is due to the patient mix presenting in primary care or GP and patient behaviour. Below we show how the actual rates per person compare to what we would have expected using the estimated rate per consultation from 2016–19. The difference in lines displays the reduction in testing per consultation compared with previous years.

The data also allow us to explore referrals by severity. 2-week wait referrals are for suspected cancer, and GPs were recommended to maintain these referrals. Other urgent referrals are for life threatening conditions that are likely not cancer, while routine referrals are for less severe conditions. Routine referrals began to fall immediately with the advice on 19 March to alleviate pressure on the secondary care system. From the week commencing 15 March to week commencing 21 March, routine referrals were 74% lower when compared with the same period in 2019.

NHS England advised that 2-week wait referrals were to be protected throughout lockdown. However, we observed around a 43% reduction in 2-week wait referrals per person over the lockdown period, compared to the same weeks in 2019. There are widespread concerns that this will have serious consequences for cancer outcomes in the coming months and years.

Immunisations

Immunisations for adults are highly seasonal as a result of the annual flu vaccine. We therefore observe a downward trend in immunisations per person throughout the start of the year. However, the observed fall in immunisations is larger than we would have expected based on previous years.

The bulk of immunisations occur during the late autumn and winter months due to flu. Lockdown greatly reduced international travel and therefore reduced the number of normal travel-related vaccinations.

Childhood immunisations remain the focus of the recovery. In the phase 3 recovery letter, GP practices were asked to make rapid progress in addressing the backlog of childhood immunisations.

Conclusion

In the face of a crisis, the NHS has undergone massive changes. Primary care, as the front door, has had to respond. It is a key gatekeeper to secondary care and, through management of long-term conditions, plays a vital role in keeping people well.

National data has already revealed huge shifts in service use during the COVID-19 pandemic. The more granular data that we've presented here explore these shifts further. The patterns we have observed are dramatic, with a steep decline in consultation rates, a switch to predominantly remote consulting and significant reductions in referrals, tests, new prescriptions and immunisations.

These data do not explain what drove each change – it could be a combination of disruption to GP services early in the pandemic, patients worried about using NHS services and the increased use of alternatives, such as NHS 111 or pharmacies.

The impact of these changes could be lasting and severe. The reductions in activity – for example, far fewer 2-week wait referrals – are clearly worrying. However, it is extremely difficult to translate what we see into a proper understanding of unmet health care need.

Plans for the recovery focus on four major aspects:

  • completely resuming cancer services
  • returning to the non-urgent, routine referrals as far as possible
  • expanding and improving mental health care
  • tackling inequalities.

Primary care must continue its response to the crisis and focus on these key service areas, while reaching out to patients who may have had care delayed. However, policymakers acknowledge that some aspects of this (for example whether secondary care is open to referrals) are not within the control of GPs.

Pandemic recovery is unchartered territory for the NHS. Access to quality, timely data analysis – and asking sensible questions of the analysis – will be vital. We have developed this analysis with that in mind. For more detail than is presented in this analysis, download the data here.

 

Toby Watt (@TLSWatt) is Senior Economist at the Health Foundation.

Zoe Firth is Economics Analyst at the Health Foundation.

Dr Rebecca Fisher (@BecksFisher) is a GP in Oxford and Senior Policy Fellow at the Health Foundation.

Ruth Thorlby (@RThorlby) is Assistant Director for Policy at the Health Foundation.

Elaine Kelly (@ElaineKTHF) is Head of Economics Research at the Health Foundation.

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