This report is predominately based on a major new white paper on the general practice workforce from the publishers of Healthcare Leader, Cogora. It looks at why general practice is facing both a recruitment and unemployment problem and it draws the following conclusions and makes six recommendations.
Conclusions
• There is still a major need to increase the number of GPs. Practices in England may not have the same demand for new GPs as five years ago but they would still like to see a minimum 20% increase in the GP workforce.
• Other healthcare professionals have taken on some more of the work, and this has been valuable in cases such as nurses and pharmacists working at the top of their licences. But GPs have the skill levels and capability to take on the majority of the work in general practice and, in most areas of activity, are the only professionals who can take on the clinical responsibility. An increase in GPs would also mean less activity overall, because their experience and training mean fewer follow-ups.
• This need for more GPs exists alongside a situation where there are GPs out of work. The reason there are few job vacancies is not that there is less demand for GPs’ services, but that practices lack funding and – increasingly – the premises space to house them. The ARRS has made non-GP practitioners a far cheaper option; not only are their salaries lower than those of GPs but they are largely paid in full by the NHS. These staff place more pressure on space-limited surgeries too.
• In many cases, these healthcare professionals are deployed inappropriately. Nurses and practice pharmacists report working above their correct level of clinical responsibility, and there is controversy about the responsibilities given to physician associates.
• Looking at the characteristics of practices around the country, it is also clear that clinical need isn’t the sole driver of how medical teams are configured. A lower number of GPs and clinical staff per patient is associated with higher deprivation levels, lower funding and more non-white patients.
• Furthermore, there is no suggestion that things are improving. Many professionals in general practice don’t see themselves still being there in five years’ time.
• There are national plans to improve training and retention for all healthcare practitioners in primary care, and these are essential. But these plans all fall short; the training expansion hasn’t accounted for an increase in training capacity. Meanwhile, moves to improve retention will fail if the day-to-day work in general practice is not improved, yet this can only be remedied through an expansion in the workforce.
• ICBs have tried to respond, but admit their ability to improve the problems is limited. The number of unemployed GPs should help PCNs and practices in dire need of staff with their recruitment problems. But unemployment and vacancies often don’t overlap in a geographical sense. Some GPs face moving long distances for work but many have personal commitments that prevent this – indeed, for some, the flexibility of general practice for family life was the attraction in the first place. Equally, the funding available often isn’t enough to tempt GPs to the areas of most need.
Recommendations
1. More funding
By now it is abundantly clear that the underlying crisis is one of funding, with severe knock-on effects on staffing and employment. There are staff available, and there are positions that need filling. The main barrier is the funding to pay for this. This has come from years of 2% funding increases at a time of huge inflation and more expenses. Successive governments have rarely delivered on promises to shift more funding into primary care. The one time this did happen to a significant degree – when the 2004 GP contract was first implemented – led to the modern golden age of general practice. There is no way of improving recruitment without more money. Wes Streeting’s commitment in December 2024 is welcome, but with the increase in employer National Insurance contributions and the previous below-inflation increases, it is unlikely to be enough.
2. More funding to deprived practices
The way core practice funding is distributed needs to be reviewed. Currently the Carr-Hill formula, which dictates the baseline funding each practice receives per patient, doesn’t take enough account of deprivation, despite its adverse effects on health. As a result, deprived practices have less funding than those in more affluent areas that have an older population. This increases inequalities, in part by the effect on staffing levels. There is a new major GP contract being negotiated, which is likely to be implemented in three to four years’ time – GPC England has set a deadline for implementation as ‘2028 at the latest’. This might completely overhaul the way practices are funded – potentially even move away from paying them based on the number of patients they have. Regardless, there must be a funding mechanism that passes a greater share of the budget to practices in deprived areas.
3. Remove restrictions from the ARRS
The introduction of GPs to the ARRS this year was a positive move but the effects are limited. There is uncertainty about long-term commitments and PCNs are only allowed to employ newly qualified GPs. But such restrictions no longer make sense. When the ARRS was first introduced, there was some justification for limiting the roles PCNs could employ, to protect other areas of the NHS from having staff taken away. The scheme originally promoted only those professions where there was deemed to be a surplus of staff (although community pharmacy has said that the inclusion of pharmacists has had a detrimental effect on that sector).
The time has come to give general practice owners free rein on who they now employ. Everyone agrees a strong general practice is essential for the NHS to function. If this requires a shift in staff, then so be it. There is also no reason this should be funnelled through primary care networks. It might be that practices feel this is the best way to organise themselves – but there is no reason it should be compulsory.
As well as increasing core funding and removing the restrictions on a staff reimbursement scheme, the Government should also consider increasing the proportion of the overall funding that is ringfenced for staffing costs. Governments have been reluctant to increase funding for practices in the past because they fear headlines about partners keeping the money for themselves. Increasing the ringfenced proportion would negate any such worries, and remove any concerns around increasing funding when it is necessary.
Again, Mr Streeting’s announcement around practice nurses being added to the ARRS is welcome. But all restrictions should be removed from the scheme.
4. Expand premises and encourage training
The 2024 Budget committed £100m for expanding the premises of 200 practices. How this will be allocated has yet to be decided. But the majority of GP premises need to be improved. Pre-2015 buildings didn’t take into account the expansion of non-GP roles that began around then; many practices are unable to accommodate new staff, whether that be GPs, nurses or other healthcare practitioners.
This has implications for long-term plans to increase the workforce, especially in terms of training. Training of any staff can’t take place without the physical space. But alongside this, fresh incentives are needed for experienced staff to become trainers. Again, this may only be possible when the workforce is increased.
5. Promote general practice as a flexible career
It is true that one big reason for the fall in numbers of fully qualified full-time equivalent GPs is that more are working less than full time. But instead of seeing this as a weakness, all parties need to see it as a strength. The way to mitigate a shortfall of full-time GPs is to have a greater number of GPs coming into the system, and an effective way of doing this is to actively promote the positive elements of the job, such as flexible working.
Such a strategy might have implications for continuity of care. But continuity has been most affected by the lack of fulltime GPs. With enough GPs – even working less than full time – strategies can be put in place to promote continuity. But without sufficient numbers, continuity will be impossible.
6, No short cuts
These proposed measures may seem obvious, and the biggest question is undoubtedly where the necessary funding will come from. But there are no short cuts to improving general practice workforce problems. Minor initiatives are no doubt well meaning, and may well bring about positive changes for a small number of practices. But they will not address the structural issues around the general practice workforce.
The fact that we have a recruitment problem and an unemployment problem running in tandem should be seen as a positive, because it provides fresh hope that we do have the staff available. But solving these twin crises will require a comprehensive, properly funded strategy. The time for sticking plaster initiatives is over.
This report is based on 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.
