Workforce challenges in general practice are not a new issue but the current recruitment crisis has been a particularly long one. Before the Coalition Government came to power in 2010, the main issue was a reduction in the number of GP partnerships available after the implementation of the 2004 contract, and there was no problem with filling vacancies.
This started changing around 2011 to 2012, with reports of practices – particularly outside London – struggling to recruit. The health secretary at the time, Andrew Lansley, announced plans in 2011 to increase GP training places by 20% to counter these problems.
But by 2015 this had become a full-blown crisis. Lansley’s successor Jeremy Hunt announced a 10-point plan to increase GP recruitment, which included a £10m fund to turn around struggling practices, incentive schemes to attract GPs to under doctored areas and a marketing campaign to promote a career in general practice.
Notably, it also included the now infamous commitment to increase the GP workforce by 5,000 within five years, as well as a promise to increase the number of non-GP healthcare professionals.
Sajid Javid, who became health secretary in 2021, made similar commitments, with a £250m winter fund to boost GP access, which allowed commissioners to fund practices to recruit locums and non-GP healthcare staff. But this came with targets around face-to-face appointments, which were unwelcome within the profession.
Increase in GP trainees
However, despite the difficulties with personnel and workload, the total number of GPs is steadily increasing. This is partly due to governments’ undoubted success in increasing the number of GP trainees through Health Education England, which was later incorporated into NHS England.
The NHS has also looked to recruit trained GPs from abroad. The latest GMC statistics show 23% of fully trained GPs are from overseas.
That all said, the overall story in terms of GP numbers is one of continuing failure. The pledges made by Hunt and Javid were not around GP headcount – they were based on fully trained full time-equivalent (FTE) GPs. By these measures, their governments failed miserably.
The fall in the number of FTE GPs alongside an increase in GP headcount is partly explained by GPs working fewer hours.
According to NHS Digital figures, GPs are increasingly working less than 37.5 hours per week. This is more or less in line with sister title Pulse’s September 2024 survey, which showed GPs are working an average 35 hours per week, and just under six sessions.
There are a number of reasons for this. It is too simplistic to attribute the trend of working less than full time (LTFT) to the rise in the proportion of female GPs which GMC research has shown more commonly work LTFT – although there is a rise in the total percentage of headcount GPs who are female from 52% in September 2015 to 58% in November 2024.
Indeed, one statistical analysis concluded it was ‘mainly a result of male GPs reducing their contracted time commitments’. This trend shouldn’t be too surprising. NHS England has actively promoted the merits of more flexible working, highlighting how GPs can pursue more portfolio careers, including stints in different healthcare settings and academia, as well as work with regulators, medical examiners and in a number of other roles.
But a bigger reason for this shift is more likely to be the increasing intensity of general practice sessions, which has forced GPs to – as the GMC puts it – ‘take matters into their own hands’ by reducing hours to improve their own wellbeing and reduce potential risks to patient care.
Regardless of the reasons for greater LTFT working, it has resulted in fewer fully qualified FTE GPs. To compound matters, this has come at a time of increasing patient numbers. This leaves the ratio of GPs to patients well below that called for by professional bodies.
The BMA has set out an aim to have one FTE GP per 1,000 patients by 2050. In 2009, there were 1,520 patients per GP19; that figure is now more than 2,100.
This compares poorly with other developed countries, with the UK having 16% fewer GPs per patient than the Organisation for Economic Co-operation and Development average.
Rising patient demand
Not only are patient numbers per GP increasing, but the demand per patient per year is increasing as well – a trend that began before the Covid-19 pandemic.
Governments have tried to ease this demand through initiatives such as Pharmacy First, and they have also expanded self-referral for patients, allowing them to bypass GPs for certain requirements such as podiatry, hearing tests or incontinence advice. It might be too soon to assess the effect on patient demand of such initiatives but so far they don’t seem to be working, with GP appointment numbers continuing to increase.
Successive Conservative administrations did acknowledge their failure to increase GP numbers. But at the same time as their ineffective recruitment initiatives, ministers and the NHS were pursuing a parallel policy for which they were far more successful in achieving their stated aims.
Around the middle of the last decade, ministers and the NHS began to pivot towards multidisciplinary working. While it is likely that this would have happened anyway, the shortfall in GP numbers made the need far more pressing.
Before 2015, the typical practice comprised GPs and nurses who provided almost all the clinical work, with the practice administration carried out by a manager and reception staff. But in the early 2010s, the idea of other healthcare staff taking on clinical work became more prominent, most notably through then RCGP chair Professor Clare Gerada.
In 2014, NHS England launched its Five Year Forward View, which recommended that GP practices become ‘multispecialty community providers’, that would employ ‘senior nurses, consultant physicians, geriatricians, paediatricians and psychiatrists to work alongside community nurses, therapists, pharmacists, psychologists, social workers, and other staff’.
Additional roles reimbursement scheme (ARRS)
In 2015, the first concrete policy change came in, with a £15m scheme for GP practices to employ pharmacists. This was turbocharged in 2019 by the new GP contract. Through the additional roles reimbursement scheme (ARRS), practices were incentivised to join ‘primary care networks’ (PCNs), groups of practices that would mainly cover populations of 30,000-50,000 patients.
The contract committed £938m of extra funding per year by 2023/24, with a total of £1.79bn directed towards the new PCNs, predominantly through the ARRS.
This scheme funded the recruitment of non-GPs to general practice, with the five-year 2019 contract providing pharmacists (building on the earlier scheme) and social prescribers in the first year, followed by physiotherapists, physician associates and paramedics in later years.
Since then, the ARRS has been expanded to include occupational therapists, dieticians podiatrists and mental health practitioners among others, with newly qualified GPs added in 2024 by the new Government. While the number of FTE GPs has gone down, the total number of practice staff has increased, mainly due to the influx of non-GP healthcare professionals. At the same time, practice nurse numbers have been rising at a steady rate.
The addition of clinical staff who are not GPs or nurses, and a huge increase in administrative staff, has led to more people than ever before being employed in general practice.
Of course, there are caveats to this – since the introduction of the ARRS, we have gone through Covid and a major economic downturn. But this has been the key policy for all recent health secretaries and NHS England, and it is likely this would have been the direction of travel regardless of these disruptions.
There has been an obvious effect on provision of patient care. In 2024, for the first time, only half of appointments in general practice were with GPs.
This shift is likely to continue, with many ARRS staff being upskilled. For example, from 2026, all new graduate pharmacists will be qualified to prescribe.
But there are two burning questions around multidisciplinary working. The first is whether the roles are clinically appropriate – and safe – for the tasks associated with them.
Here, much of the debate has focused on the role of physician associates (PAs). The RCGP and BMA are united in wanting to limit their scope of practice to exclude tasks that should be done by fully trained GPs, such as managing undifferentiated patients. But PAs do not have a huge role in general practice, making up a fraction of the workforce.
The NHS workforce plan commits to expanding their number to 10,000 by 2036 without saying how many will be in general practice. Importantly, health secretary Wes Streeting has launched a review into the role. This question becomes more relevant when looking at the more established roles. A survey by sister title Nursing in Practice revealed that nurses feel they are taking on responsibilities way above the levels they should be within multidisciplinary teams.
Asha Parmar, an advanced care practitioner in London, points to covering two practices with populations of 10,000 and 5,000: ‘All the liability of all things nursing relies on you – immunisations, infection control, smears, diabetic physical checks, wound dressings, stock, fridge responsibility.’
The knock-on effects of secondary care pressures – and gaps in ICBs commissioning certain care – are also adding to complexity. A practice nurse in South Yorkshire says: ‘We do have fewer breaks. This is for various reasons, partly because chronic disease reviews are now more complex due to multimorbidity, socio-economic and mental health problems impacting increasingly on health, and more options in terms of medical and lifestyle management to discuss. We also have had an increase in workload that used to be absorbed by secondary care – for example, wound care.’
The effectiveness of ARRS staff
The second burning question is less concerned with patient safety than the usefulness of ARRS staff. It is still too early for long-term studies on the effectiveness of the scheme. But for many GPs, even established staff are often not effective in easing workload, especially as they may need GP support in consultations. One GP partner in Salford says: ‘Apart from pharmacists and perhaps physios, I feel the ARRS funding has been a massive black hole that swallows huge amounts of GP funding for roles such as social prescribers that make little difference to workload.’
Others say ARRS staff can often increase workload. A GP partner in Warwickshire says: ‘I don’t want an advanced care practitioner on a high salary seeing a patient every 15 minutes for a single issue when I’m still legally responsible for them even though I’ve not seen their patients.’ The partner says the PCN-employed ACP is very competent, but ‘can’t prescribe and asks to review five patients a day with a GP’, adding: ‘I want a GP who can deal with complex cases, triage effectively, see non-differentiated patients safely.’
Another GP in a deprived area agrees: ‘ANPs are helpful but can often add another step to the management of a patient. Although a GP appointment can be more costly, it can mean fewer appointments are needed to sort out a problem, so money can be saved in the long run.’ The capabilities of ARRS staff are not uniform.
Furthermore, it is misleading to suggest these new staff are ‘free’ for practices. The funding for the ARRS doesn’t go directly to the practice, but to the PCN. A survey by sister title Pulse PCN of 276 GPs who have a say in their PCN’s decisions, found a mix in how ARRS staff are distributed across a network’s member practices.
And in exchange for this funding, PCNs – through their member practices – have to take on more work, such as enhanced care for care home residents. A practice manager in Yorkshire says: ‘We do have access to some ARRS staff including ANPs and paramedics. But in our view the vast sums spent on the ARRS care home team vastly outweigh the need – in cost terms, the money is wasted and would be better spent on our wider patient population by practices rather than PCNs employing GPs through core funding.’
The nature of the ARRS funding also means staff may not have the same commitment to a practice and, being part of the PCN, are less likely to be truly embedded in the practice.
A nurse team lead in the north of England says: ‘ARRS staff seem to be unaware of the QOF [Quality and Outcomes Framework, a scheme that incentivises practices to achieve set clinical goals] and its impact on practice finances. This makes the nurse team feel demoralised as we have to chase information to achieve QOF and bring in money. [ARRS staff] are less likely to be impacted by a poor QOF achievement as they’re not paid by the practice.’
Recruitment of key roles
With these two issues of safety and utility, the ARRS presents problems to practices. Practices do want to recruit certain staff – particularly GPs, nurses and pharmacists (even with concerns around cost-effectiveness for the latter two).
A joint survey from sister titles Pulse and Management in Practice found practices would like a 19% increase in the number of GPs if recruitment issues were not a problem. Furthermore, only 35% of practice managers said they had no need to hire GPs. There are many caveats to this. The main one is that, due to the problems of the past 10 years, many practices have given up on recruiting GPs, with their work absorbed into the team.
But there is little doubt about the demand for pharmacists and nurses, with a shortfall of 47% and 29% respectively. One practice manager in Humber and North Yorkshire says: ‘We’ve been working to invest in our pharmacy team to relieve GPs from prescription admin and medication reviews. But clinical pharmacists and pharmacy technicians are like hen’s teeth.’
A practice manager in Blackpool says they can’t afford to match salaries for nurses and pharmacists. ‘We currently have four practice nurses; they do the bulk of our chronic disease management and are worth their weight in gold. Nurses are particularly difficult to recruit, mainly because the local out-of-hours provider pays significantly more than we can ever offer. We had an advert out for a pharmacist for six months without a single applicant. Ideally four pharmacists would work for us.’
This competition leaves practices and PCNs vulnerable to them leaving. A GP partner in the Home Counties says: ‘We have taken on several ARRS paramedics and clinical pharmacists, spent two to three hours per week of my time training them in the ways of primary care, only to have them leave for jobs in other PCNs.’
Dr Bethany Anthony, a research officer at Bangor University who wrote a paper on the ARRS, says: ‘There was some evidence that substituting GPs with nurses for common minor health problems is cost-effective. A separate qualitative systematic review uncovered a number of barriers and facilitators to pharmacists and PAs providing general medical services instead of GPs.’
For the individuals working in general practice the effects are even greater – and this is having sector-wide consequences.
Deprived practices
The issues around recruitment and unemployment are not uniform across the country. The local changes faced in an area – whether that be GPs out of work or problems with recruitment across professions – depend on a number of factors, such as geography deprivation and funding levels.
An analysis of data on every GP practice in England, using our publisher, Cogora’s ‘Data Dashboard’ tool, highlights these differences. A striking finding is that practices in more affluent areas have a higher number of GPs and clinical staff per patient than those in the most deprived areas. Linked to this are vast differentials in staff based on ethnic population.
Being located in a deprived area brings up a number of challenges for practices. The first is the health needs of the patient population. Even without including issues around access to healthcare, it is ‘well established that deprivation… is associated with poorer health, including mental health’ and patients in deprived areas are more likely to develop ‘serious mental illness, obesity, diabetes and learning disabilities’. Patients in the most deprived areas face the onset of multimorbidity 10-15 years earlier than those in the most affluent areas.
Practices in deprived areas attest to the problems around health needs (which are exacerbated by a lack of support services). A practice manager in Blackpool says: ‘A large portion of our patient list has chronic diseases due to smoking, obesity, drug and alcohol abuse, etc. I believe Blackpool has the highest drug-related death toll in England. It is particularly difficult to manage these patients when they have poor living conditions, little money and no motivation to change their ways to improve their health. Our GPs, pharmacists, nurses and other staff all provide patient education to these patients, but we would ideally like to have more time with them. More GPs, nurses and pharmacists would mean we can bring them in more frequently and give them education on their illness and how to manage it.’
A GP in a deprived area of Hampshire says: ‘We are by far the most deprived practice in our area, with a very young population, poor mental health and long-term conditions from a young age.’
This is where another problem for deprived practices comes in. The same GP adds: ‘The town in general is relatively wealthy, but we cover three large estates of social housing. Our demographics have a significant part to play in our lower funding, which results in a low weighted list and thus lower remuneration.’
Because, despite these extra health needs, deprived practices do not necessarily get paid more – and, in many cases, their deprivation leads to lower funding. The Carr-Hill formula was introduced in 2004 to calculate how much practices would receive per patient in the form of the ‘global sum’ – this forms the bulk of a practice’s income. The formula is based on patient age and sex, list turnover, rurality and ‘staff market forces factor’, which is based on geographical variations in staff costs. Deprivation is not an explicit factor. There is another element – ‘additional needs of patients’ – which looks at mortality and illness before the age of 65 and does, to an extent, benefit deprived practices.
But these additional needs are based on data from before 2000. As deprived practices tend to have younger populations, they often end up with lower-than-average global sums.
On top of this, practices receive income for extra services, such as via the QOF, which rewards performance against national clinical benchmarks, and enhanced services, which can be locally or nationally mandated. But the targets are harder to meet for practices in deprived areas. For example, one of the main sources of income is vaccination, which brings in money from the QOF and enhanced services. For childhood vaccinations, there are step increases for the final patients within the cohort they vaccinate. But for these practices, that is far harder to achieve.
Their populations are more transient, more likely to have received their vaccinations overseas and more likely mistrust vaccination, especially minority ethnic families.
An analysis of the Cogora Data Dashboard shows that practices with the top 20% most affluent patient populations receive £137.17 per patient (not including premises costs) compared with £135 for the 20% most deprived patient populations. This has been a problem highlighted constantly in the 20 years since the pivotal 2004 GP contract was introduced, most recently by the Nuffield Trust.
As well as specific health needs, and often lower income, deprived practices face another recruitment problem – they need to pay more to attract staff. One GP in Leicester says: ‘I think it has been forgotten that the inner city is a completely different world to the suburbs. Certainly in our region, inner-city practices often have to offer higher salaries to attract staff like practice nurses, pharmacists and GPs. Hence there is less funding for other aspects and these higher-funded staff may in some cases be less committed to long-term improvements of inner-city practices.’
Recruitment problems bring other costs. The Hampshire GP says: ‘We have struggled to replace a retiring partner but after over a year of advertising, finally recruited a partner. The lack of response to the usual adverts (before the current GP unemployment crisis) led to us needing to use agencies, resulting in high fees. We interviewed good candidates, who became salaried GPs rather than partners, but each appointment cost thousands of pounds, including locum fees. Some applicants specifically stated they wanted a more wealthy clientele.’
There is an even stronger correlation between a practice’s funding per patient and its staffing levels, with those who receive the least funding having far lower levels of staffing.
This is more explainable than the correlation between deprivation and staffing; the Carr-Hill formula is supposed to provide more funding for practices with greater demand, so in theory lower funded practices should have less need for staff.
But challenges not fully accounted for by the funding formula – including deprivation – cause particular problems with recruitment.
One GP partner, whose practice is in the bottom 20% when it comes to practice funding per patient, says: ‘We used to use a remote pharmacist to support the practice when one of us was on leave (we have never 100% backfilled GP sessions as it has never been affordable).
‘We now no longer do this, so when a colleague is on holiday, in addition to busier days, I have to do two hours or more in the evenings for repeat prescriptions. We took this decision after our profit share was down approximately £20,000 per partner from March 2022 to March 2023 (in hindsight, 2021-22 was artificially bolstered by Covid jabs).’
Lack of funding
There is both a shortage of GPs in the system, and a shortage of jobs for GPs, which could be seen as a ludicrous situation.
Practice managers say there are two reasons for this, and the ARRS touches on both. First, there is a lack of funding; second, practice premises are often inadequate to accommodate GPs.
In 2019, as part of the five-year contract, the BMA GP Committee and NHS England agreed to set annual increases of around 2% a year. At the time, many saw this as helpful for GPs – and there were even suggestions that other parts of the NHS were envious.
Up until 2021/22, GP practices were seeing a real-terms increase in funding. Part of this would have been the money they received for carrying out Covid vaccinations. But 2022/23 saw a real-terms funding decrease.
Since then, we have seen huge inflation and the cost-of-living crisis, yet the funding uplift remained at around 2% a year. This means that there has been a drastic cut in practices’ real-terms funding. The Labour Government’s first Budget has exacerbated matters with the increase to employers’ National Insurance Contributions (NICs), which was intended to raise money for the NHS. GP practices were considered the big losers in this policy; they were not guaranteed public funding from the increase because they were considered ‘private sector’, yet GP practices do not benefit from tax breaks for smaller businesses because they are considered ‘public sector’ for this purpose.
Since then, Wes Streeting has announced the increase in funding of £889m a year – roughly 6%. This funding has been welcomed by the profession, although cautiously. The Cogora white paper analysis suggested the increase in National Insurance will cost practice £260m. Furthermore, the details of how the funding will be provided to practices – and, crucially, what extra work they will be expected to do – won’t become clear until 2025/26 contract negotiations with the BMA’s GP Committee England are concluded.
But practices are currently facing a funding squeeze that has the effect of making ARRS staff look more attractive, even if the available roles are not the most appropriate for patient care.
These staff are not only paid lower salaries but their costs are at least partly reimbursed by the NHS.
Dr Ian Sweetenham, a GP partner in Cambridgeshire, says: ‘We couldn’t find GPs two years ago. Now that I have them coming out of my ears, I have no money to employ them.’
The general practice funding shortfall leaves practices facing unwelcome decisions. Around 6% of practices said they have had to make redundancies, while a further 20% said they had to decide not to replace departing staff.
This is affecting care. A GP partner in Leicestershire says: ‘As a practice we are always short of appointments, patient demand is tremendous. However, purely for financial reasons and the fact that the practice is struggling to function at a profit, when our three – session salaried GP resigned we made the decision not to replace them. Instead, we decided to try to manage as best as we could without these sessions. This was in spite of the fact that when we advertised to recruit a replacement for another departing GP in the last year, we had more than 20 applicants so would have had no difficulty finding a good-quality candidate to fill the sessions had we chosen to.
‘In addition to this, we have also chosen not to replace two reception staff members who left – again, in the hope to save money. I reiterate, not for profit, but hoping to break even.’
In this context, cheaper non-GP staff look more attractive. One GP partner in Buckinghamshire said their practice had to ‘restructure [to] keep our doors open and allow us to continue to provide a service including not replacing all the clinical sessions a retiring GP used to offer. More GP sessions are being replaced by cheaper clinicians’.
GP pay is often highlighted when practice funding is under scrutiny. In 2022, following such scrutiny, the Government amended the GP contract so that partners earning more than £150,000 would be forced to declare their earnings. But simply reducing earnings would not enable them to hire more GPs.
The GP partner from Warwickshire says: ‘I earn good money as apart-time partner, and there’s an argument that my partners and I could earn less and there would be money for another GP.
‘However, it isn’t as simple as that. We’re being offered two days of an advanced care practitioner anyway by the PCN, and it seems silly not to use this. One of our nurses has just completed her ACP training, so we’ll have her for another two-and-a-half days. I’d rather have another GP, but we’re reluctant to have both. We’re unsure what Wes Streeting plans for general practice, and we don’t want to commit to another GP unless we know our funding will continue at the same level.’
Lack of premises space
Even if practices did have money, the state of GP premises often means there is nowhere for additional staff to practise. GP premises are in dire need of modernising – a major 2023 RCGP report found they were ‘inadequate’, concluding that the allied healthcare professional staff had ‘expanded greatly in recent years, without a parallel expansion of clinical space for them to work in’. While the Budget in November 2024 did commit £100m to modernising GP premises, it specified that this would be limited to 200 surgeries.
One GP in Northamptonshire says: ‘We do not have anymore space in our building to recruit additional clinical or administrative staff, and this has led to us running at a far higher number of patients per FTE staff that we would ideally have. In our recent round of recruitment to salaried GP roles, we had many more suitable candidates that we have the space to employ and undertook competitive interviews to select our current employees including ARRS-subsidised recently qualified GP roles.
‘We really need to find an additional or alternative site but options for funding this are limited or unattractive. We already undertake remote working where it is possible to do so safely, and most of our ARRS staff are based in other GP surgery buildings within our PCN. Some clinical rooms are even shared between clinical staff within a session, with a staff member using a room while another has left to undertake a care home round.’
This is a common problem. Dr Grant Ingrams, chief executive of Leicester, Leicestershire and Rutland LMC, says his practice ‘has GPs working from home at times but there are continued problems finding space for people to work from’. Another GP in West London says they ‘could certainly do with additional nurses but are already struggling with space for existing staff, who are having to cope with hot-desking’. A GP partner in Lancashire says: ‘In 2023, we changed some storerooms into additional clinical rooms and we still don’t have enough space. We have no expansion land as the NHS sold it off years ago. We have nowhere else to go to get more rooms. This impacts who we can hire and what days they can work, as we find clinicians have to room-share or change rooms daily depending on who is in.’
This chapter is part of a major new white paper from the publishers of Healthcare Leader, Cogora, on the changing general practice workforce in England, in conjunction with the Rebuild General Practice campaign group. Alongside our sister titles – Pulse, Pulse PCN, Management in Practice, Nursing in Practice and The Pharmacist – we have surveyed around 2,500 general practice professionals, interviewed more than 100 frontline practitioners, analysed hundreds of data for every practice in England and brought together all the editorial expertise within our titles.
Download our General Practice Workforce White Paper here.
