“If general practice fails, the whole NHS fails.” So goes the received wisdom. But poor political choices, policy failure and the fallout from the pandemic have left general practice on the brink of disaster.
Last week the Health Foundation published its projections regarding the future of the general practice workforce. They make for grim reading. In none of the modelled scenarios will there be enough GPs or practice nurses over the next 10 years. Currently, around one in eight GP posts are vacant (though these aren’t equally distributed—there are fewer GPs in the most deprived areas of the country). If existing policies aimed at boosting the number of GPs and other practice staff work, and more initiatives are added (particularly focusing on blending newer staff roles—like physios and paramedics—into general practice teams) we stand a chance of containing the shortfall—to around one in 10 vacant GP posts by 2030/31. But few experts believe that to be a realistic possibility. The government has never been on track to meet its target of 6,000 more GPs by 2024, and is likely to miss it by some distance.
Unless new policies to recruit and retain GPs are successfully introduced, we’re likely to see a shortfall of one in four GPs by 2030/31. The same grisly number—one in four posts vacant—will be true for practice nurses too. But in the analysts’ pessimistic scenario, if rising demand for care isn’t sufficiently offset by bringing additional staff into general practice, and the number of GPs quitting the profession continues to rise, then one in two GP posts could be vacant by 2030/31.
Workforce shortages of this magnitude are an existential threat to an essential NHS service. Last year, general practice delivered almost 370m appointments—a whopping 18.5 per cent increase on 2019 (and with fewer GPs). GPs play a crucial role in keeping people well, and in reducing the demand on hospitals. As “gatekeepers,” they control who gets referred for non-emergency hospital care—and they look after people waiting for specialist services. When demand for general practice exceeds what it can supply—as it has done recently—patients suffer. A wealth of evidence shows that health systems with strong primary care are the most efficient, cost-effective and safe. General practice can’t be allowed to fail, but what will it take to keep it alive?
First, general practice needs support to get its own house in order. Retaining existing GPs is vital. The overwhelming driver of GPs quitting is their relentless and rising workload. That must reduce—and with it, GP job satisfaction should rise. GPs consistently say that they want longer appointments and more time with patients; that’s likely to benefit the public too. Reducing the amount of paperwork GPs do will help. Technology has a role to play in helping GPs and their teams increase efficiency—as it does in helping patients access general practice—but there is work to be done in understanding what works, and in supporting practices to implement new innovations well. Above all, “digital” must not become an inadvertent barrier to accessing care. And alongside this is fixing the basics—getting working IT, joined up between GP and hospital services—and making sure that GP premises are fit for purpose. Delivering these requires money.
Second, GPs must learn to work with different health professionals as part of the core primary care team. Since 2019, an expanded range of roles have been funded to work through general practices—including physios, pharmacists, paramedics and mental health practitioners. General practice needs help in managing and making the best use of these staff. GPs and patients value continuity of care—seeing the same person over time and building a trusted relationship. Continuity must be preserved—but this may be continuity within a wider team, and must be delivered alongside rapid access for those needing same-day care.
Third, politicians must level with themselves and with the public. For too long there has been an expectation that there will—one day soon—be enough GPs. The Health Foundation’s projections require us to think differently. General practice urgently needs a proper workforce plan. But even then, there will be shortages for 10 years or more. Politicians and senior NHS leaders must instead think about how to deliver a service—and set expectations around what that service can deliver—in the context of severe GP shortages. This will require real policy change, and some difficult conversations with the public about how they should use the service and what they can expect. Politicians and NHS leaders must be clear that people may not always have immediate access to a GP of their choice. But they should always have access to high-quality primary care, delivered by an expanded general practice team. Raising expectations, then bashing GPs for failing to deliver the undeliverable must stop.
Destabilise general practice and you destabilise the NHS.
