- Across the UK, the number of GPs relative to the size of the population has fallen in a sustained way for the first time since the 1960s.
- The fall in number of GPs has been particularly marked in certain regions of England such as North West London and the East of England. These regions also have the lowest total number of GPs per 100,000 people, whereas Scotland has the highest.
- The fall in GPs per person reflects insufficient numbers previously being trained and going on to join the NHS; failure to recruit enough from abroad; and more practitioners leaving for early retirement.
Checking the vital signs for general practice
Across the UK questions are being raised about access to GP services. For example, in England, while 84% of patients describe their overall experience of their GP practice as good, a much lower proportion who accept an appointment report being able to get one at a time when they wanted or sooner. The trend has been going in the wrong direction. In Wales meanwhile, practices in some areas have had to shut down patients’ access to out of hours services.
Staffing levels are clearly a key factor in this – so what has been happening that might explain the troubling performance? In this blog I focus on trends in the medical component of the practice workforce – GPs themselves.
Changes in how data are collected over time and between the four nations make tracking the number of family doctors difficult, and the trends should be treated with some degree of caution. That said, we were able to draw on existing data tables published by:
- the Office for Health Economics, an organisation founded in 1962 to, among other things, collect and analyse health care data for the UK
- NHS Digital, the public body formed in 2013 , who have published information on trends across the four UK nations in the decade to 2017.
Due to constraints in what information was available, we primarily focused on the number of GPs by headcount, and we exclude those in training (registrars); those on ‘retainer’ schemes designed to support those with caring responsibility; and those working on a temporary basis (locums). We have used the number of registered patients as a measure of the size of the population, because this measure allows us to use data going further back in time.
The headline trend in GP numbers
The data shows that there has been a recent sustained fall in the number of GPs relative to the size of the population across the UK nations. This does not appear to have happened since the 1960s. For the overall number of GPs to have kept pace with the number of people in the UK since 2014 we would have needed some 3,400 more GPs.
As the below chart shows, the level of cover of GPs varies across the UK and across the regions of England. The highest levels are in Scotland (76 GPs per 100,000 population) and the lowest in North West London (54).
As has been previously highlighted, some differences are justifiable because the need for health care varies due to factors like age, poverty, and rurality in different areas.
However, a recent piece of work by a colleague noted that “there are significantly fewer GPs per head in poorer areas of England than in richer areas, people find it harder to get a GP appointment and they are less likely than their richer counterparts to have a good experience of visiting their GP.” This suggests some of the differences might be unjustified and lead to certain areas being less well served.
While the historic data by region is even more limited, it does suggest that there have been inconsistent trends in recent years. For example, while the number of GPs rose by over 1 per cent in the South West of England and Northern Ireland (and in Scotland over a slightly different time period), it fell by over 5 per cent in North West London. At a national level it is primarily England and Wales whose declines in GP staffing drive the UK-wide trend, while other countries remain more stable.
Part-time working and locums
Are these trends real – or have we missed something due to the gaps in the data?
NHS Digital found no figures available for temporary locum GPs in Scotland and Northern Ireland, so we couldn’t include them. But the latest estimates for England suggest that the changes here have been marginal; while there have been breaks in the data, the published information suggests that any rise is in the order of a couple of hundred GPs since September 2015. It is possible these numbers might miss some 'infrequent locums' who do not regularly work at a practice, may cover very few sessions and are typically employed on an ad hoc basis. However, for context, to have kept pace with the number of people in the UK since 2015 we would have needed around 2,500 more GPs.
Ideally, to understand the true capacity within the general practice profession we would want to count GPs as ‘full time equivalent’ – capturing whether a rise in part-time working means the level of GPs is effectively lower.
And based on data specifically from England, there has been an increase in part-time working. GPs were employed to work on average 82.1% of a full-time contract in September 2015, compared to 79.8% in December 2018. This would be equivalent to around a 1,000 fall in headcount across 42,000 GPs.
Focusing on full-time equivalents also suggests that the trend in locums may be even less of a material consideration than it might look. In England, locums are on average contracted to work at less than a quarter of a full-time contract.
The scale of the problem
So how worried should we be? In one way we might have underestimated the fall in GPs per person. Demographic changes over time – such as an ageing population – may mean that the ratio of GPs to patients would need to actually rise to keep up with need.
We should also remember that nobody wanted this to happen – it reflects a series of failures and accidents whose effects are likely to continue. In England an ambition was set in 2016 to increase GP numbers by 5,000 by 2020 – but this target seems likely to be missed. While training places are now being increased, we have seen that somewhere in the region of one in three posts for specialty GP training don’t result in a GP joining the NHS. All this means the future outlook is difficult. Our recent joint report with the Health Foundation and The King's Fund suggested the shortfall in GPs could grow by around 4,500 full-time equivalents in five years unless urgent action is taken.
On the other hand, practices have shown considerable resilience during this period and, with the number of medical school places and specialist GP training posts being increased, there is at least a promise of more new GPs entering the NHS in the future.
We should not forget that GPs are only one part of the practice workforce, as we have highlighted elsewhere. Our recent work with the other health think-tanks found that there was no way of filling the gap between the supply of GPs and the need for them in the next few years. But we concluded that greater use of other professionals, like physiotherapists and pharmacists, could still make it possible to deliver as much care as was needed. Of course, such a big shift in the workforce under the great strain that exists will be difficult.
We need to keep monitoring these trends, ideally with more comparable data, and look for ways that the NHS can minimise the impact on patients while we turn the situation around.
Palmer W (2019) 'Is the number of GPs falling across the UK?' Nuffield Trust blog, 08 May.