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Chapter 2: General practitioners

Chapter 2: General practitioners

By Kathy Oxtoby
9 March 2023

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May the workforce be with you
What primary care wants
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about What primary care wants

Chapter 1
Integrated care boards
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about Integrated care boards

Chapter 3
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about Pharmacists

Chapter 4
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about Dentists

Chapter 5
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about Optometrists

Chapter 6
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about Nurses

The End
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about Conclusion

GP practices across the country are experiencing significant and growing strain, with declining GP numbers, rising demand, difficulties in recruiting and retaining staff, and knock-on effects for patients, according to professional bodies.

Professor Kamila Hawthorne, chair of the Royal College of GPs (RCGP), says: ‘GPs and our teams are working to our limits to deliver safe, timely and appropriate care – often increasingly complex care – to the growing numbers of patients that need it.’

The reality of this ‘overstretched, under-resourced, and understaffed service’ means that ‘GPs and our teams are buckling under unsustainable and unrelenting pressures. It’s leaving many GPs exhausted, burnt out, and facing little choice but to evaluate their future in NHS general practice’, she says.

While there are ‘more GPs in training than ever before’, given that it takes ten years to train a GP and when more are leaving the profession than entering it, ‘we’re fighting a losing battle’, says Professor Hawthorne.

A recent RCGP survey estimated that the profession could lose up to 15,000 GPs from the workforce in the next five years, with many citing burnout, workload, and being unable to deliver the patient care they are trained to provide as their reasons for considering leaving.

According to the BMA, the overall number of GPs has seen little growth since 2015, with the number of GP partners declining significantly over that time.

In February 2020, in a bid to reverse the stasis in GP workforce numbers, the government announced a drive to recruit an additional 6,000 GPs by 2024. ‘Yet despite these promises, as of November 2022, there is now the equivalent of 1,973 fewer fully qualified full-time GPs compared to September 2015, when current records began,’ says Dr Kieran Sharrock, acting chair of the General Practitioners Committee England.

To tackle the workforce crisis, Dr Sharrock says: ‘We have to make the NHS a place where people want to work, and where they feel valued.’

He says the BMA is ‘ready to engage with the Government and NHS England about how to devise a thorough plan for the future of general practice, including looking at how to retain and recruit more doctors’.

‘Investment will make the NHS an attractive place to work, encouraging more people to join and stay. Investment means repairing dilapidated NHS estates, recruiting more staff so every practice has access to a strong multi-disciplinary team for workload sharing, and solving long-term issues like failing IT infrastructure.

‘Bureaucratic targets, oversight and scrutiny from regulators, paperwork which takes doctors and their teams away from patient care, and negative rhetoric in the press cause morale to be low and make clinicians want to leave,’ he says.

At a local level, Dr Sharrock says integrated care boards (ICBs) ‘must make sure they prioritise tackling these challenges and the wider difficulties facing general practice within their upcoming five-year plans’.

‘Solving the workforce crisis also means addressing punitive pension taxation, which is driving talented doctors away from the NHS unnecessarily,’ he says.

The BMA has been involved in helping to design GP recruitment schemes – for example, the Targeted Enhanced Recruitment Scheme, done in conjunction with NHSE and other organisations. This scheme aims to attract GP trainees to work in places where it is traditionally hard to recruit, like rural areas.

‘With the number of GPs plummeting, it’s clear that we need more than this to recruit and retain doctors, which is why the Government must address the wider issues in the NHS as a matter of urgency,’ says Dr Sharrock.

He says there is a GP retention scheme headed up by NHSE, ‘but again, this simply isn’t enough to retain the workforce – people are still leaving in their droves’.

Doctors need to be enabled to work in a ‘safe environment where their workload is manageable, and they feel supported’, says Dr Sharrock. ‘ICBs should also be exploring how they can find local solutions to keep GPs working in their areas, including developing escalation plans in which excess work is absorbed by system working. ICBs must ensure GPs have a strong voice on local decision-making boards.’

Professor Hawthorne says the Government ‘must act to turn the tide on decades of underinvestment and poor workforce planning by devising and implementing a recruitment and retention strategy that goes beyond its manifesto pledge of 6,000 more GPs’.

‘This should include an evaluation and revamp of existing retention schemes to ensure every GP can access tailored support to stay in the profession,’ she says.

The RCGP also wants funding for general practice returned to 11% of the total NHS spend, investment in IT systems and premises, and steps to cut bureaucracy so GPs can spend more time with their patients.

In its The state of medical education and practice in the UK workforce report 2022, the GMC proposes removing the barriers preventing specialty and associate specialist (SAS) and locally employed (LE) doctors from fulfilling roles within primary care.

Charlie Massey, GMC chief executive, says reforming the rules so skilled doctors in non-training roles can work in primary care would be ’a step in the right direction’ to stem the flow of doctors leaving the profession.

‘Making these changes will not only improve doctors’ wellbeing, but also what they can deliver for patients. If doctors are happier in their working environments, they will achieve better results, which is in the best interests of patient safety.’

The BMA calls on the government to urgently address the workforce crisis in general practice and the wider NHS ‘to ensure we are properly resourced to do this’, says Dr Sharrock. ‘The foundation of this is making the NHS a place where people want to work, and that means properly valuing staff and equipping them with the tools they need to give patients the timely and safe care that they need and deserve.’

The numbers

GPs on the GMC register UK: 70,988*

GPs on the GMC register England: 58,877*

GPs in England (NHS):  36,488 headcount (Jan 23)

GPs full-time equivalent (FTE, 37.5 hours a week): 27,287 (Jan 23) 

GP partners FTE: 16,500 (Dec 2022)

Salaried GPs FTE: 10,000

Locum GPs FTE: 700

Qualified GPs in training UK: 3,348 (GMC March 23) 

Qualified GPs in training England: 2,837 (GMC March 23)

Training to be a GP: 15,177 across 2022 (GMC March 23)

According to the BMA, as of January 2023, there is the equivalent of 2,078 fewer fully qualified full-time GPs compared to the September 2015 baseline (when the current collection method began).

The BMA states that over the last year, the NHS has lost 402 individual (headcount) GP partners and 244 salaried, locum and retainer GPs. This has created a net loss of 646 individual GPs since January 2022. In FTE terms of 37.5 hours per week, this amounts to an equivalent loss of 470 full-time fully qualified GPs in the last year alone.

Health Education England (HEE) recently published data on GPs in training (23 November 2022), stating that more than 4,000 new trainees have accepted placements to join the profession. HEE says that NHS Digital figures show 9,628 GPs in training grade in GP placements across England as of September 2022.

*These figures include all GPs, including those working in an ad-hoc locum role and the private sector. Additionally, some doctors may be both on the GMC specialist register and the GP register, but only working in their specialist capacity, so may not appear in the NHS figures for GPs.

Sources: NHS Digital and BMA

Training and pay

A medical degree typically takes five years. After medical school, graduates will complete a two-year foundation programme. Graduates can then decide what they would like to specialise in, including general practice. GP specialty training typically lasts three years so, on average, it takes 10 years to train a GP.

There are several different ways GPs can train to work in the NHS. GP specialty training is the most common route into the profession in the UK. After their foundation training, medical graduates then decide their speciality, one of which is general practice. GP clinical training takes three years to complete

There are GP trainee schemes across the country, with many practices offering placements for graduates. Existing doctors who want to switch their specialty, or those wishing to return to practice can also go via the GP speciality training route.

GPs can also work in the NHS via combined training or, if they already hold a European qualification in general practice or family medicine, by applying directly to the GMC. GPs can also work in the NHS via a certification of eligibility for GP registration.

Contractor income has eroded by 9% since 2008/09 compared to 2020/21. However, there was an isolated spike in net income for 2020/21, which reflected the monumental efforts that GPs made to the pandemic response and their leading role in vaccinating the nation as they received additional short-term and temporary emergency Covid response funding given to practices to enable them to deliver the vaccine programme.

Without the isolated spike, income would have eroded significantly more. As Government data shows, it also came after real-term pay cuts in GP income over the previous 15 years.

Likewise, salaried GPs’ pay has eroded by around a fifth between 2008/09 and 2020/21. They may have seen their working hours or arrangements impacted by the pandemic as services were reconfigured – regional variations, workforce supply and demand impacted their income.

To learn more about general practice, visit Healthcare Leader’s sister title Pulse.

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