Performance Tracker 2022/23: Spring update - General practice

The pandemic affected general practice in different ways as it progressed. In the early stages, GP teams conducted far fewer appointments as patients followed advice from the government to stay away from the service unless in need of emergency care. Then, during the rollout of the Covid vaccine, they played a key role delivering doses in their communities. Now, three years after the pandemic began, 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, ¹³⁶ NHS England, GP Patient Survey 2022, NHS England, July 2022, retrieved 27 September 2022, www.gp-patient.co.uk/surveysandreports 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 led to 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 burnout, 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. ¹⁴⁹ NHS England, Investment in General Practice in England, 2016/17 to 2020/21, NHS England, 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 2023/24 ¹⁵⁰ NHS England, NHS Long Term Plan, NHS England, 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. ¹⁵¹ NHS England, Investment in General Practice in England, 2016/17 to 2020/21, NHS England, 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 GP teams 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. ¹⁵² 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. ¹⁵³ NHS England, Investment in General Practice in England, 2016/17 to 2020/21, NHS England, 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 ¹⁵⁴ General Practitioners Committee, Focus On…..How Your Practice is Funded, General Practitioners Committee, 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. ¹⁵⁵ 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 by March 2024 ¹⁵⁶ NHS England, ‘Expanding our workforce’, NHS England, (no date) retrieved 27 September 2022, www.england.nhs.uk/gp/expanding-our-workforce and 6,000 more GPs, ¹⁵⁷ Iacobucci G, ‘Tories promise 6000 extra GPs by 2024’, BMJ, 2019, vol. 367, retrieved 27 September 2022, www.bmj.com/content/367/bmj.l6463 which would represent a 17.4% increase in the total number of GPs, compared with March 2019. ¹⁵⁸ NHS Digital, ‘General Practice Workforce, England, Bulletin Tables, 31 July 2022’, NHS Digital, 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 0.4% between 2019 and 2021, with the population aged 65- plus growing by 1.1%. ¹⁵⁹ Office for National Statistics, ‘Estimates of the population for the UK, England and Wales, Scotland and Northern Ireland’, ONS, 23 December 2022, retrieved 5 January 2023, https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/populationestimatesforukenglandandwalesscotla… 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. ¹⁶⁰ Department of Health, Resource Allocation: Weighted capitation formula: Seventh edition, Department of Health, 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. ¹⁶⁵ NHS England, GP Patient Survey 2022, NHS England, 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 government, then headed by Liz Truss, announced an ambition for every patient to see a GP within 14 days. ¹⁶⁶ Department of Health and Social Care, ‘Our plan for patients’, Department of Health and Social Care, 22 September 2022, retrieved 27 September 2022, www.gov.uk/government/publications/our-plan-for-patients/our-plan-for-patients#our-plan-for-patients The Sunak government re-committed to this ambition in the autumn statement at the same time as providing the NHS with a further £3.3bn funding per year for 2023/24 and 2024/25 ¹⁶⁷ HM Treasury, Autumn Statement 2022, 17 November 2022, retrieved 12 December 2022, p.26 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1118417/CCS1022065440-001_SECURE_HMT_Autumn_Statement… – though general practice will receive only a portion of this increase. It is, however, unclear what impact that money will have on helping primary care achieve the government’s three manifesto promises that relate to the service: 50 million more appointments, recruiting an additional 26,000 direct patient care staff, and hiring 6,000 more GPs. The government has admitted that the latter of these is unachievable, ¹⁶⁸ Campbell D, ‘No 10 set to break promise of 6,000 more GPs in England, Sajid Javid says’, The Guardian, 21 November 2021, https://www.theguardian.com/society/2021/nov/02/no-10-set-to-break-promise-of-6000-more-gps-in-england-sajid-javid-says which casts doubt on the likelihood of meeting its stated goal in the autumn statement of improving appointment access.

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 fell in 2022 compared to 2021, from 22.6 million to 22 million – a 2.5% decline, though there was a large spike in December, with the second highest ever level of received calls. ¹⁷⁰ 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…  Despite this lower call volume, the proportion of calls that the service answered fell from 79.2% in 2021 to 76.9% in 2022 – though if December is excluded from the analysis, the number of answered calls was higher than in 2021, at 80.5%.

GP teams carried out more appointments in 2022 than before the pandemic, but it is unclear whether they saw more patients

After a decline in 2020, the number of general practice appointments delivered in 2022 rose above the amount carried out in 2019. This was true for both GP appointments (which rose from 155.1 million in 2019 to 160.9 million in 2022, a 3.7% uplift) and appointments with other practice staff, such as practice nurses, physiotherapists or counsellors (which increased from 136.8 million in 2019 to 157 million in 2022, a 14.8% rise).

While the number of appointments increased in 2021/22, this data is not comparable to previous years. With a ‘telephone-first approach’, GP teams 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 GP teams 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, ¹⁷² Odebiyi B, Walker B, Gibson J, Sutton M, Spooner S and Checkland K, 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%. Since then, the proportion of telephone appointments has been steadily falling and in December 2022, GP teams conducted 27.8% 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 should be respected. The move during the pandemic to an ‘online triage’ model may also partly explain the trend. ¹⁹¹ 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. ¹⁹² 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, ¹⁹³ 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. ¹⁹⁴ Newbould J, Abel G, Ball S, Corbett J, Elliott M, Exley J, Martin A, Saunders C, Wilson E, Winpenny E, Yang M and Roland M, ‘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 an increased proportion of remote appointments. There is a risk that it exacerbates existing inequalities ¹⁹⁵ Parker R, Figures E, Paddison CA, Matheson JI, Blane DN and Ford  JA, ‘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. ¹⁹⁶ 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, ¹⁹⁷ 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. 35, www.nuffieldtrust.org.uk/files/2022-06/1656424637_nuffield-trust-remote-by-default-web-final.pdf although more work needs to be done to understand their effect on outcomes.

The benefits to general practice 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. ¹⁹⁸ Royal College of General Practitioners, ‘General practice in the post Covid world’, 11 May 2021, RCGP.ORG.UK, p.4, https://www.rcgp.org.uk/getmedia/4a241eec-500b-44f7-96fe-0e63208f619b/general-practice-post-covid-rcgp.pdf Telephone appointments were found to be effective for “a considerable part of patient workload”, ¹⁹⁹ 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. ²⁰⁰ 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, patients are asked to attend a face-to-face appointment for further examination.

There are also clinical risks associated with remote consultations, if not implemented correctly. For example, GP teams reported issues such as a loss of visual information, a loss of information from a physical examination ²⁰¹ 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. ²⁰² 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. 2, www.nuffieldtrust.org.uk/files/2022-06/1656424637_nuffield-trust-remote-by-default-web-final.pdf

Telephone consultations also contributed to GPs’ stress, for a number of reasons. ²⁰³ Rosen R, Wieringa S, Greenhalgh T, Leone C, Rybczunska-Bunt S, Hughes G, Moore L, Shaw SE, Wherton J and Byng R, ‘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. ²⁰⁴ Rosen R, Wieringa S, Greenhalgh T, Leone C, Rybczunska-Bunt S, Hughes G, Moore L, Shaw SE, Wherton J and Byng R, ‘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 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. ²⁰⁵ Rosen R, Wieringa S, Greenhalgh T, Leone C, Rybczunska-Bunt S, Hughes G, Moore L, Shaw SE, Wherton J and Byng R, ‘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 Third, they often found telephone and video calls more tiring than face-to-face appointments ²⁰⁶ Rosen R, Wieringa S, Greenhalgh T, Leone C, Rybczunska-Bunt S, Hughes G, Moore L, Shaw SE, Wherton J and Byng R, ‘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/6/3/BJGPO.2021.0204 and that telephone appointments often increased the amount of time they spent working. ²⁰⁷ Newbould J, Abel G, Ball S, Corbett J, Elliott M, Exley J, Martin A, Saunders C, Wilson E, Winpenny E, Yang M and Roland M, ‘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. ²⁰⁸ Greenhalgh T, Rosen R, Shaw SE, Byng R, Faulkner S, Finlay T, Grundy E et al, ‘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 GP teams 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. ²¹⁰ 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 rate has continued to increase, rising to 8.1% in 2022, though this is still below pre-pandemic levels.

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 20.3 million in 2022, down from 21.5 million in 2019 – a fall of 5.8%. 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, ²¹⁴ 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 ^{, 215} Patient Safety Learning, ‘Rejected outpatient referrals are putting patients at risk and increasing workload pressures on GPs’, Patient Safety Learning, 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. ²¹⁶ NHS England and NHS Improvement, Monthly Referral Return (MRR): Data definitions, NHS England and NHS Improvement, 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. ²²⁶ NHS England, 2022/23 Priorities and Operational Planning Guidance, NHS England, 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 The National Audit Office reports that GPs are already exceeding this target, seeking A&G for 22 of 100 first outpatient appointments between April and June 2022. ²²⁷ Comptroller and Auditor General, Managing NHS backlogs and waiting times in England, Session 2022–23, HC 799, National Audit Office, 17 November 2022, p. 9, https://www.nao.org.uk/wp-content/uploads/2022/11/managing-NHS-backlogs-and-waiting-times-in-England-Report.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 A&G requests in 2020/21 resulted in 1 million fewer “unnecessary face-to-face outpatient attendances”, ²²⁸ NHS Commissioning Board, Our 2020/21 Annual Report: Health and high quality care for all, now and for future generations, NHS Commissioning Board, 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 judgment ²²⁹ 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. ²³⁰ 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 ²³¹ 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. ²³² 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 Conservative Party then added to this goal in its 2019 election manifesto, ²³³ 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. ²³⁴ 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 regular quarterly data updates on the number of staff employed under the ARRS in September 2021. From that time series, the total number of DPC staff increased from 11,321 in March 2019 to 36,583 in December 2022. This is an increase of 25,262 staff – a 223.1% rise in just under four years. This leaves the government with only a further 738 DPC staff to recruit before March 2024 to hit their target of an increase of 26,000, effectively guaranteeing that they have fulfilled that manifesto promise. 

But there are a number of concerns about the implementation of this recruitment drive. First, it is not clear that primary care networks (PCNs) – still relatively new themselves – have a clear vision for these new employees, meaning that PCNs might not be utilising new staff members effectively. ²³⁷ 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, 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. ²³⁸ 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. 18, www.kingsfund.org.uk/sites/default/files/2022-02/Integrating%20additional%20roles%20in%20general%20practice%20report%28web%29.pdf  

It is also not clear what additional activity these staff members are carrying out. Appointments that they conduct are not currently captured separately* in general practice appointment data and the NHS does not release any other data relating to these appointments. There are now more DPC staff than GPs working in primary care and it should therefore be a priority for NHS England to show their impact on the service.

^{*The general practice appointment data does not provide separate figures for appointments carried out by all DPC staff in PCNs and there is no public data on other primary care activity they undertake.}

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

The total number of GPs – fully qualified, permanent GPs and GP trainees – increased by 2,504 between December 2019 and December 2022, from 33,513 to 36,017. This increase, however, hides variation in the split of trainee GPs and fully qualified, permanent GPs. The latter group saw a decline of 418 between December 2019 and December 2022 – a 1.5% fall to 26,706. ²⁴⁵ 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-andpersonal-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. ²⁴⁶ 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 Of these 6,000, half were intended to be fully qualified, permanent GPs and half trainees. ²⁴⁷ Health Education England, ‘Over 4,000 trainee GPs accepted on placements’, press release, 23 November 2022, retrieved 6 December 2022, https://www.hee.nhs.uk/news-blogs-events/news/over-4000-trainee-gps-accepted-placements Given the decline in fully qualified, permanent GPs outlined above, the government is not on track to hit its target by 2024. ²⁴⁸ 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-andpersonal-medical-services

Despite declining numbers of fully qualified, permanent GPs, GP recruitment continues to improve, with 9,311 GP trainees in December 2022 – an increase of 2,922 (45.7%) compared to December 2019. ²⁴⁹ 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-andpersonal-medical-services This is the second year in a row when the number of new GP trainees has exceeded 4,000, and the fifth year in a row that Health Education England has surpassed its targets for GP trainees. ²⁵⁰ Health Education England, ‘Over 4,000 trainee GPs accepted on placements’, press release, 23 November 2022, retrieved 6 December 2022, https://www.hee.nhs.uk/news-blogs-events/news/over-4000-trainee-gps-accepted-placements
 

Despite better recruitment, the number of GPs is not keeping pace with the number of patients registered with practices. Including GP trainees, the number of GPs rose 6.7% between September 2015 and December 2022, compared to 9.4% for the number of patients. If trainees are excluded, however, the picture is considerably worse. The number of fully qualified, permanent GPs declined 6.8% in that time, meaning that there are now 2,273 patients for every fully qualified, permanent GP, compared to 1,938 in 2015 – a 13.3% increase. ²⁵⁹ NHS Digital, ‘General Practice Workforce, England, Bulletin Tables, 30 September 2022’, 27 October 2022,
retrieved 6 December 2022, https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/30-september-2022  

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 often, therefore, in more need of care. There are also increasing rates of people living with multiple long-term conditions, both in the 65-plus 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. ²⁶⁰ 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. ²⁶¹ 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-multiplehealth-problems-midlife This in turn drives higher demand for primary care services. ²⁶² 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/makingsense-of-the-evidence-multiple-long-term-conditions-multimorbidity

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 December 2022, 77% of GPs worked fewer than 37.5 hours a week, compared with 66.7% in September 2015. ²⁶³ 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-andpersonal-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. ²⁶⁴ 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 This is partly because working hours are measured by how many ‘sessions’ a GP carries out a day – a crude measure that takes into account only the time that GPs spend with patients. In reality, GPs must finish administrative work after the end of a session. ²⁶⁵ BMA, ‘The notion of a “part-time” GP is often anything but, says BMA’, 11 October 2021, retrieved
28 September 2022, www.bma.org.uk/bma-media-centre/the-notion-of-a-part-time-gp-is-often-anythingbut-says-bma

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 greater levels of stress, and they rated ‘hours of work’ as the category with the lowest overall satisfaction. ²⁶⁶ 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 8.8% in the 12 months to December 2022. ²⁶⁸ 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-andpersonal-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 changes in the number of GPs leaving the service. Concerningly, the age group with the largest increase since the pandemic in the proportion leaving the workforce is the under-30s, where 21.9% of the workforce left the service in the 12 months to December 2022. While this is an improvement on the level of September 2022, this is still 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. This increase in the youngest GPs leaving the service could also explain at least in part why higher GP trainee numbers are not translating into more fully qualified, permanent GPs.