Fixing public services: The NHS

The NHS is broken. That is no longer just the opinion of think tanks, the press and the public, but is now official government policy. ¹¹¹ ‘Wes Streeting says NHS is broken as he announces pay talks with junior doctors’, The Guardian, 6 July 2024, https://www.theguardian.com/society/article/2024/jul/06/wes-streeting-nhs-broken-announces-talks-junior-doctors  Wes Streeting, the new Labour health and social care secretary, is largely correct. Problems in the NHS are well documented and extensive. There is almost no part of the service that is performing better now than it was on the eve of the pandemic. The previous government launched a spate of recovery plans for the service, including one for elective care, one for urgent and emergency care and one for primary care. But despite those plans, improvements have been marginal.

“Building an NHS fit for the future” is one of the new government’s five missions. ¹¹² Labour Party, ‘Mission driven government’, (no date) retrieved 5 July 2024, https://labour.org.uk/change/mission-driven-government  And Labour has made a range of commitments on the NHS that mean that spending is likely to increase. In its election manifesto, it committed to delivering the NHS Long Term Workforce Plan. ¹¹³ Labour Party, Change: Labour Party manifesto 2024, 2024, p. 97, https://labour.org.uk/wp-content/uploads/2024/06/Change-Labour-Party-Manifesto-2024-large-print.pdf  Separately, it has made clear that it is aiming to return to target on elective and A&E care by the end of this parliament. ¹¹⁴ Triggle N, ‘Labour promises to hit 18-week NHS waiting target within five years’, BBC News, 29 May 2024, www.bbc.co.uk/news/health-69070207  While delivering these ambitions is likely to require more spending, Labour will need to wrestle with the fact that recent spending increases in hospitals have not generated commensurate performance improvements.

This chapter lays out four of the biggest challenges facing the NHS across general practice, hospitals and community care:

• hospitals have a productivity problem
• delivering the planned workforce will be extremely difficult
• health and care services are too hospital-centred
• the number of fully qualified GPs and GP partners has fallen since 2019.

The chapter also touches on areas such as adult social care and public health, as these are both affected by and affect performance in the NHS.

Hospitals have a productivity problem

More money for hospitals is not translating into improved performance

Despite a substantial increase in hospital funding and staffing since 2019, the NHS has failed to deliver a commensurate increase in activity. The government spent 11.9% more on hospitals’ day-to-day spending in real terms in 2022/23 than it did in 2019/20. That extra funding has translated into more staff. There were 20.1% more doctors and 23.2% more nurses working in hospitals in March 2024 than in December 2019.

Despite staffing levels increasing more quickly than they did in the 2010s, rates of activity have grown more slowly on average than they did during that decade. Cancer appointments have grown the fastest of the four areas of activity that we looked at, by an average of 6.1% a year since 2020. But that lags far behind the 10.6% a year increases that hospitals achieved between 2010 and 2019.* Although cancer appointments are growing the fastest out of the activity types that we looked at, they comprise a relatively small proportion of total hospital activity. By far the biggest component is outpatient appointments, which have risen by an average of 2.1% a year since 2020, compared with 4.1% in the 2010s. Growth in diagnostic tests has also been slower than might have been expected (3.0% since 2020, versus 5.2% in the 2010s), although the worst-performing area is elective activity, which has been growing by an average of 0.7% a year since 2020 – an outcome that is contributing to the stubbornly high elective waiting list.

There has also been a smaller improvement in urgent and emergency care than might be expected given additional staff. There have been record waits in A&E departments in recent years. More than 1.5 million people waited more than 12 hours in A&E** in 2023/24 (9.7% of those who attended A&E), up from 477,000 in 2019 (2.9% of attendees). The last time the NHS met its target for no more than four-hour waits in A&E was in July 2015. Ambulance performance has improved from the record worst during the winter of 2022/23, but response times are still well above target: in 2023/24, the mean response time for category 2 ambulance incidents*** was 36:23 minutes, down from 50:00 in 2022/23 but still more than double the target of 18:00.

Poor productivity is the result of decisions that governments have taken over decades, but particularly since 2010. The coalition and then Conservative governments chose to hold down inputs – capital spending, wages and staff numbers – into the service. ¹¹⁶ Hoddinott S, Fright M and Pope T, ‘Austerity’ in Public Services: Lessons from the 2010s, Institute for Government, 2022, www.instituteforgovernment.org.uk/publication/report/austerity-public-services-lessons-2010s  This made measured health productivity**** in the UK grow quickly throughout the 2010s: quality-adjusted productivity grew at a rate of 1.1% a year between 2010/11 and 2019/20, compared with 0.5% a year between 2001/02 and 2009/10.

^{* We used this period as the comparator because it was unaffected by the pandemic.}

^{** This is type-1, or major, A&E units.}

^{*** This includes suspected stroke victims and people with chest pains.}

^{**** The Office for National Statistics (ONS) describes productivity as “a measure of the amount of service provided… for the quantity of inputs used”. See ONS, ‘8. Glossary’, 2024, retrieved 4 July 2024, www.ons.gov.uk/economy/economicoutputandproductivity/publicservicesproductivity/articles/publicservicesproductivityestimateshealthcare/financialyeare…}

But those ‘productivity improvements’ stored up issues for the future – a legacy that the current NHS is now reaping, as we describe below. Covid caused a large and sudden drop in health productivity as much NHS activity ground to a halt. But even since Covid restrictions were lifted, productivity has not returned to pre-pandemic levels: in 2021/22, it was still 6.6% below 2019/20 levels and only 2.9% above 2010/11 levels.

Hospitals are falling apart and staff do not have enough equipment

For decades, governments have under-invested in health capital compared with similar countries. But investment fell further in the 2010s, as the then government cut capital budgets and allowed an NHS under strain to shift funding from its capital budget to its day-to-day budget. Capital spending has increased since 2020, but so far this has not been enough to overcome the cumulative under-investment of earlier years.

The results have been disastrous. Hospitals are falling apart, with one hospital alone suffering from at least 40 leaks of raw sewage in recent years. ¹²⁰ Campbell D, ‘Crumbling hospitals cause over 100 patient care disruptions a week, NHS figures show’, The Guardian, 26 January 2024, https://www.theguardian.com/society/2024/jan/26/crumbling-english-hospitals-cause-over-100-patient-care-disruptions-week  There is not enough diagnostic equipment for staff to carry out timely tests. IT systems are outdated and fragmented, making it difficult to communicate across the system. And IT hardware is not much better; computers work sporadically and slowly. These factors all make it much harder for hospital staff to work effectively. ¹²¹ Hoddinott S, Davies N, Fright M, Nye P and Richards G, Performance Tracker 2023, ‘Hospitals’, Institute for Government, 2023, www.instituteforgovernment.org.uk/publication/performance-tracker-2023/hospitals

Hospitals do not have enough beds

A long-term decline in the number of hospital beds has hindered patient flow. Between 1987/88 and 2023/24, the NHS cut hospital beds by more than half (-52.5%). Some of this was for good reason. The NHS started treating more people out of hospital and, as treatments improved, people needed to stay in hospital for less time, reducing the need for beds. But there is evidence that this has now gone too far. The strategy of cutting bed numbers in pursuit of increased efficiency has been shown to be vulnerable to increases in length of stay, as has happened in the years since the pandemic. This has resulted in the NHS having to raise admission thresholds, thus admitting fewer people into hospital. ¹²² ‘NHS hospitals forced to cut admissions by over half a million due to lack of beds, new analysis shows’, The Health Foundation, 2023, https://www.health.org.uk/news-and-comment/news/nhs-hospitals-forced-to-cut-admissions-by-over-half-a-million-due-to-lack-of-beds

The resulting lack of beds means that there is consistently high bed occupancy.* There is no month since September 2020 in which the average national bed occupancy in hospitals** was below 85% – the level that the Royal College of Emergency Medicine deems to be “safe”. ¹²⁸ Royal College of Emergency Medicine, ‘NHS crisis continues as hospital bed numbers near capacity’, 22 February 2024, https://rcem.ac.uk/nhs-crisis-continues-as-hospital-bed-numbers-near-capacity  This has ramifications for many elements of hospital performance. It is harder to admit people from A&E departments. And hospitals are forced to cancel elective procedures that require an admission. In short, patients are not able to flow through the system.

Hospitals are badly under-managed

Effective management is vital if the NHS hopes to make the most of its expensive and extensive workforce. Despite that, the number of managers per NHS worker has fallen since 2010. In March 2024, 2.96% of the NHS workforce were managers, down from 3.75% in September 2009 – a decline of more than a fifth (21.0%). By comparison, across the entire UK economy, approximately 11% of staff work in management roles, ¹²⁹ Office for National Statistics, ‘Dataset: EMP04: Employment by occupation’, 11 September 2018, retrieved 5 July 2023, www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employmentandemployeetypes/datasets/employmentbyoccupationemp04  although a good proportion of management work in hospitals is (and should be) carried out by doctors and nurses. Management spending is also lower versus other countries. The UK spent 1.9% of its health spending on administration in 2021, below countries such as Ireland, the Netherlands, Germany and France, which spent 2.2%, 3.7%, 4.4% and 5.5% respectively. ¹³⁰ Anandaciva S, How Does the NHS Compare to the Health Care Systems of Other Countries?, The King’s Fund, 2023, p. 60, https://assets.kingsfund.org.uk/f/256914/x/7cdf5ad1de/how_nhs_compares_other_countries_abpi_2023.pdf  But there are also comparison issues here, as the type of funding model that each country employs affects administration costs. ¹³¹ Mueller M, Hagenaars L and Morgan D, ‘Administrative spending in OECD health care systems: where is the fat and can it be trimmed?’, in OECD, Tackling Wasteful Spending on Health, 2017, p. 233, www.oecd-ilibrary.org/administrative-spending-in-oecd-health-care-systems-where-is-the-fat-and-can-it-be-trimmed_5jg33l5fvls6.pdf?itemId=%2Fcontent%2…

More management is not always a good thing. After a certain point, the benefits of additional managers will start to decline. But work carried out by academics at the University of Leeds found that the ratio of managers to staff in hospitals in England was below the optimal level (1.8% versus 3%). ¹³² Veronesi G, Kirkpatrick I and Altanlar A, ‘Are public sector managers a “bureaucratic burden”? The case of English public hospitals’, Journal of Public Administration Research and Theory, 2019, vol. 29, no. 2, p. 27, https://eprints.whiterose.ac.uk/138767/3/JPART%20Are%20public%20sector%20managers%20a%20bureaucratic%20burden%20PURE.pdf  

^{* This does not necessarily mean that the NHS has to increase the number of beds in hospital. It could also try to treat more people in other settings such as community care, or through improved prevention.}

^{** With a type 1 (major) A&E unit.}

This lack of management capacity makes it difficult to use scarce NHS resources effectively. Operating theatres may be under-used, rotas may be poorly designed and administrative work that is not done may fall to front-line staff.

The NHS Long Term Workforce Plan ¹³⁴ NHS England, NHS Long Term Workforce Plan, 2023, https://www.england.nhs.uk/publication/nhs-long-term-workforce-plan/  lays out specific targets for doctors, nurses and allied health professionals,* but there are no ambitions for management or administrative staff. While easier to train than clinical staff, it is short-sighted to assume that there will be a reliable supply of well trained managers. Without commensurate planning and hiring of that portion of the workforce, the new government risks not achieving as much from the expanded clinical workforce as it might otherwise.

Staff are less experienced than they were before the pandemic

There was a large movement of staff out of the NHS after the worst of the pandemic in 2021. Staff left for a number of reasons, including burnout from high workloads during the pandemic and dissatisfaction with pay. The NHS workforce has also rapidly expanded in recent years. The result is that staff are less experienced on average than before. For example, the number of nurses on the Nursing and Midwifery Council’s (NMC) register with fewer than five years’ experience grew by 57.2% between September 2017 and September 2023, while the number of nurses with more than 30 years’ experience fell by 2.9% over the same period. All else being equal, less experienced staff will be less effective in their roles.
 

^{* Allied health professionals are NHS staff who provide a range of services such as physiotherapy, pharmacy, osteopathy and podiatry.}

The problem is not contained to hospitals

Productivity issues are most visible in hospitals (largely because hospitals are the part of the health and care system for which there is the best data) but both the causes and the effects of these issues are visible across the wider health and care system.

One of the most high-profile examples of this is in social care. A key determinant of patient flow – and therefore performance – is the ability of hospitals to discharge patients in a timely manner. But hospitals have difficulty discharging people who no longer need to be in hospital. Throughout April 2024, approximately 12,750 patients a day remained in hospital despite no longer meeting the criteria to reside. ¹⁵⁵ NHS England, ‘Urgent and emergency care daily situation reports 2023–24’, (no date) retrieved 5 July 2023, www.england.nhs.uk/statistics/statistical-work-areas/uec-sitrep/urgent-and-emergency-care-daily-situationreports-2023-24  Given there were 100,902 general and acute beds available in hospitals in that month, ¹⁵⁶ NHS England, ‘Critical care and general & acute beds – urgent and emergency care daily situation reports’, (no date) retrieved 5 July 2023, www.england.nhs.uk/statistics/statistical-work-areas/bed-availability-andoccupancy/critical-care-and-general-acute-beds-urgent-and-emergency-care-dai…  it means that roughly one in eight beds were occupied by people who did not need to be in hospital. This partly reflects problems inside hospitals, but is also indicative of a lack of capacity in other services, particularly social care. The Nuffield Trust estimates that 43% of those delayed more than seven days and 47% of those delayed more than 21 days are waiting for social care. ¹⁵⁷ Nuffield Trust, ‘Delayed discharges from hospital’, QualityWatch, Indicator, 14 December 2023, www.nuffieldtrust.org.uk/resource/delayed-discharges-from-hospital  Conversely, delays in discharges increase the risk that people lose their mobility, necessitating additional support from social care and other services.

Delivering the planned workforce will be extremely difficult

The proposed expansion in training places is incredibly ambitious

Parliament, think tanks and bodies such as the National Audit Office spent years calling for a thorough and extensive workforce plan for the NHS. The Sunak government finally delivered that plan in June 2023 with the NHS Long Term Workforce Plan (LTWP). ¹⁵⁸ NHS England, NHS Long Term Workforce Plan, 2023, https://www.england.nhs.uk/wp-content/uploads/2023/06/nhs-long-term-workforce-plan-v1.21.pdf  The vision laid out in that document is ambitious and welcome. By 2031/32, its aims include:

• doubling the number of medical school training places
• increasing the number of GP training places by 50%
• increasing adult nursing training places by 92%. ¹⁵⁹ NHS England, NHS Long Term Workforce Plan, 2023, P.7, https://www.england.nhs.uk/wp-content/uploads/2023/06/nhs-long-term-workforce-plan-v1.21.pdf

Labour has committed to delivering the LTWP but doing so will require expanding the number of training places in universities and the number of educators in services. Work from the Health Foundation estimates that those training for clinical roles will account for approximately 16% of all first year student enrolments in 2031/32, up from 11% in 2022/23. ¹⁶⁰ Shembavnekar N, Kelly E and Charlesworth A, ‘How feasible are the NHS Long Term Workforce Plan commitments on training?’, The Health Foundation, 2023, https://www.health.org.uk/publications/long-reads/how-feasible-are-the-nhs-long-term-workforce-plan-commitments-on-training  In other words, one out of every six students in the UK will be studying to enter a clinical role.

The Sunak government committed £2.4 billion of funding between 2024/25 and 2028/29 to expand university training places. ¹⁶¹ Comptroller and Auditor General, NHS England’s Modelling for the Long Term Workforce Plan, Session 2023–24, HC 636, National Audit Office, 2024, p. 4, https://www.nao.org.uk/wp-content/uploads/2024/03/NHS-Englands-modelling-for-the-Long-Term-Workforce-Plan.pdf  But that money is being put into a higher education system that is under immense financial pressure, with many universities warning that they may have to close or substantially pare back the services and courses that they offer. ¹⁶² Adams R, ‘Universities in England risk closure with 40% facing budget deficits, says report’, The Guardian, 16 May 2024, www.theguardian.com/education/article/2024/may/16/universities-in-england-risk-closurewith-40-per-cent-facing-budget-deficits-report-office-for-stude…

There will also need to be an increase in clinical placements – a challenge that the LTWP itself acknowledges. ¹⁶³ NHS England, NHS Long Term Workforce Plan, 2023, P.89, https://www.england.nhs.uk/wp-content/uploads/2023/06/nhs-long-term-workforce-plan-v1.21.pdf  The LTWP’s proposal for addressing this (“We will work with stakeholders… to ensure clinical placements are designed into health and care services, and placement providers know what core standards they need to meet” ¹⁶⁴ NHS England, NHS Long Term Workforce Plan, 2023, P.89, https://www.england.nhs.uk/wp-content/uploads/2023/06/nhs-long-term-workforce-plan-v1.21.pdf ) is incredibly vague and does little to reassure that there is a clear plan for how the government can achieve this target.

More training places requires more permanent, qualified staff to train incoming staff. These staff (referred to from here on as ‘educators’) are already under substantial pressure. In its 2023 survey of educators and trainees, the General Medical Council (GMC) found that less than half of educators (46%) can devote the full amount of time that they are supposed to to training due to competing pressures. ¹⁶⁵ General Medical Council, National Training Survey: 2023 results, 2023, p. 3, www.gmc-uk.org/-/media/documents/national-training-survey-2023-initial-findings-report_pdf-101939815.pdf  The NHS released a strategy for increasing the size of the educator workforce, ¹⁶⁶ NHS, Educator Workforce Strategy, 2023, www.hee.nhs.uk/sites/default/files/EducatorWorkforceStrategy.pdf  but is yet to publish the implementation plan for that strategy. ¹⁶⁷ NHS England, ‘Implementing the Educator Workforce Strategy’, (no date) retrieved 5 July 2023, www.hee.nhs.uk/our-work/educator-workforce-strategy/implementing-educator-workforce-strategy  Concerns about growing the educator workforce seem particularly pertinent in general practice, where there are fewer fully qualified GPs working in the service than in 2019.

Implementing the NHS Long Term Workforce Plan (LTWP) will be expensive

Aside from the practical implementation challenges, implementing the LTWP will be expensive and have implications for the new government’s wider taxation and spending plans. The Institute for Fiscal Studies estimates that the government will need to increase NHS spending by 3.6% a year in real terms to meet the ambitions of the LTWP. ¹⁶⁸ Warner M and Zaranko B, ‘Implications of the NHS Workforce Plan’, in Institute for Fiscal Studies, IFS Green Budget 2023, https://ifs.org.uk/publications/implications-nhs-workforce-plan  While this is below the average increases in government health spending of 4.3% a year between 1949/50 and 2009/10, it is well above the 1.7% a year average between 2009/10 and 2019/20. This amount also understates the spending that would be needed to deliver the LTWP as it only includes staffing costs, whereas the LTWP modelling assumes sustained capital investment in technology and the estate. ¹⁶⁹ Comptroller and Auditor General, NHS England’s Modelling for the Long Term Workforce Plan, Session 2023–24, HC 636, 2024, p. 35, www.nao.org.uk/wp-content/uploads/2024/03/NHS-Englands-modelling-for-the-Long-Term-Workforce-Plan.pdf  Funding the LTWP will likely require difficult trade-offs, either in terms of more taxation or borrowing, or else cuts to other public services.

The NHS has become reliant on international recruitment

The LTWP states that nearly a quarter of staff are currently recruited internationally and that the goal is to reduce that number to “around 9–10.5% of our workforce” in 15 years’ time. ¹⁷⁰ NHS England, NHS Long Term Workforce Plan, 2023, p. 8, www.england.nhs.uk/wp-content/uploads/2023/06/nhs-long-term-workforce-plan-v1.21.pdf  But recent trends have gone in the opposite direction. Since the middle of the pandemic, the NHS and the adult social care sector have increasingly relied on recruitment from outside the UK to fill workforce vacancies. The number of joiners to the NHS’s doctor and nursing workforce from outside the UK rose by 43.9% and 71.9% respectively between March 2020 and December 2023. In comparison, the number of joiners from the UK was relatively flat in the same period. That trend has been even more stark in the GP workforce. The proportion of GP trainees that are from the UK fell from 70.7% in September 2015 to 49.6% in April 2024. A similar dynamic has taken place in the social care workforce.

There was a large exodus of staff from both the NHS and adult social care workforces from June 2021 onwards. A record 10.8% of NHS staff voluntarily resigned in the 12 months to June 2022, more than 10% higher than the pre-pandemic record of 9.7%. ¹⁷¹ Hoddinott S and Davies N, Performance Tracker 2022/23: Spring update, ‘Hospitals’, Institute for Government, 2023, www.instituteforgovernment.org.uk/performance-tracker-2022-23/hospitals  That was for a number of short- and long-term reasons such as dissatisfaction with pay, more attractive pay in competing sectors and pandemic burnout. This led to a large number of vacancies and services subsequently turning to international recruitment as a way to grow their workforces.

But relying on international recruits has generated a political backlash. After record- high net migration numbers, the Sunak government tightened visa rules for health and care workers at the end of 2023. ¹⁷² House of Commons, Hansard, ‘Legal migration: vol. 742’, 4 December 2023, https://hansard.parliament.uk/commons/2023-12-04/debates/921A08A2-F615-48F2-8C56-423A29556F9F/LegalMigration  That decision could jeopardise the ability of both the NHS and the adult social care sector to find enough staff. Even if the new government can expand training places in line with ambitions in the LTWP, it will need to find a way to balance the immediate needs of the workforce against political pressure to reduce net migration. This is particularly true if there is not a reversal in the poor staff retention record of recent years.

There is a risk of further industrial action

Delivering the LTWP also relies on retaining and getting the most out of the existing workforce. The last parliament saw the worst period of industrial relations in the NHS’s history. Nurses, ambulance workers, consultants and junior doctors have all walked out of hospitals at various points since 2022.

The Sunak government resolved all but the junior doctors’ dispute. But industrial relations are still poor across the service. The British Medical Association (BMA) – the union that represents most doctors – is balloting GP partners on industrial action. ¹⁷³ BMA, ‘GP leaders in England vote to launch a ballot for collective action’, 16 May 2024, https://www.bma.org.uk/bma-media-centre/gps-leaders-in-england-vote-to-launch-a-ballot-for-collective-action  And the Royal College of Nursing (RCN) – the union that represents a large proportion of the nursing workforce – has threatened renewed strike action in 2024. ¹⁷⁴ Mitchell G, ‘RCN ramps up warning over potential strikes in 2024’, Nursing Times, 15 December 2023, www.nursingtimes.net/news/workforce/rcn-ramps-up-warning-over-potential-strikes-in-2024-15-12-2023

The key driver of industrial disputes (and wider retention problems) is dissatisfaction with pay. Satisfaction with pay remains below pre-pandemic levels across the entire health service, but has fallen furthest among doctors: only 13.6% of junior doctors were satisfied with pay in 2023, down from 46% in 2020.

The upcoming reports by pay review bodies and the government’s response to these could trigger further industrial action. These would lead to the cancellation or rescheduling of elective procedures and absorb limited management capacity in trusts, distracting from some of the productivity-enhancing improvements that those managers could be working on. It could also potentially further reduce staff goodwill and discretionary effort – a factor that interviewees claimed is contributing to lower hospital productivity. ¹⁷⁶ Freedman S and Wolf R, The NHS Productivity Puzzle: Why has hospital activity not increased in line with funding and staff?, Institute for Government, 2023, p. 38, www.instituteforgovernment.org.uk/sites/default/files/2023-06/nhs-productivity-puzzle_0.pdf

Health and care services are too hospital-centred

Hospitals have long been the centrepiece of the NHS. They receive more funding and attention than any other part of the health and care system. To an extent, this is understandable. Equipping, staffing and operating a modern hospital is an intensely complex and expensive endeavour and it is where the NHS delivers some of the most visible and easily understood health care. And ambulance delays and A&E waits make for more dramatic news stories than the quiet and largely unseen – although invaluable – work of staff such as health visitors and district nurses.

Too often, there has been a tendency to wait for people’s health to deteriorate before then treating them in hospital. This is an expensive way to run a health and care system. This information is not unknown to the NHS: the King’s Fund estimates that governments have been attempting to shift care away from hospitals and to better integrate disparate parts of the health and care system since 1974. ¹⁸⁴ Baird B, Fenney D, Jefferies J and Brooks A, Making Care Closer to Home a Reality, The King’s Fund, 2024, p. 50, https://assets.kingsfund.org.uk/f/256914/x/ab65341d7a/making_care_closer_home_reality_report_2024.pdf  New Labour attempted it with the establishment of primary care trusts in 2000. ¹⁸⁵ Primary Care Trust Network, NHS Confederation, The Legacy of Primary Care Trusts, 2011, p. 3, www.nhsconfed.org/system/files/2021-07/The_legacy_of_PCTs.pdf  More recently, the 2019 NHS Long Term Plan made “boost[ing] ‘out-of-hospital’ care, and finally dissolv[ing] the historic divide between primary and community health services” one of the key priorities of its “new service model for the 21st century”. ¹⁸⁶ NHS, The NHS Long Term Plan, 2019, p. 13, www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf

The NHS and government have not made the most of integrated care systems One of the key innovations in the last parliament was the NHS-wide introduction of integrated care systems (ICSs) under the Health and Care Act 2022. ICSs are intended to join up health and care services at a local level, and shift the focus of the NHS away from output metrics and towards health outcomes such as population health and health inequalities. ¹⁸⁷ NHS England, ‘What are integrated care systems?’, (no date) retrieved 5 July 2023, www.england.nhs.uk/integratedcare/what-is-integrated-care  This work is led by integrated care boards (ICBs) at a local level, through which the majority of NHS funding flows.

The theory behind the introduction of these systems is sound, but implementation has thus far fallen short. The Conservative government put ICBs on a statutory footing in July 2022 and then decided to cut their management budgets by 30% in March 2023. ¹⁸⁸ Integrated Care System Network, NHS Confederation, The State of Integrated Care Systems 2022/23: Riding the storm, 2023, www.nhsconfed.org/publications/state-integrated-care-systems-202223  This meant that ICB leaders then spent the following months cutting programmes and staff that they had only recently launched or hired.

ICBs have also often been pulled into firefighting in the acute hospital sector. This is partly because of the context of the past few years. NHS strikes started five months after the establishment of ICBs in December 2022 and improvements in hospital performance have been anaemic since the end of the pandemic, absorbing press and ministerial attention. As a result, ICBs have been under pressure from ministers and NHS England to focus on hospital performance. As the old adage goes, what you measure matters and there is far more data about what is happening in hospitals. ¹⁸⁹ Baird B, Fenney D, Jefferies J and Brooks A, Making Care Closer to Home a Reality, The King’s Fund, 2024, p. 17, https://assets.kingsfund.org.uk/f/256914/x/ab65341d7a/making_care_closer_home_reality_report_2024.pdf

Acute hospital trusts have a disproportionately strong voice in ICBs. They have by far the biggest budgets and the most staff. Funding flows – for example, payment by results, wherein NHS England pays hospitals for carrying out more elective activity – also incentivise more activity in hospitals. ¹⁹⁰ Baird B, Fenney D, Jefferies J and Brooks A, Making Care Closer to Home a Reality, The King’s Fund, 2024, p. 21, https://assets.kingsfund.org.uk/f/256914/x/ab65341d7a/making_care_closer_home_reality_report_2024.pdf  As a result, ICBs have often focused on issues in hospitals at the expense of reforms to the wider health and care system.

The number of fully qualified GPs and GP partners has fallen since 2019

The number of fully qualified GPs has declined most in the most deprived parts of England

There has been a steady attrition of fully qualified GPs from the general practice workforce in recent years. Between September 2015 and May 2024, the number of fully qualified full-time equivalent (FTE) GPs declined by 1,570 or 5.5%. While there was an increase of 477 fully qualified GPs between July 2023 and May 2024, this still leaves the total much lower than in 2016. During the same period, the number of patients in general practice grew by 11.3%. There are now 2,350 patients for every GP in England, up from 1,990 in September 2015 – an increase of 18.0%.

That change has not happened equally across England. The ratio of patients to GPs has increased far more quickly in the most deprived parts of the country as both the numbers of GPs working in those areas has declined and the number of patients has grown. In March 2024, in the most deprived decile of the country there were 16.3% more patients for every GP compared with the least deprived parts of the country – 2,526 compared with 2,172.

This trend poses a substantial threat to the effectiveness of general practice and any government’s ambitions to improve access to primary care, reduce health inequalities and make a shift towards a more preventative model of health care.

Higher numbers of GP trainees are not translating into fully qualified GPs

The NHS has focused on improving the supply of GP trainees. It has been incredibly effective at doing this: the number of GP trainees increased from 2,671 in 2014 to 4,032 in 2022 – an increase of 51%. The LTWP lays out an ambition to further increase this to 6,000 by 2031.

But rapidly rising numbers of GP trainees are not translating into the necessary fully qualified GP workforce. Between September 2015 and September 2022, 27,784 GP trainees started training placements. ¹⁹⁵ NHS England, ‘Over 4,000 trainee GPs accepted on placements’, 23 November 2022, www.hee.nhs.uk/newsblogs- events/news/over-4000-trainee-gps-accepted-placements  While not all trainees who start their training finish it, a good proportion will and they will then be eligible to work as fully qualified GPs. Despite that, the number of GPs fell from 28,590 in September 2015 to 27,020 in May 2024 – a decline of 1,570 or 5.5%. Some GPs have retired at the end of their careers or otherwise left the service, but others have not taken their place.

There are several reasons for this. Interviewees reported that trainees are often put off working in the service by high workloads. This is supported by General Medical Council (GMC) polling, which shows trainee burnout increasing consistently between 2020 and 2023. ¹⁹⁶ General Medical Council, National Training Survey: 2023 results, 2023, p. 23, www.gmc-uk.org/-/media/documents/national-training-survey-2023-initial-findings-report_pdf-101939815.pdf

Paradoxically, there are reports of very few available jobs for salaried GPs, despite high demand for their services. ¹⁹⁷ Parr E, ‘Thousands of new GPs could be unemployed this summer, warns BMA’, Pulse Today, 30 May 2024, www.pulsetoday.co.uk/news/workforce/thousands-of-new-gps-could-be-unemployed-this-summer-warns-bma  It seems that this is due to a lack of core funding (which has risen less quickly than inflation since 2019) – the pot of money that GP partners use to pay for the majority of practice staff salaries – and the previous government’s decision to prohibit GPs from using funding from the Additional Roles Reimbursement Scheme (ARRS) to hire GPs. And the situation is not expected to improve, with the LTWP assuming, bizarrely, no growth in fully qualified GPs over the course of this parliament. ¹⁹⁸ Comptroller and Auditor General, NHS England’s Modelling for the Long Term Workforce Plan, Session 2023–24, HC 636, 2024, pp. 42–4, www.nao.org.uk/wp-content/uploads/2024/03/NHS-Englands-modelling-for-the-Long-Term-Workforce-Plan.pdf

Some of this is also due to a growing lag between GPs finishing training and joining the fully qualified workforce. Only 44.9% of those trainees who completed training in the year ending June 2022 had joined the workforce after a year, compared with 48.2% of those finishing training in the year ending June 2019.

There is a crisis in the GP partner workforce

Hidden beneath the headline figures of declining numbers of fully qualified GPs is a greater crisis in the GP partner workforce.* While the number of fully qualified GPs declined by 5.5% between September 2015 and May 2024, the GP partner workforce declined even more precipitously, by 25.9%.

^{* The GP workforce is split into GP partners, who are effectively independent contractors who own and operate practices, and salaried GPs, who practices employ to deliver GP services.}

The issue is most severe among younger GP partners. The number of GP partners under the age of 40 more than halved (-53.0%) between September 2015 and May 2024, falling from 4,152 to 1,949. In comparison, the number of salaried GPs under the age of 40 rose from 3,793 to 5,090 in the same time period, an increase of 34.2%.

Partnership is often unattractive because it requires substantial up-front investment of personal money, particularly into the premises. ²⁰⁴ Hoddinott S, Delivering a General Practice Estate that is Fit for Purpose, Institute for Government, 2024, p. 11, www.instituteforgovernment.org.uk/publication/general-practice-estate  The unlimited liability model of many partnerships means that GP partners can often find themselves personally responsible for paying off practice liabilities in the event they want to wind up the partnership. ²⁰⁵ GP Partnership Review: Final report, GOV.UK, 2019, p. 17, https://assets.publishing.service.gov.uk/media/5c3ca241ed915d50b4b47223/gp-partnership-review-final-report.pdf  Partnership is also incredibly inflexible. Once a GP enters a partnership, they are generally tied to a location for a number of years, if not decades. Finally, being a GP partner is much harder in a context of constrained spending increases. They have to manage tight budgets that, since 2019 at least, have not kept pace with inflation.

For a service where delivery relies on GPs taking on partnership, this should sound serious alarm bells about the sustainability of the current model.

Pressure on GPs is rising and funding is not keeping pace

This workforce crisis is happening for a few reasons. GP workloads have arguably never been higher. GPs delivered a record 161.9 million appointments in 2023/24, up from 154.1 million in 2019/20 – an increase of 5.0%. This is a remarkable achievement given the fall in the number of fully qualified GPs in that time. But it likely comes at a cost. In the most recent GP Worklife Survey (conducted in 2021), GPs reported that increasing workloads were the most significant stressor in their jobs. ²⁰⁶ Odebiyi B, Walker B, Gibson J and others, Eleventh National GP Worklife Survey 2021, PRUComm, p. 15, https://prucomm.ac.uk/assets/uploads/Eleventh%20GPWLS%202021.pdf  This is understandable: they were rapidly changing ways of working and attempting to handle the needs of a population during a global pandemic. It is likely that workloads have risen further since 2021. And there is arguably an invisible backlog of unmet need that general practice is attempting to manage. NHS England’s decision to manage demand off the elective waiting list through the increased use of diversionary measures such as advice and guidance has exacerbated this.* In its assessment of advice and guidance, the National Audit Office (NAO) argues that “it is unclear whether GPs will be able to manage the additional workload that might result”. ²⁰⁷ Comptroller and Auditor General, Managing NHS Backlogs and Waiting Times in England, Session 2022–23, HC 799, National Audit Office, 2022, p. 24, www.nao.org.uk/wp-content/uploads/2022/11/managing-NHSbacklogs-and-waiting-times-in-England-Report.pdf  

Another source of dissatisfaction – particularly among GP partners – is that the Conservative government did not adjust the 2019 GP contract enough (which ran between 2019/20 and 2023/24) to account for the full range of new responsibilities during and after the pandemic and the rising costs that were a result of the bout of inflation that gripped the country from 2022. ²⁰⁸ Hoddinott S and Davies N, Performance Tracker 2023, ‘General practice’, Institute for Government, 2023, www.instituteforgovernment.org.uk/publication/performance-tracker-2023/general-practice#the-2023/24-gp-contract-does-not-increase-funding-in-line-wit…-

One area of funding that has exceeded inflation is the ARRS pot of money. The ARRS has funded an enormous increase in the number of what are known as ‘direct patient care’ (DPC) staff.** Between March 2019 and March 2024, the number of DPC staff working in primary care grew from 11,519 to 50,794 – an increase of 39,275, or 341%. The number of DPC staff is now almost double (1.89 times) the fully qualified GP workforce, having started the last parliament at approximately 40%.

^{* Under advice and guidance, GPs discuss with colleagues in hospitals whether or not they need to refer someone for more specialist care. The stated aim of this is to ensure that patients’ care is managed in the most appropriate setting.}

^{** This includes staff groups such as pharmacists, care co-ordinators and social prescribing link workers.}

The addition of ARRS staff was intended to improve access to care and to reduce pressure on GPs. For example, pharmacists can now prescribe some things like the oral contraceptive pill and take patients’ blood pressure. ²¹¹ Department of Health and Social Care and NHS England, Delivery Plan for Recovering Access to Primary Care, NHS England, 2023, p. 2, www.england.nhs.uk/wp-content/uploads/2023/05/PRN00283-delivery-plan-forrecovering-access-to-primary-care-may-2023.pdf  While this is likely to have increased the number of people seen in general practice, there is also evidence that it has worsened GP workloads. ARRS staff are doing a lot of the low-complexity work that GPs previously did. But high levels of demand for GP services mean that the appointment slots that were previously taken up by less complex patients are immediately filled with more complex patients. GPs are then required to treat as many complex patients in the same amount of time while also managing many of these new staff. ²¹² Baird B, Lamming L, Bhatt R’T, Beech J and Dale V, Integrating Additional Roles into Primary Care Networks, The King’s Fund, 2022, https://assets.kingsfund.org.uk/f/256914/x/1404655eb2/integrating_additional_roles_general_practice_2022.pdf

The new government must make stemming the steady drip of fully qualified GPs from the service a priority. This is particularly true for GP partners, on whom the current model of general practice relies.