The perfect storm: from a recruitment to an employment crisis in British general practice

Nada Khan is an Exeter-based GP and clinical academic, and an Associate Editor at the BJGP.

It feels like an almost unbelievable situation given the focus in past years on the GP recruitment and retention crisis, but senior general practice leaders are now warning of an employment crisis in general practice.  Dr Amanda Doyle, NHS England’s national director of primary care, has suggested that newly qualified GPs may struggle to find the jobs they want, a sentiment echoed by the British Medical Association (BMA) who warn of a ‘non-existent’ job market for GPs.¹  These concerns are on the back of a recent Royal College of GPs (RCGP) survey of over 2000 members in June which reports that 61% of GPs and 72% of GP trainees searching for a GP position found it difficult to find an appropriate job.²  And competition for those positions is rising.  Locum opportunities have dried up in many regions, which is likely contributing to increasing competition for the decreasing number of salaried GP posts advertised over the past year.³  Yet, while GPs are struggling to find work, patient demand and complexity is increasing and patient satisfaction with access to and availability of GP appointments is decreasing.⁴  This new, warped reality is serving nobody, but how have we ended up in this situation?

Drivers of an employment crisis

The answer is simple – jobs will follow the money, or perhaps more aptly, the lack of core money in general practice.³  Overall funding for GPs is falling in real terms, with practices concerned not just about staffing but about viability and cashflow, with some practices reducing staffing levels to remain open.⁵  The flawed GP contract and ongoing dispute over uplifts to the core practice contract funding and pay for contractor GPs is fuelling decisions about what practices can afford to provide in terms of clinical cover.  With ongoing contract negotiations and a ballot to take some form of action to voice dissatisfaction with the contract already in the mix, it’s time to try again with NHS England to build a case for appropriate investment in general practice staffing.  The upcoming election and newly formed government will impact on GP funding negotiations, but BMA analyses suggest that even if a new government was to more than quadruple the current uplift offer, practices would still be facing a funding shortfall compared with 2018/19.⁶

Additional roles in practice

While the number of fully qualified GPs working in general practices has fallen since 2019, the number of Primary Care Network (PCN) funded staff providing direct patient care under the additional roles reimbursement scheme (ARRS) has increased substantially.³  There is concern that these additional roles are being used as low-cost GP ‘replacements’ in the face of those GP core funding concerns, which is a sorry state of affairs given that the original goals of the ARRS programme were to help reduce GP workload and improve practice efficiency in the face of inadequate GP staffing supply.  ARRS initially aimed to enable GPs to work ‘at the top of their license’, not supplant their role or offer a more cost-effective staffing solution to practices struggling under the punitive terms of the currently imposed GP contract.⁷  Pulse recently pulled together figures to look at the association between practice income and staffing, which suggested that the lowest paid practices employed more physician associates, with potentially up to double the number of physician associates working in the least funded practices.⁸  Causation is difficult to attribute here, but Pulse suggests that lower paid practices might be unable to hire GPs and are role-substituting with physician associates whose salaries are reimbursed through the ARRS.

The ARRS funding going to PCNs is ringfenced for employing professionals such as nurse practitioners, physician associates and pharmacists but cannot be used to employ GPs.  GPs have been campaigning to get GPs included in the ARRS scheme to allow practices to use this money to employ salaried GPs.  NHS England, however, pushed back on this request stating that GPs are a ‘core’, not an ‘additional role’, suggesting that ARRS should not compensate for a shortage of core capacity in general practice.⁹  This is a difficult position to maintain with ARRS roles funded differently, and some might say preferentially, than the currently underfunded core roles.

There is clearly a building tension here between funding and roles in primary care.  The problem is not about the increasing multi-disciplinary team in primary care, which for many practices has been a positive step.¹⁰  The issue is how these roles, and GP roles are differentially funded.  The RCGP is continuing to ask for flexibility around ARRS funding around staffing requirements.²  How ARRS is implemented and what it funds needs to be kept under close review to avoid exacerbating staffing issues in general practice and undermining the original goals of the programme.

What do we need?

It is important to fully understand the scale of potential employment problems for GPs and why it is happening.  Much of what we know is through anecdotal evidence, informal surveys and chats from colleagues.  We need more information and evidence about who is impacted (newly qualified GPs, locums or salaried GPs) and which regions of the UK are affected and why.  The BMA is currently surveying GP locums on their experiences of locum work availability and the perceived factors impacting on appropriate jobs, including the impact of ARRS, but we need to understand the problem from the perspective of GP partners and others holding the purse strings.

A lack of jobs could act as a ‘push’ factor for those considering leaving the NHS altogether.  A BMA survey showed that 26% of GP trainees plan to work abroad alongside increasing concerns about the lack of jobs and the impact of roles including physician associates on future career prospects.¹¹  The recruitment and retention ‘crisis’ in general practice is far from being resolved, and it risks being seriously exacerbated by a lack of jobs in general practice.  To avoid feeding this perfect storm, we need to better understand the scale of the problem and its drivers, and act quickly to better support practices and the already weakened GP workforce.  

References

1. Colivicchi A. NHS England director admits GP trainee jobs ‘are not there for them’: Pulse; 2024 [Available from: https://www.pulsetoday.co.uk/news/workforce/nhs-england-director-admits-gp-trainee-jobs-are-not-there-for-them/.
2. GPs struggling to find jobs while patients are ‘crying out’ for appointments, says College: Royal College of General Practitioners 2024 [Available from: https://www.rcgp.org.uk/News/member-research-jobsearch-struggle.
3. Khan N. Amidst a GP workforce crisis, where did all the jobs go? Br J Gen Pract. 2024;74(739):72-3.
4. Fisher RB, J.; Alderwick, H.; Price, E.; Ansari, A.; Dixon-Woods, M.; Sinnott, C. Rethinking access to general practice: it’s not all about supply: The Health Foundation; 2024 [Available from: https://www.health.org.uk/publications/long-reads/rethinking-access-to-general-practice-it-s-not-all-about-supply.
5. BMA opens GP referendum on 2024/25 contract changes: British Medical Association; 2024 [Available from: https://www.bma.org.uk/bma-media-centre/bma-opens-gp-referendum-on-202425-contract-changes.
6. Protect your patients, protect your GP practice: British Medical Association; 2024 [Available from: https://www.bma.org.uk/our-campaigns/gp-campaigns/contracts/gp-contract-202425-changes.
7. Investment and evolution: A five-year framework for GP contract reform to implement The NHS Long Term Plan. BMA and NHS England; 2019.
8. How low-funded practices are more likely to rely on physician associates: Pulse; 2024 [Available from: https://www.pulsetoday.co.uk/analysis/special-investigations/the-rise-of-the-physician-associates/how-low-funded-practices-are-more-likely-to-rely-on-physician-associates/.
9. Colivicchi A. NHS England will not add GPs to ARRS because they are ‘not additional’: Pulse; 2024 [Available from: https://www.pulsetoday.co.uk/news/2024-25-gp-contract/nhs-england-will-not-add-gps-to-arrs-because-they-are-not-additional?.
10. Bramwell D, Hammond J, Warwick-Giles L, Bailey S, Checkland K. Implementing the Additional Roles Reimbursement Scheme in seven English Primary Care Networks: a qualitative study. Br J Gen Pract. 2024;74(742):e323-e9.
11. Survey reveals extent of pressures on GP registrars: British Medical Association; 2024 [Available from: https://www.bma.org.uk/news-and-opinion/survey-reveals-extent-of-pressures-on-gp-registrars.

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