Given the need for a fundamental shift away from hospital and towards community care, as discussed in our recent report, having enough staff in primary care is of paramount importance. But staff shortages are a major issue, with a 9.1% vacancy rate in community care September 2023, higher than the NHS total. And hidden within the shortages throughout primary care, there are pockets of even more severe shortages, where patient care is even more impacted because there are not enough staff.
Two of these pockets are areas of socioeconomic deprivation and coastal areas. The population of both tend to be sicker, due to the link between deprivation and illness, and the links between coastal communities, older age and deprivation meaning demand for health care is high.
Despite this high demand, deprived areas have fewer GPs per patient, and coastal communities 7% fewer nurses per patient. In previous work, we’ve argued that deprived areas do not receive the same level of GP funding as more affluent areas, because of the ways in which funding allocations are weighted. This shortage of staff has a serious impact on patient care. For example, people in the most income deprived areas in England are 20% more likely to have cancer diagnosed at a late stage compared to the least deprived areas.
With rising multimorbidity, an aging population, and a recent increase in deep poverty, the health needs of deprived or coastal communities, and therefore the pressures on primary care in these areas, are likely to increase into the future. Without a sustained increase in staffing, these needs will be even less likely to be met than they are now. So, what can be done to increase recruitment and retention of NHS staff into primary care in these areas?
Formal measures are underway, and it is hoped that these will help. For example, the NHS Long Term Workforce Plan aims to address these imbalances in staff, with pilot schemes in progress to improve overall recruitment and retention in coastal areas, and plans to focus new medical training posts in more deprived areas.
To ease GP shortages, schemes such as Welcome Back to Work, which provides support to GPs returning to the workforce after a break from clinical practice, could lessen the problem of losing experienced staff permanently. Evidence suggests that GPs often stay in the area where they train, so encouraging GP practices in coastal or more deprived areas to become training practices could help recruitment and retention. In addition, some support schemes for newly qualified GPs already exist, such as the GP Trailblazer programme, which places newly qualified GPs in deprived areas, and supports them through teaching and mentoring.
However, enabling previous GPs to return to work, training new GPs and supporting newly qualified GPs all take time from practices, and in the current climate, both are in short supply. Time, especially, has been identified as a key barrier to training.
Of course, GP practices are about more than GPs. A recent development to bolster the numbers of other roles in primary care was the introduction of the Additional Roles Reimbursement Scheme (ARRS). Research has found that these additional roles could have a substantial benefit, especially if they can be targeted to meet the needs of specific areas.
But as with GP recruitment and retention, hiring other staff has been challenging in more deprived and coastal areas, due to lack of weighted funding to meet the additional requirements of these areas, lack of capacity to work out how these new roles could best be used, and lack of time to support the individuals working in these roles. When additional need is taken into account, there are 14% fewer ARRS staff per 100,000 patients in the most deprived PCNs compared to the least.
There are ways in which primary care can improve recruitment and retention despite these challenges. Examples of good practice include actively recruiting from the local community, such as via local colleges or through localised training schemes. Accessing support through GP federations, local commissioners or through the GP Improvement Programme can also be helpful. But given the pressures currently facing GPs, it is unsurprising some feel caught in a vicious cycle, with insufficient time in the short term to make changes that would be of benefit in the long term.
Primary care staff shortages in deprived and coastal areas are a large and growing problem that impacts both patients and staff in these areas. There are steps the NHS can take to improve the situation, but sustained investment is needed to recognise the additional challenges in these areas, and to create the fundamental shift towards community care that the system as a whole requires.
By Saoirse Mallorie, Senior Analyst, The King’s Fund
