This post is the second of a three part series on the state of primary care by two of CHPI’s founding trustees: practicing GP Jonathon Tomlinson and academic and author Colin Leys. This piece is authored by Colin,and here you can find the first post ‘Threats and Opportunuties’ and the third post ‘Continuity of care vs ‘transactional’ care’.
In May 2022 there were 35,434 fully qualified GPs working for the NHS in England, and another 8,133 trainee GPs working with them. However, only 23% of the fully qualified GPs worked full time: most of the rest (69%) worked between 15 and 37.5 hours a week, while the remaining 8% worked 15 hours or less. This is partly due to the fact that 57% of all GPs are now women, many of whom want to split their time between work and family responsibilities.
It is also due to the stress involved in the work: today GPs typically find themselves working late into the evening to complete what has nominally been an 8 hour day. The reason why GPs’ work has become so stressful is that the effective (full time equivalent) GP workforce has stopped growing, while the population has steadily increased, and needs more care.
Since about 2015 the number of fully qualified FTE GPs in England has declined by 6%, due to retirements and resignations. This is roughly offset by an increase in the number of trainees, who by 2022 comprised 22% of the total GP workforce, so that the total number of FTE GPs has remained constant. But the population has been rising by about 400,000 a year, meaning that the average number of patients per GP in England has risen to 2,200 (the average in both Norway and France is 1,200). The population is also ageing; 18% are now over 65, and have greater health care needs. So between 2007 and 2014 the number of consultations per GP increased by 12%, and the average consultation time increased by 6%, a combined 16% rise in the GP workload. Since then the need for consultations has continued to rise. By 2019 a GP in England was often seeing 40 patients a day. In ‘under-doctored’ areas one in ten GPs was seeing up to 60 a day, twice as many as they considered safe.
On top of this, since 2014 government policy has been to shift work from hospitals to community care, without a corresponding shift of resources: for example the work of following up treatments given by hospital consultants is now often left to GPs instead of being done by the consultant or someone in their team. On top of this GPs have acquired a wide range of additional responsibilities: besides the work of referrals, hospital letters, and prescriptions, there are child protection reports, benefits appeals, Primary Care Network meetings, audits and quality improvement, and patient complaints, as well as the training and supervision of trainee GPs. As a result GPs often have to spend as many hours on this work as on seeing patients, which means that to make an additional week’s worth of appointments available to patients requires more than one additional full time GP.
An independent review carried out for the government in 2014 foresaw the GP crisis we are now facing. It concluded that ‘current numbers of GP trainees are inadequate and are likely to lead to a major demand-supply imbalance by 2020.’ The review recommended ‘a substantial and sustained increase in GP training numbers, coupled with other measures to boost workforce supply’. And this was before the downturn in the number of fully qualified GPs that began in 2015.
But with the implementation of the Health and Social Care Act in 2012, which envisaged the NHS becoming a health care market, forward planning for the NHS workforce was effectively abandoned, and this remains the case: NHS England refuses to put any figure on the number of GPs expected to be needed at any point in the future, or to say how the numbers currently in training relate to future needs.
In 2021 the government did raise the number of GP training posts from 3,250 a year to 4,000, but this is clearly not sufficient. Given that three quarters of all fully qualified GPs work less than full time, two or even more GPs need to be trained for every full-time post that needs to be filled. Moreover many newly qualified GPs now look for a ‘portfolio’ of jobs – working as locums or for the Care Quality Commission, or doing private work such as menopause medicine or digital online medicine – rather than making the care of NHS patients their exclusive focus, or even their main one. Health Education England, which is responsible for medical training, actually stresses the opportunity to have a ‘portfolio career’ – i.e. not to be just a GP – as one of the attractions of training as a GP, which doesn’t help.
On top of the shortage of GPs willing to work as general practitioners, the GP workforce is not distributed according to need. The number of patients per FTE GP varies from 1600 to 2,800, the poorest communities having the fewest GPs per head. GPs are independent contractors to the NHS, not NHS employees, and can’t be required to work where they are most needed. Down to 2001 a Medical Practices Committee (MPC) could prohibit the appointment of GPs to new posts in already well-provided areas, steering them to find jobs areas of greater need. But in 2001 the MPC was abolished; no mechanism has since existed to correct the imbalance, and it has grown steadily worse. There is thus an unregulated market for GPs combined with a restricted supply – the ideal conditions for the operation of Julian Tudor Hart’s law of inverse care. The areas most in need of more GPs are the least likely to get them.
The problem of unequal provision is not just a matter of new GPs being unwilling to work in areas where the need is greatest. The level of practice funding is also inversely related to need. The Carr-Hill funding formula for general practices adopted in 2004 did not take into account the greater cost of providing care to patients in deprived areas, and subsequent changes in GP funding have made the problem worse. As a result, since 2015 practices in the most deprived areas have consistently received 7% less funding per patient than practices in the most affluent areas. After much discussion a proposal to end the unfairness was eventually put to GPs in 2008, but was rejected, because it came with no additional funding. Practices in better-off areas would have had to accept budgets cuts to pay for the change. It seems clear that so long as GPs remain independent contractors, equity in the distribution of GPs and other resources can only be achieved with additional funding.
The independent contractor model of general practice has often been questioned, and has in any case been undergoing some significant changes. This and other organisational issues are the subject of the next blog in this series.
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