Performance Tracker 2022: General practice

The pandemic affected general practice in different ways as it progressed. In the early stages, GPs conducted far fewer appointments as patients stayed away from the NHS. Then, during the rollout of the Covid vaccine, they played a key role delivering doses in their communities. Now, into the third year of the pandemic, general practice is attempting to cope with a huge surge in demand, as many of those who stayed away come forward for care. The level of pressure on an already overstretched workforce is immense: GPs delivered more appointments in 2021/22 than in any year on record.

Despite this increased activity, there is evidence that many people have tried but failed to book an appointment, contributing to increasing public dissatisfaction with the service. Those appointments that did take place were delivered in different ways, with a large proportion being carried out over the telephone. The outcomes of appointments also changed: referrals from general practice to secondary care dropped during 2019/20 (before the pandemic) and remained below pre-pandemic levels in 2020/21 and 2021/22. Despite a recruitment drive that has increased the number of GPs in training contracts and brought a large and rapid expansion of the wider primary care workforce, the combination of growing demand, additional responsibilities and new ways of working is worsening stress and burn-out, in turn contributing to a deteriorating retention of GPs in primary care.

Covid costs have driven high spending in general practice

Spending on general practice in 2020/21 was 35.5% higher in real terms including Covid costs, and 31.7% higher in real terms excluding Covid costs, than in 2009/10. ¹⁹³ NHS England, Investment in General Practice in England, 2016/17 to 2020/21, 12 May 2022, retrieved 27 September 2022, www.england.nhs.uk/publication/investment-in-general-practice-in-england-2016-17-to-2020-21 The increase in spending in 2019/20 and 2020/21 followed the launch of the NHS Long Term Plan, in January 2019, which aimed to increase spending on general practice and community health services by at least £4.5 billion by 2023/24 ¹⁹⁴ NHS England, NHS Long Term Plan, 7 January 2019, p. 14, www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf – a target that NHS England is currently on track to meet, even when excluding additional Covid spending.

NHS England spent £704.8 million on Covid measures in primary care in 2020/21. ¹⁹⁵ NHS England, Investment in General Practice in England, 2016/17 to 2020/21, 12 May 2022, retrieved 27 September 2022, www.england.nhs.uk/publication/investment-in-general-practice-in-england-2016-17-to-2020-21 Of this, £333.8m related to the Covid vaccination programme, where GPs carried out a greater proportion of vaccinations than forecast and more affordably than dedicated vaccination centres – the average cost for each dose was £24 and £34 respectively. ¹⁹⁶ Comptroller and Auditor General, The Rollout of the COVID-19 Vaccination Programme in England, Session 2021– 22, HC 1106, National Audit Office, 25 February 2022, p. 7, www.nao.org.uk/wp-content/uploads/2022/02/The-rollout-of-the-COVID-19-vaccination-programme-in-England.pdf The remaining £371m included funding for measures such as opening on bank holidays, personal protective equipment (PPE) provision and an enhanced flu vaccination scheme. ¹⁹⁷ NHS England, Investment in General Practice in England, 2016/17 to 2020/21, 12 May 2022, retrieved 27 September 2022, www.england.nhs.uk/publication/investment-in-general-practice-in-england-2016-17-to-2020-21 It is currently unclear how much NHS England will need to continue spending over the coming years to deal with ongoing Covid pressures in general practice.

Spending on staffing has also driven increased expenditure

Spending on primary care organisations – a category that includes recruitment, retention, locum payments and seniority payments in general practice ¹⁹⁸ General Practitioners Committee, Focus On…..How Your Practice is Funded, January 2009, p. 6, www.mysurgerywebsite.co.uk/website/IGP217/files/65%20How_your_Practice_is_Funded.pdf – increased 21.7% a year in real terms on average from 2018/19 (the last year before the NHS Long Term Plan came into effect) to 2020/21. ¹⁹⁹ NHS England, Investment in General Practice in England, 2016/17 to 2020/21, 12 May 2022, retrieved 27 September 2022, www.england.nhs.uk/publication/investment-in-general-practice-in-england-2016-17-to-2020-21 This was partly to support the government’s ambition to have a further 26,000 primary care staff ²⁰⁰ NHS England, ‘Expanding our workforce’, (no date) retrieved 27 September 2022, www.england.nhs.uk/gp/expanding-our-workforce and 6,000 GPs ²⁰¹ Iacobucci G, ‘Tories promise 6000 extra GPs by 2024’, BMJ, 2019, vol. 367, retrieved 27 September 2022, www.bmj.com/content/367/bmj.l6463 by March 2024, which would represent a 17.4% increase in the total number of GPs, compared with March 2019. ²⁰² NHS Digital, ‘General Practice Workforce, England, Bulletin Tables, 31 July 2022’, 25 August 2022, retrieved 27 September 2022, https://files.digital.nhs.uk/6F/703A43/GPW%20Bulletin%20Tables%20-%20July%202022.xlsx

Demand for general practice is reportedly high, but difficult to quantify

Demographic changes continue to push up demand for primary care. The population in England grew by 0.5% between 2019 and 2020, with the population aged 65+ growing by 1.2%. ²⁰³ Office for National Statistics, ‘Estimates of the population for the UK, England and Wales, Scotland and Northern Ireland’, 25 June 2021, retrieved 27 September 2022, www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/populationestimatesforukenglandandwalesscotlandandnor… Adjusted for age- and sex-based factors, demand for GP services is estimated to have risen 0.6% in 2022 compared with 2021, due to purely demographic factors. ²⁰⁴ Department of Health, Resource Allocation: Weighted capitation formula: Seventh edition, 2011, p. 61, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/216320/dh_124947.pdf

However, this projection is unlikely to represent true levels of demand since the pandemic. Interviewees and anecdotal reports indicate that primary care is facing more demand than ever, although this is difficult to quantify: NHS England records the numbers of appointments that GPs and other primary care staff carry out, but not how many people try but fail to book an appointment.

However, surveys of patients registered with a GP practice indicate that unmet demand is substantial and has increased. In the annual GP Patient Survey, only 56.2% rated their experience of making an appointment as ‘good’ or ‘better’ in 2022, down from more than 70% in 2021. And among those who avoided making a GP appointment in 2022, 26.5% did so because they found it too difficult, up from 11.1% in 2021. ²⁰⁵ NHS England, GP Patient Survey 2022, July 2022, retrieved 27 September 2022, www.gp-patient.co.uk/surveysandreports

The survey indicates that, overall, satisfaction with the service that general practice teams are providing is down: only 72.4% described their experience as ‘good’ or ‘very good’ in 2022, down from 83% a year earlier. Patients’ inability to make appointments, due to excessive demand, appears to be a major driver of this.

In September, the new government headed by Liz Truss announced an ambition for every patient to see a GP within 14 days. But little additional resources have been provided to deliver this and practices will not face any meaningful consequences for failing to do so. ²⁰⁶ Department of Health and Social Care, ‘Our plan for patients’, 22 September 2022, retrieved 27 September 2022, www.gov.uk/government/publications/our-plan-for-patients/our-plan-for-patients#our-plan-for-patients

Another proxy for health demand – and, by extension, demand for GP services – is the number of calls made to the NHS 111 service. The number of calls that the service received rose to 23.2 million in 2021/22, ²⁰⁷ NHS England and NHS Improvement, ‘Integrated Urgent Care Aggregate Data Collection (IUCADC including NHS 111) Statistics Apr 2021 – Mar 2022’, NHS England, March 2022, retrieved 27 September 2022, www.england.nhs.uk/statistics/statistical-work-areas/iucadc-new-from-april-2021/integrated-urgent-care-aggregate-data-collection-iucadc-including-nhs… a 20.5% increase from the 19.2 million received in 2020/21. ²⁰⁸ NHS England and NHS Improvement, ‘Integrated Urgent Care Aggregate Data Collection (IUCADC including NHS 111) Statistics Apr 2020 – Mar 2021’, NHS England, March 2022, retrieved 27 September 2022, www.england.nhs.uk/statistics/statistical-work-areas/iucadc-new-from-april-2021/nhs-111-minimum-data-set/nhs-111-minimum-data-set-2020-21 But the proportion of calls that the service answered fell from 86.6% in 2020/21 to 76.9% in 2021/22.

GP teams carried out more appointments in 2021/22 than before the pandemic, but it is unclear whether they saw more patients

After a decline in 2020/21, the number of general practice appointments delivered in 2021/22 rose above the amount carried out in 2019/20. This was true for both GP appointments (which rose from 154.2 million in 2019/20 to 161.9 million in 2021/22, a 5% uplift) and appointments with other practice staff, such as practice nurses, physiotherapists or counsellors (which increased from 136.7 million in 2019/20 to 146.2 million in 2021/22, a 7% rise).

While the number of appointments overall increased, this data is not comparable to previous years. With a ‘telephone-first approach’, GPs can end up conducting two, shorter appointments for some patients – an initial telephone appointment followed by a face-to-face appointment – which would previously have been recorded as one, longer appointment. It is therefore difficult to tell whether GPs are actually seeing more patients, or just recording more appointments because patients require both telephone and in-person appointments to resolve their health problem.

Appointments are also not the only component of GP workloads – just under 60% of GPs’ time is spent on direct patient care, ²⁰⁹ Odebiyi B, Walker B, Gibson J and others, Eleventh National GP Worklife Survey, PRUComm, 13 April 2022, p. 27, https://prucomm.ac.uk/assets/uploads/Eleventh%20GPWLS%202021.pdf meaning that 40% of GP activity is not observed by looking at appointment data.

GPs continue to deliver appointments differently

The way that appointments are delivered has also changed. In the year to February 2020, telephone appointments accounted for only 13.5% of all consultations. In April 2020, this increased to 47.8%, and has remained high, although declining, since. In 2021/22, GPs conducted 34.1% of appointments by telephone. This trend has persisted despite the NHS issuing guidance in May 2021 that all GP practices should offer patients face-to-face appointments and that patient preferences for face- to-face consultations should be respected.

The move during the pandemic to an ‘online triage’ model may also partly explain the trend. ²¹⁰ Clarke G, Pariza P and Wolters A, ‘How are total triage and remote consultation changing the use of emergency care?’, The Health Foundation, 3 December 2020, retrieved 27 September 2022, www.health.org.uk/news-and-comment/charts-and-infographics/how-are-total-triage-and-remote-consultation-changing-the-us Having completed an online triage form, GPs often follow up with a telephone appointment, which might then lead to a face-to-face appointment. ²¹¹ NHS England, ‘Using an online form to contact your GP’, NHS, (no date) retrieved 25 May 2022, www.nhs.uk/nhs-services/gps/using-an-online-form-to-contact-your-gp-surgery

The continuation of this mode of appointment delivery may also be because patients often prefer it. Telephone appointments eliminate the need for people to attend and wait in a GP surgery, saving them time and money. This can translate into higher patient satisfaction: one survey showed that 58% of patients either agreed or strongly agreed that telephone appointments were a convenient way of receiving care, ²¹² Anderson J, Walsh J, Anderson M and Burnley R, ‘Patient satisfaction with remote consultations in a primary care setting’, Cureus, 2021, vol. 13, no. 9, e17814, retrieved 27 September 2022, www.ncbi.nlm.nih.gov/pmc/articles/PMC8498974 while another survey showed that 56% of respondents rated telephone appointments as more convenient than face-to-face ones. ²¹³ Newbould J, Abel G, Ball S and others, ‘Evaluation of telephone first approach to demand management in English general practice: observational study’, BMJ, 2017, vol. 358, retrieved 27 September 2022, www.bmj.com/content/358/bmj.j4197

But there are disadvantages for patients with a ‘remote-first approach’. There is a risk that it exacerbates existing inequalities ²¹⁴ Parker R, Figures E, Paddison CA and others, ‘Inequalities in general practice remote consultations: a systematic review’, BJGP Open, 2021, vol. 5, no. 3, retrieved 27 September 2022, https://pubmed.ncbi.nlm.nih.gov/33712502 among vulnerable and elderly patients. ²¹⁵ Rosen R and Leone C, Getting the Best Out of Remote Consulting in General Practice: Practical challenges and policy opportunities, Nuffield Trust, 29 June 2022, p. 33, www.nuffieldtrust.org.uk/files/2022-06/1656424637_nuffield-trust-remote-by-default-web-final.pdf There is also concern that remote appointments lead to worse clinical outcomes for patients, ²¹⁶ Ibid., p. 35. although more work needs to be done to understand their effect on outcomes.

The benefits to GPs of increased numbers of remote appointments are mixed

The benefits of remote appointments for clinicians are more ambiguous than they are for patients. Some clinicians like working remotely and, during the pandemic, appreciated that they were able to work with a lower risk of catching Covid. Telephone appointments were found to be effective for “a considerable part of patient workload”, ²¹⁷ Iacobucci G, ‘GPs should return to offering face-to-face appointments without prior triage, says NHS’, BMJ, 2021, vol. 373, retrieved 27 September 2022, www.bmj.com/content/373/bmj.n1251 in particular simpler, single-issue problems. ²¹⁸ Hewitt H, Gafaranga J and McKinstry B, ‘Comparison of face-to-face and telephone consultations in primary care: qualitative analysis’, British Journal of General Practice, 2010, vol. 60, no. 574, pp. e201–e212, retrieved 27 September 2022, www.ncbi.nlm.nih.gov/pmc/articles/PMC2858552 But for more complex or uncertain cases, GPs asked patients to attend a face-to-face appointment for further examination.

There are also clinical risks associated with remote consultations. For example, GPs reported issues such as a loss of visual information, a loss of information from a physical examination ²¹⁹ Rosen R and Leone C, Getting the Best Out of Remote Consulting in General Practice: Practical challenges and policy opportunities, Nuffield Trust, 29 June 2022, p. 21, www.nuffieldtrust.org.uk/files/2022-06/1656424637_nuffield-trust-remote-by-default-web-final.pdf and a reduced incidence of patients raising ‘door knob’ concerns as they left their appointment. ²²⁰ Ibid., p. 2.

Telephone consultations also contributed to GPs’ stress, for a number of reasons. ²²¹ Rosen R, Wieringa S, Greenhalgh T and others, ‘Clinical risk in remote consultations in general practice: findings from in-COVID-19 pandemic qualitative research’, BJGO Open, 2022, retrieved 27 September 2022, https://bjgpopen.org/content/early/2022/06/30/BJGPO.2021.0204 First, GPs often found it difficult to extract a full history from patients remotely, which reduced their confidence in their diagnoses. ²²² Ibid. Second, if working from home, they lost the ability to consult with colleagues in the way they would have done if they had been in the GP surgery. ²²³ Ibid. Third, they often found telephone and video calls more tiring than face-to-face appointments ²²⁴ Ibid. and that telephone appointments often increased the amount of time they spent working. ²²⁵ Newbould J, Abel G, Ball S and others, ‘Evaluation of telephone first approach to demand management in English general practice: observational study’, BMJ, 2017, vol. 358, retrieved 27 September 2022, www.bmj.com/content/358/bmj.j4197 Finally, GPs felt that remote appointments were more transactional, which in turn lowered their job satisfaction. ²²⁶ Greenhalgh T, Rosen R, Shaw SE and others, ‘Planning and evaluating remote consultation services: a new conceptual framework incorporating complexity and practical ethics’, Frontiers in Digital Health, 2021, retrieved 28 September 2022, www.frontiersin.org/articles/10.3389/fdgth.2021.726095/full

Referrals to secondary care dropped after the onset of the pandemic and have remained low

Whether or not GPs are working more or seeing more patients, the data shows that they are less likely to refer patients to hospital. The proportion of GP appointments that have resulted in a specific and acute referral has dropped over the course of the pandemic. But we are not seeing referral rates return to pre-pandemic levels. Between October 2018 (when the appointment time series began) and February 2020, 9% of GP appointments resulted in a referral. This fell to 6.2% between March 2020 and February 2021. From March 2021 to March 2022, the rate increased to only 7.7%, despite the expectation that more patients would require referral to secondary care – having been unable to access care during the pandemic. ²²⁷ NHS Digital, ‘Appointments in general practice, July 2022’, NHS Digital, 2022, retrieved 28 September 2022, https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice

The lower rate of referral has translated into fewer absolute referrals, despite more appointments taking place. The number of specific and acute referrals – from both GPs and other sources – was 20 million in 2021/22, down from 21 million in 2019/20. This is despite a drop in referrals to 15 million in 2020/21, which could have indicated pent- up demand for referrals to secondary care.

There are multiple reasons for this decrease. First, there was a slight downward trend in referral rates before the pandemic, which, if continued, could explain some of the observed decline, although this was not a long-running trend and there was no particular reason to expect it to continue. Second, there are claims that hospitals are blocking referrals, ^{228 Bostock N, ‘Barriers to hospital referral are harming patients, GPs warn’, GP Online, 1 March 2022, retrieved 28 September 2022, www.gponline.com/barriers-hospital-referral-harming-patients-gps-warn/article/1748233   229 Patient Safety Learning, ‘Rejected outpatient referrals are putting patients at risk and increasing workload pressures on GPs’, 6 May 2022, retrieved 9 August 2022, www.patientsafetylearning.org/blog/rejected-outpatient-referrals-are-putting-patients-at-risk-and-increasing-workload-pressure-on-gps} although this should not affect the overall number of referrals, as we observe referrals when a GP refers a patient, whether or not there is then a follow-up appointment. ²³⁰ NHS England and NHS Improvement, Monthly Referral Return (MRR): Data definitions, August 2020, retrieved 25 May 2022, p. 6, www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2021/06/Monthly-Referral-Return-MRR-Guidance-v0.3.pdf Third, it may be that, before making a referral, GPs are following up initial telephone appointments with face-to-face consultations, meaning more appointments taking place for each referral, on average.

Fourth, and arguably most importantly, is new encouragement from NHS England for GPs to consult their secondary care colleagues in advance about whether a referral is the best course of action. This mechanism is known as ‘advice and guidance’ (A&G). NHS England has introduced a target for GPs to register 16 specialist advice requests, including A&G, for every 100 first outpatient appointments, by March 2023. ²³¹ NHS England, 2022/23 Priorities and Operational Planning Guidance, 22 February 2022, retrieved 26 May 2022, www.england.nhs.uk/wp-content/uploads/2022/02/20211223-B1160-2022-23-priorities-and-operational-planning-guidance-v3.2.pdf

There are advantages and disadvantages to the increased use of A&G. It can help speed up treatment and enable patients to receive the care they need closer to home. NHS England also claims that the 1.6 million total A&G requests in 2020/21 resulted in 1 million fewer “unnecessary face-to-face outpatient attendances”, ²³² NHS Commissioning Board, Our 2020/21 Annual Report: Health and high quality care for all, now and for future generations, 3 February 2022, retrieved 3 May 2022, p. 28, www.england.nhs.uk/wp-content/uploads/2022/02/nhs-commissioning-board-annual-report-2020-to-2021-print.pdf thus helping to ease the pressure on secondary care. In contrast, some argue that mandated A&G ignores GPs’ better judgement ²³³ Doctors’ Association UK, ‘DAUK’s joint letter to the health secretary – lack of access to secondary care referral pathways’, Doctors’ Association UK, 3 December 2021, retrieved 3 May 2022, www.dauk.org/news/2021/12/03/open-letter-to-rt-hon-sajid-javid-we-write-to-you-as-a-very-concerned-group-of-gps-regarding-the-lack-of-access-to-secon… and increases the risk that patients who A&G screens out return to primary care, increasing demand for that service. ²³⁴ Potter C, ‘NHSE: GP “advice and guidance” requests avoided one million “unnecessary” referrals’, Pulse, 9 February 2022, retrieved 28 September 2022, www.pulsetoday.co.uk/news/referrals/nhse-gp-advice-and-guidance-requests-avoided-over-one-million-unnecessary-referrals

The wider primary care workforce is growing, in line with government targets

In 2019, the NHS announced its ambition to recruit an extra 20,000 direct patient care (DPC) staff – in particular, clinical pharmacists, social prescribing link workers, physician associates, physiotherapists and paramedics ²³⁵ NHS England and NHS Improvement, Network Contract Directed Enhanced Service: Additional Roles Reimbursement Scheme guidance, NHS England and NHS Improvement, December 2019, p. 3, www.england.nhs.uk/wp-content/uploads/2019/12/network-contract-des-additional-roles-reimbursement-scheme-guidance-december2019.pdf – by March 2024. ²³⁶ Ibid. The Conservative Party then added to this goal in its 2019 election manifesto, ²³⁷ The Conservative and Unionist Party, The Conservative and Unionist Party Manifesto 2019, The Conservative and Unionist Party, 24 November 2019, p. 10, retrieved 28 September 2022, www.conservatives.com/our-plan/conservative-party-manifesto-2019 bringing the total target to 26,000 additional DPC staff. The aim of this recruitment drive is to reduce some of the burden on GPs and thereby support the broader target of delivering 50 million more general practice appointments by 2024. ²³⁸ NHS England and NHS Improvement, Network Contract Directed Enhanced Service: Additional Roles Reimbursement Scheme guidance, NHS England and NHS Improvement, December 2019, p. 3, www.england.nhs.uk/wp-content/uploads/2019/12/network-contract-des-additional-roles-reimbursement-scheme-guidance-december2019.pdf The NHS is now supporting primary care networks to recruit these staff by reimbursing them for any staff hired in addition to the baseline that was set in March 2019 under the Additional Roles Reimbursement Scheme (ARRS).

The NHS only began releasing quarterly data updates on the number of staff employed under the ARRS scheme in September 2021. From that time series, the total number of DPC staff increased from 11,321 in March 2019 to 30,626 in June 2022. This is an increase of 19,305 staff – a 170.5% rise in just over three years. If recruitment continues at the same rate as it has to date, the NHS will recruit more than 29,000 more DPC staff by March 2024 – more than 3,000 in excess of the target.

But there are a number of concerns about the implementation of this recruitment drive. First, it is not clear that primary care networks – still relatively new themselves – have a clear vision for these new employees. This means that new staff members are not being effectively used. ²³⁹ Baird B, Lamming L, Bhatt R’T, Beech J and Dale V, Integrating Additional Roles into Primary Care Networks,The King’s Fund, 2022, p. 9, www.kingsfund.org.uk/sites/default/files/2022-02/Integrating%20additional%20roles%20in%20general%20practice%20report%28web%29.pdf Second, GP practices are concerned about the financial sustainability of the DPC workforce when the additional funding ends in 2023/24. As it stands, there is no guarantee that funding will continue, meaning that a number of DPC staff could lose their jobs when the scheme comes to an end. ²⁴⁰ Ibid., p. 15. Third, the expansion of the primary care workforce may be putting additional pressure on GPs. Some GPs report that DPC staff take on the easy cases, leaving GPs with the more complex casework. In addition, GPs are required to take on a greater supervisory role as they manage a larger team. ²⁴¹ Ibid., p. 18.

The number of GPs has grown, but not by enough to meet demand

The number of regular GPs increased between 2020/21 and 2021/22. There were 34,749 regular, full-time equivalent (FTE) GPs in June 2022 – 756 (2.2%) more than in the same month in 2021. ²⁴² NHS Digital, ‘General Practice Workforce, England, Bulletin Tables, 31 July 2022’, 25 August 2022, retrieved 28 September 2022, https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services Boris Johnson made GP recruitment one of his core election commitments, promising to increase the number of GPs by 6,000 between March 2019 and March 2024. ²⁴³ Iacobucci G, ‘Tories promise 6000 extra GPs by 2024’, BMJ, 2019, vol. 367, retrieved 28 September 2022, www.bmj.com/content/367/bmj.l6463 By March 2022, there were 1,728 more regular GPs than in March 2019,* meaning that the government is not on track to hit its target by 2024, assuming similar levels of recruitment and retention. ²⁴⁴ NHS Digital, ‘General Practice Workforce, England, Bulletin Tables, 31 July 2022’, 25 August 2022, retrieved 28 September 2022, https://files.digital.nhs.uk/6F/703A43/GPW%20Bulletin%20Tables%20-%20July%20 2022.xlsx

Regular GP numbers include GPs in training grades – which accounted for 7,890 of the 34,749 GPs in England (or 22.7%) in June 2022. ²⁴⁵ Ibid. There has been an increase in the number of GPs in training grades recently as the government has pushed for improved GP recruitment, from 5,857 in June 2019 to 7,890 in June 2022. Excluding GPs in training grades and locums, the number of fully qualified, FTE GPs was 26,859 in June 2022, a decline of 6.1% since September 2015, the start of this time series. ²⁴⁶ Ibid.

The introduction of the recruitment target in 2019 reversed the trend of declining GP numbers (including those in training grades) and, as a result, these were 3.4% higher in June 2022 than in September 2015. ²⁴⁷ Ibid. But increasing GP numbers are not keeping pace with demand for services. The number of patients registered with GPs grew 8.5% over the same time period. ²⁴⁸ Ibid.

This increase in patient numbers also does not take into account the changing demographics of the population – patients are now, on average, older than in 2015 and therefore in need of more care. There are also increasing rates of people living with multiple long-term conditions, both in the 65+ and working-age populations. One study estimates that the proportion of people over the age of 65 with more than one condition could rise from 54% in 2015 to 68% in 2035. ²⁴⁹ National Institute for Health and Care Research, ‘Multiple long-term conditions (multimorbidity): making sense of the evidence’, 30 March 2021, retrieved 28 September 2022, https://evidence.nihr.ac.uk/collection/making-sense-of-the-evidence-multiple-long-term-conditions-multimorbidity Among working-age adults, 34% now have chronic health conditions at ages 46–48. ²⁵⁰ UCL Faculty of Education and Society, ‘Over a third of adults have multiple health problems in midlife’, 28 July 2021, retrieved 28 September 2022, www.ucl.ac.uk/ioe/news/2021/jul/over-third-adults-have-multiple-health-problems-midlife This in turn drives higher demand for primary care services. ²⁵¹ National Institute for Health and Care Research, ‘Multiple long-term conditions (multimorbidity): making sense of the evidence’, 30 March 2021, retrieved 28 September 2022, https://evidence.nihr.ac.uk/collection/making-sense-of-the-evidence-multiple-long-term-conditions-multimorbidity

_{* We compare March 2022 to March 2019 despite there being more recent data (to June 2022) because there is seasonality in the number of GPs in training grades, which we include in our total number of GPs. There is a large spike in the number of GPs in training grades in September every year, as doctors complete their second foundation year of training and start their GP training course. There then tends to be attrition throughout the year, meaning that comparing June 2022 with March 2019 might make the current level of GPs look artificially low.}

GP trends are worsening the mismatch in supply and demand

Workforce trends that are seeing more GPs working part-time or leaving the service are exacerbating the problem of demand for general practice services outstripping the supply of GPs. By June 2022, 76.5% of GPs worked fewer than 37.5 hours a week, compared with 66.7% in September 2015. ²⁵² NHS Digital, ‘General Practice Workforce, England, Bulletin Tables, 31 July 2022’, 25 August 2022, retrieved 28 September 2022, https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services

But headline figures in relation to the increasing number of part-time GPs hide a more complex picture. Part-time GPs often work up to or more than the 37.5 hours required of their FTE colleagues, while FTE GPs can work 50 hours a week or more. ²⁵³ Royal College of General Practitioners, ‘GP working hours more complex’, 21 November 2021, retrieved 28 September 2022, www.rcgp.org.uk/News/GP-working-hours-more-complex#:~:text=%22When%20GPs%20work%20’less%20than,they’re%20not%20seeing%20patients This is partly because working hours are measured by how many ‘sessions’ a GP carries out a day – a crude measure that only takes into account the time that GPs spend with patients. In reality, GPs must finish administrative work after the end of a session. ²⁵⁴

The higher workloads discussed above are contributing to GP stress and worsening retention in primary care. When polled, GPs identified increased workloads and increased demand from patients as the two factors that most contribute to increasing levels of stress, and they rated ‘hours of work’ as the category with the lowest overall satisfaction. ²⁵⁵ Odebiyi B, Walker B, Gibson J and others, Eleventh National GP Worklife Survey, PRUComm, 13 April 2022, p. 13, https://prucomm.ac.uk/assets/uploads/Eleventh%20GPWLS%202021.pdf

After an improvement during the pandemic that saw a low of only 6.7% of GPs leaving the service in the 12 months to June 2021, retention has gradually worsened again, reaching 8.9% in the 12 months to June 2022. ²⁵⁶ NHS Digital, ‘General Practice Workforce, England, Bulletin Tables, 31 July 2022’, 25 August 2022, retrieved 28 September 2022, https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services It should also be noted that because this is a 12-month rolling average, the measure does not fully capture any recent large increases in the number of GPs leaving the service. Of concern is that the age group with the largest increase in the proportion leaving the workforce is the under-30s, where 20.6% of the workforce left the service in the 12 months to March 2022. This trend is worrying for the future GP workforce. If the under-30 cohort leaves in large numbers, then there will be fewer GPs in the future to staff the service.