Dr David Jenner Presents an In-depth Analysis of Staff Numbers in Primary Care Teams, Assesses the Impact on Services, and Suggests Strategies to Tackle Shortages
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Find key points and implementation actions for clinical pharmacists in general practice at the end of this article
For several years now, there has been recognition that GPs and the wider primary care workforce are under pressure. Gone are the days when a career in general practice was seen as highly desirable and fulfilling. Nowadays, GP practices are finding it difficult, if not impossible, to recruit and retain staff; as a result, many surgeries are closing or merging.
Recruitment in General Practice: Broken Promises
In 2015, the Secretary of State for Health and Social Care, Jeremy Hunt, responded to the developing workforce crisis by promising a further 5000 GPs by 2020 to take forward the Government’s ambitious plans for primary care.1 This pledge was captured in the Five year forward view;2 however, the additional GPs failed to materialise, and in the year to September 2017, the total number of full-time equivalent (FTE) GPs in fact fell by 1193.1
In 2018, Mr Hunt’s successor, Matt Hancock, reiterated the Government’s commitment to recruit an additional 5000 GPs3 but, by June 2018, the workforce had fallen by more than 1400 FTE GPs relative to when the target was set in 2015.3 Later that year, Mr Hancock quietly withdrew the deadline for the workforce increase,3 but only after exaggerating progress towards meeting the target by including trainees in the number of GPs working in the NHS.4
The 2019 Conservative Party manifesto reaffirmed the Government’s pledge to provide more GPs—this time, 6000 by 2024–2025, and 50 million more GP appointments a year.5,6 However, half of these primary care doctors will be trainee GPs, 500 of whom will be recruited each year up to a total of 3000, and who will spend more time in training in general practice.6 Under the plans, the remainder are to come from international recruitment and better retention of staff.5
Published in 2016, the General practice forward view set out ambitions for 1500 extra practice pharmacists and 1000 physician associates by 2020 in primary care,7 although it was unclear if these targets related to FTE or headcount. A further promise in the Conservative Party manifesto in 2019 was for 50,000 more nurses and 6000 other primary care healthcare professionals such as physiotherapists and pharmacists, alongside earlier commitments to provide 7500 extra nurse associates and 20,000 other primary care healthcare professionals.5 Plans to recruit more than 20,000 new members of the multidisciplinary primary care team by 2023–2024 via the Additional Roles Reimbursement Scheme (ARRS) were revealed in the new GP contract, which was published in January 2019.8
Given all these plans and pledges, what is the reality today? In November 2021, the current Secretary of State for Health and Social Care, Sajid Javid, admitted to the Health and Social Care Select Committee that the Government is not on track to meet the target of 6000 more GPs.9 Mr Javid said that more must be done to support GPs to discourage them from leaving the profession.9 However, Mr Javid’s winter emergency package, intended to help GPs during the challenging winter period, was deemed ‘an unacceptable response to the current crisis’ by 93% of BMA members, and threatened to result in more staff leaving the profession.10
The Current GP Workforce
When calculating the number of GPs currently working in primary care, different agencies use different figures. NHS England is claiming an increase in GPs by including trainees,11 but the official data for England issued by NHS Digital tell a different story (see Table 1).12,13
Table 1: The Changing GP Workforce in England12,13
|October 202113||September 202012||September 201512|
|FTE fully qualified GPs, excluding GPs in training grades||27,659||27,702||28,115|
|FTE GPs, including GPs in training grades||36,118||35,155||33,056|
|FTE GP partners||16,823||17,486||20,732|
An FTE GP trainee does not equate to an FTE fully qualified GP in terms of direct patient care. GP trainees do not work at the same pace as fully qualified GPs, they have time away from patient care for study and supervision, and they spend some of their training period in hospital jobs.
One issue that may be contributing to the workforce shortfall is an increase in part-time working. Many GPs wish to reduce (or have reduced) their hours because fulfilling the core contract has become so stressful and onerous. Some GPs work part time to allow for parenting responsibilities, and many do so because they are also working in other important roles—in particular, with medical schools and as primary care network (PCN) medical directors. This may take them away from front-line patient care, but these other roles remain vital for the continued provision of the GP workforce and delivery of care.
The Future of GPs Currently Working in Primary Care
On the face of it, there are encouraging signs: we are training more GPs, so the entrance to the profession is clearly open wide. However, when it comes to GPs exiting the profession, the statistics are frightening (see Box 1).13,14
|Box 1: The Ageing GP Workforce in 202113,14|
And, sobering news as to the career intentions of GPs was provided by the BMA Tracker Survey conducted in April 2021 (although it is important to remember that the results reflect the intentions of the BMA members surveyed, which may not be enacted):15
- 32% (1352) of nearly 4200 respondents were considering early retirement compared with 14% in June 2020
- 50% (2099) were considering reducing their hours
- 17% (728) were considering moving abroad
- 21% (882) were considering leaving the NHS for another career
- 25% (1065) said that they were more likely to be taking a career break.
The International Recruitment Programme
The most recent figures for the international recruitment programme are from 2018, and show that only 58 GPs have been recruited from the scheme so far,16 representing less than 3% of the 2000 target set by NHS England in 2017 for completion by 2020.17 No data have since been published, suggesting that this programme is not delivering large numbers of new GPs.
In summary, there is real promise in the number of new applicants to GP training schemes (provided they commit to careers in general practice), but real concern over retention of the current workforce.
Recruitment to the Wider Primary Care Team
There is good news regarding the recruitment of pharmacists to GP practices—The Nuffield Trust estimates that 2148 pharmacists were employed in PCNs and GP practices in the first quarter of 2021, up 1923 from 225 in the first quarter of 2016.18 For physician associates, the number employed in PCNs and GP practices in the first quarter of 2021 was 507, an increase of 484 from 23 in the first quarter of 2016.18 This may be a reflection of the fact that physician associates are as yet unable to prescribe or request X-rays, which may be a barrier to their recruitment by practices and PCNs.
The arrival of the COVID-19 pandemic in the UK in early 2020 made recruitment more complex, and diverted GPs and practice managers from this important task. PCNs have reported difficulty in recruiting to additional roles in primary care. Indeed, in a survey conducted by Pulse in summer 2020, 64% of 179 PCN clinical directors said that their network had so far failed to fill its ARRS allocation for 2020–2021.19 And in the 2021 Guidelines in Practice survey, healthcare professionals reported difficulties for PCNs in the recruitment of appropriately qualified staff,20 despite NHS England’s claims that there is sufficient supply.8
In the South West, where I work, there are no university pharmacy schools west of Bath, and across the country there is a shortage of pharmacists in community pharmacy,21 never mind to supply approximately six FTE clinical pharmacists in every PCN serving 50,000 patients, as required by NHS England by 2023–2024.8 Consequently, in April 2021, pharmacists were added to the Home Office’s Shortage occupation list.22
Is the ARRS On Track?
NHS England Board papers from June 2021 show that, as of 31 March 2021, PCNs had successfully recruited more than 9100 extra staff towards the 26,000 manifesto goal.23 This implies that, despite the pandemic, the programme is on course to meet its target. However, in a letter from NHS England to CCGs in October 2020, NHS England withheld 40% of ARRS funding (£173 million) from CCGs,19,24 suggesting that there is a real shortfall of recruitment against FTE roles, as the NHS England figures quote headcounts rather than FTE. Data for the other roles covered by the ARRS are currently unavailable, but the key indicator of progress against the target will be the monies withheld by the Government for ‘under-recruitment’ when these are published.
How Will Workforce Shortages Impact PCN Development?
The Guidelines in Practice survey on attitudes to the NHS restructure revealed real concern from 77% of respondents that workforce shortages will hinder both the development of PCNs and the Government’s new integrated care system (ICS) agenda, to which PCNs are key.20
The advent of PCNs and the accompanying Directed Enhanced Services (DES) brings additional work to primary care in the form of new service specifications,25 with the intention that associated costs will be met by the ARRS, and by ‘reward monies’ available from the Investment and Impact Fund (IIF); this has been expanded to include 666 new indicators.26 These specifications will generate significant extra work, including structured medication reviews, weekly ward rounds of patients in care homes, and the agreement of a care plan for every new admission to a care home within 1 week of arrival.25
Unfortunately, the staff reimbursed by the ARRS are often not suitably qualified to do this extra work, and the assumption that they will free up GPs’ and senior nurses’ time is often not correct—for example, pharmacists can perform structured medication reviews, but unless they have additional training and a prescribing qualification, a GP will have to make or approve the medication changes. Patients often now present with multiple problems outside the competence of ARRS staff such as paramedics and physiotherapists, and requiring GP input. There has, as yet, been no change in legislation to allow a wider range of healthcare professionals to issue sick notes, sign death certificates, and undertake other administrative tasks, which revert to GPs.
Challenges Around Implementation
Many of the new service specifications have been delayed to enable services to prioritise their response to the pandemic,27,28 but those already introduced as part of the DES in 2020 are proving challenging to implement.8,25 One key challenge for PCNs is the provision of ‘extended access’ appointments, at times outside of the practice’s contracted hours, 7 days a week—including bank holidays—from October 2022.8,25,27,29 Delivery of these extra appointments will become the contractual responsibility of PCNs rather than the commissioning responsibility of CCGs; thus, despite the workforce shortfall, constituent PCN practices will have to underwrite the provision and provide the staff to implement this specification.
On 3 December 2021, NHS England announced the suspension of some GP targets in recognition of the pressures currently faced by primary care.30 The measures are intended to facilitate acceleration of the COVID-19 booster vaccination programme in response to the emergence of the Omicron variant, and are detailed in Box 2.30
|Box 2: Measures Introduced in December 2021 to Support Increased Vaccination for Participating Practices30|
QoF=Quality and Outcomes Framework; IIF=Investment and Impact Fund; CQC=Care Quality Commission
Contains public sector information licensed under the Open Government Licence v3.0.
In future, when these suspensions are lifted, the published PCN DES specifications will require detailed care planning for those most at risk of admission;8,25 indeed, the IIF will offer reward monies related to standardised admission rates per care home resident and for specific medical conditions.26 Other targets in the IIF reward a range of prescribing indicators, vaccination rates, markers for access to GP services, and patient satisfaction with this access.26 The workforce shortfall may make it difficult for practices to meet these targets.
Also, some indicators in the IIF appear somewhat perverse, such as rewards for referrals to the community pharmacy scheme—in many areas, community pharmacy does not exist locally (for example, for rural dispensing practices), or does not have the workforce to respond to such referrals.21,26
The new GP contract promised initially partial, then later full, reimbursement of salaries for additional roles, tightly regulated by profession, salary range, and training requirements.8 Unfortunately, there was no associated estate strategy to house these additional team members, nor any allowance for the costs of recruiting, training, managing, and supervising them. This is in stark contrast to the GP trainee scheme, in which salaries are not only fully reimbursed, but there is also funding available to GP trainers, and training packages are provided to both trainers and trainees at no extra cost to the practice.31,32
Another issue with the PCN DES is that a large proportion of the funding (through the ARRS) is linked to successful recruitment, but if PCNs cannot recruit the staff—or if the staff leave—the work remains, even though a portion of the reimbursement is lost.25 This work will then often default to GPs and other members of the team.
In addition, the lack of reimbursement for nurses, nurse practitioners, GPs, or extra managers under the ARRS does not give PCNs and GP practices sufficient flexibility to meet the demands of their core contracts, the Quality and Outcomes Framework, the PCN DES, and the IIF, and means that they are subject to micromanagement from NHS England through CCGs.
What Should be Done to Solve the Shortfall?
Many GPs now feel that the expectations of the PCN DES exceed any benefits from the core funding to practices associated with the scheme and the reimbursement for staff; thus, the BMA is currently surveying the willingness of practices to submit an undated resignation from the PCN DES to force a renegotiation of the GP contract.33
What measures can be taken to improve the workforce situation?
The lack of planning and support to enable practices to recruit, house, train, and supervise additional members of the primary care team is a barrier to the success of the ARRS. Going forward, extra funding should be available to support practices to employ and train additional members of the primary care team, as per the GP training scheme.31,32
In addition, the range of roles covered by the ARRS should be broadened to allow PCNs and GP practices to choose which additional team members to recruit to best meet demands in their locality.
The Government wants GPs to refer more patients to community pharmacy for appropriate clinical services,34 but pharmacists are in short supply.21 In addition, PCNs have reported difficulty finding appropriately qualified healthcare professionals to fill other roles.20 Therefore, the number of trainees entering these professions must be increased, and more training provided to help existing staff to diversify.
It may be possible for the BMA to renegotiate the core contract to address the fact that many GPs wish to reduce their hours (or already have) in response to the stress of the job. However, at present, the core contract and PCN DES appear to be getting more complex, with greater demands on a dwindling workforce—could this be simplified in recognition of the GP effort in the COVID-19 vaccination programme?
As things stand, additional team members are often unable to order X-rays and prescribe medications, and so are incapable of relieving the unsustainable workloads faced by healthcare professionals working in primary care. Changes in legislation and extra training are needed to allow a wider range of healthcare professionals to tackle routine tasks such as approving medication changes, issuing sick notes, and signing death certificates.
Although some targets have been temporarily eased to enable the primary care workforce to deliver the accelerated vaccination programme,30 they will be reinstated; barriers to their attainment, such as workforce shortages and the backlog of care caused by the pandemic, must be taken into account.
Also, more should be done to ensure that targets set are relevant and fair to all PCNs, bearing in mind that they can serve very different populations (for example, not all are served by a community pharmacy or have any care homes).
Fundamentally, more must be done to retain staff already working in the NHS—possibilities include expanding and simplifying access to the National GP Retention Scheme,35 dedicated support for GPs nearing retirement age, and revisions to pension legislation.
Furthermore, at their annual appraisal, GPs should be asked about their career intentions, and what, if anything, could persuade them to keep working in the NHS, and increase—or at least not reduce—their hours. This information could then be fed back to policy makers to help secure the existing workforce.
What Does the Future Hold for PCNs?
So, what is in the future for PCNs in the new world of ICSs, which are destined to become statutory bodies in July 2022?36 Details in the 2021 Health and Care Bill (HCB) relating to GPs and PCNs are sparse, but the Bill does mention inclusion of a GP representative on each ICS board, and a pooled local budget that includes primary care funding.37
Reassuringly, GP contracts will remain centrally negotiated for now,8 but over time, as ICSs begin planning and negotiating local contracts with PCNs, will the core contract move from GP level to PCN level? This is already the case with some local enhanced service contracts. The move to ICSs in the HCB opens the door to planning at different levels; indeed, The King’s Fund suggests that one unit of planning will be ‘neighbourhoods’ —populations of 30,000–50,000 people that map closely with PCNs.38 In time, will these neighbourhoods be allocated budgets for care, and will their performance be managed to deliver against those budgets, like CCGs?
It is not currently clear what the future holds for PCNs, but if there was to be a mass resignation of practices from the PCN DES, the whole Government policy would be under threat, suggesting that a compromise on the terms of the DES would be likely. At the latest Local Medical Committee conference, a motion to instruct the BMA not to negotiate any extension to the PCN DES beyond 2023 was reportedly passed,39 which clearly casts doubt on the future of PCNs.
In a final twist, the current Chair of the Health and Social Care Select Committee, Jeremy Hunt, tabled an amendment to the HCB requiring the Secretary of State for Health and Social Care to publish a report detailing the system for assessing and meeting NHS workforce needs in England every 2 years.40 Ominously, this proposal was rejected in the House of Commons on 23 November 2021.40
The GP workforce and wider primary care team are under extreme pressure, yet more and more is being asked of the service based on the assumption that staff are available for recruitment through the ARRS and can successfully free up GPs to deliver the core contract and PCN DES specifications. The evidence so far suggests that these additional staff are too few and insufficiently qualified to relieve the pressure on GPs, and may in fact consume more GP time in supervision and training.20
Recruitment to GP training schemes looks positive, but can we retain the older GP workforce long enough for these new recruits to take over? To keep the workforce ‘bath’ full, it will be necessary not only to keep the tap running to supply new staff, but also to slow the exit of experienced older staff, especially GPs—and that will be the biggest challenge for PCNs going forward.
FTE=full-time equivalent; PCN=primary care network; DES=Directed Enhanced Service; ARRS=Additional Roles Reimbursement Scheme
Dr David Jenner
GP, Cullompton, Devon and member of the Guidelines in Practice Editorial Advisory Board
|Implementation Actions for Clinical Pharmacists in General Practice|
Written by Ziad Laklouk, Senior Clinical Pharmacist, Soar Beyond Ltd, and Didcot Primary Care Network
The following implementation actions are designed to support clinical pharmacists in general practice to effectively deliver the PCN contract DES specifications as part of an MDT.
PCN=Primary Care Network; DES=Directed Enhanced Service; MDT=multidisciplinary team; KPI=key performance indicators