Author: Liz Knight
Published: 14 May 2020
The NHS purportedly is in the middle of a primary care workforce crisis which, for some, is the biggest threat to the post-Covid implementation of the NHS Long Term Plan (LTP). This is despite a collective commitment from NHS leaders and government to increase both funding, and the number of hires, across primary and secondary care. Is the primary care workforce in crisis or, in fact, will the NHS adapt and thrive as workforce roles become more responsive in a post-Covid ‘new normal’?
The reduction in real term funding to the NHS is leading to poor performance
The NHS is one of the largest single employers in the world
A staggering 1.6m staff are employed by the NHS in the UK, to put this in context that makes the NHS the 5th largest employer globally, behind McDonald's, who employ 1.9m staff across 118 countries. Within the UK, the NHS is one of the largest public sector employers, accounting for 37% of the total public sector workforce.
The NHS workforce has grown since 2008 but workers in other health and social care have declined dramatically
Public sector employees have seen a significant shift in the number of employees in the last ten years. Between 2008 and 2018, there was a decline in employees in public administration, (-17%) education (-7%) and, most worryingly, “other health and social work” (which declined by 37% to 230,000 employees). It is only the NHS that has seen a growth in employees, growing by 13% to 1.61 million people.
As the budget to the NHS changes, there will undoubtedly be an impact on workforce numbers
In 2018/19, health spend in England was c£129bn. Eighty-nine per cent of the budget was spent on NHS England budget, with the remaining 11% spent by the Department of Health on public initiatives, infrastructure, training and education. Although there has been a promise to increase funding to the NHS by 2023/24, costs have been rising at a faster rate than inflation, which means that in real terms the increased yearly budget for the NHS is reducing in real terms . Experts from Nuffield Trust, Health Foundation and King’s Fund all have concluded that the combination of budget restrictions and increasing demand in NHS services are leading to poor performance stating that “quality of care in some services is being diluted”. This is unlikely to change as the UK emerges from public spending peak of the Covid-19 pandemic.
Growth in the primary care NHS workforce has lagged behind
According to the ONS, in 2018/19 over 39% of the NHS workforce consisted of doctors, nurses and midwives, with two nurses for every doctor. There are approximately 145,000 doctors across the NHS, yet only 24% are GP’s, who are battling with an increase in demand for services and an increasingly ageing population.
Doctors have increased at vastly different rates between primary and secondary care
Prior to the Covid-10 pandemic, it was estimated that general practice was handling 300 million patient consultations each year compared to 23 million visits to A&E. Although it may take a while for consultations to return to pre-Covid levels, general practice will still take the lion’s share. Funding for hospitals has been growing twice as fast as for general practice, yet two A&E visits cost, on average, more than a year’s worth of GP care per patient.
The number of doctors overall has increased at a rate of c.2.3% annually, however, there is a disparity between the growth in hospital and community doctors and GPs. The number of FTE hospital doctors per 1,000 people increased by 72% between 1996 and 2016. The number of FTE GPs fell by 5% over the same period1. These trends mirror the changes in spending in these areas over time; the amount of budget allocated to primary care has fallen in real terms by 0.7% p.a. since 2011/12.
If general practice fails, then the NHS fails, so why is the workforce not growing according to demand?
The numbers of nurses, midwives and health visitors are also declining
Since 2005 the number of FTE nurses, midwives and health visitors has been declining from 5.8 per thousand population to 5.3 in 2017. Given that reforms to primary care are empowering more nurses, midwives and health visitors with increased responsibilities, which are designed to refocus GPs on complex care, it is concerning that workforce numbers are not increasing in line with expected demand.
However, the Long-Term Plan will support the stabilisation of the primary care workforce
At the beginning of January 2019, NHS England and the BMA’s General Practitioners Committee published a new, five-year GP contract framework to support the implementation of the NHS Long Term Plan. The contract acknowledges the shortfall in the workforce is one of the biggest challenges facing general practice.
As the number of GPs are not growing in line with demand, it is putting more pressure on those already in general practice. The new contract aims to combat the dwindling GP numbers and increase in GPs who are retiring or working shorter hours (due to either taxation or from wanting an improved work-life balance).
The new contract promises increased investment for GPs, including additional headcount, training and retention programmes, and specialist mental health support for GPs who need it. Whilst the new contract framework focuses on reforms to the recruitment and retention of GPs, there are additional changes which will also have a direct impact on their work:
- Focus investment on other roles to enrich their skill mix and support GPs to “work at the top of their license”
- Implement the new ‘Time of Care’ programme which will help practices reduce their workloads and free up GPs through £30bn investment
- Free up GP time by increasing the number of clinical pharmacists from 491, to 1,300 by March 2019
- Implement incentives to encourage up to 1,000 physician associates to join general practice
- Enable practices to operate flexibly as hubs to share community nursing, mental health and clinical pharmacy teams
- Create networks of practices to ensure that 100% of the population will be able to access out of hours appointments, giving practices the ability to “share the load”
As the reforms are implemented, it is likely that GP numbers will stabilise at 0.5 FTE’s per 1,000, as the roles of GPs continue to be redefined and more of their responsibilities are shared across a more diverse workforce.
As the Long-Term Plan continues to be implemented, and the post-Covid world emerges, it is inevitable that the roles of GPs will continue to shift. It is imperative that funding is adaptable and, where possible, predictive, to allow the NHS to be more responsive in how it hires, trains, retrains and scales up workforces.
The NHS is committed to adapting, the Covid-19 response is proof that the system is willing and able to change. However, PCNs and GPs will need to be willing to work as a collective to implement the new contract framework. By 2023, GPs roles should have been devolved in a way which will not only benefit GPs but also better meet patient needs. The reporting on the growth of GPs will no longer be an indicator of the success of primary care, instead, success should be measured by the efficacy of the services and availability of services to patients.
The primary care workforce in trouble the NHS has a clear opportunity to adapt and thrive as workforce roles become more responsive, supported by the new GP contract.