We have seen how there are GPs out of work at the same time as there is a recruitment crisis. In the second part of our series examining the general practice workforce, Jaimie Kaffash explores what is causing such a contradiction
There is both a shortage of GPs in the system, and a shortage of jobs for GPs in England, which could be seen as a ludicrous situation. As reported in a new white paper by Cogora, the publishers of Management in Practice, a survey of 387 practice managers found there are two – obvious, but true – reasons for this: first, a lack of funding; second, practice premises are often inadequate to accommodate GPs.
Practices’ financial squeeze
In 2019, as part of the five-year contract, the BMA GP Committee and NHS England agreed to set annual increases of around 2% a year. At the time, many saw this as helpful for general practice – and there were even suggestions that other parts of the NHS were envious. Up until 2021/22, GP practices were seeing a real-terms increase in funding. Part of this would have been the money they received for carrying out Covid vaccinations. But 2022/23 saw a real-terms funding decrease (see chart, further down page).
Since then, we have seen huge inflation and the cost-of-living crisis, yet the funding uplift remained at around 2% a year. This means that there has been a drastic cut in practices’ real-terms funding. The Labour Government’s first Budget has exacerbated matters with the increase to employers’ National Insurance Contributions (NICs), which was intended to raise money for the NHS. GP practices were considered the big losers in this policy; they were not guaranteed public funding from the increase because they were considered ‘private sector’, yet GP practices do not benefit from tax breaks for smaller businesses because they are considered ‘public sector’ for this purpose, according to the chief secretary to the Treasury on Question Time (see from 37:20).
Since then, Wes Streeting has announced an increase in funding of £889m a year – roughly 6%. This funding has been welcomed by the profession, although cautiously. One analysis suggested the increase in National Insurance will cost practices £260m. Furthermore, the details of how the funding will be provided to practices – and, crucially, what extra work they will be expected to do – won’t become clear until 2025/26 contract negotiations with the BMA’s GP Committee England are concluded.
But practices are currently facing a funding squeeze that has the effect of making ARRS staff look more attractive, even if they want GPs.
One managing partner at Blackpool says: ‘Having one additional GP would mean our wait times reduce, the workload is shared better between all our current doctors and better patient satisfaction. Unfortunately, it is just not feasible for us to hire more GPs.
‘We currently spend approximately £1.6 million on our staffing bill; we are careful with who we hire and for what but we find the income we get from the global sum payment just isn’t sufficient. We do not pay the highest rates in Blackpool. The global sum payment is £1.66 million, so as you can see all our global sum goes on staffing.’
Tight finances have forced practices to drastically cut spending on locums. One practice manager in South Cumbria says: ‘In the autumn of 2023, we recognised that we needed to reconsider our use of GP locums due to the increasing costs and incoming funding not keeping up with inflation and other rising costs, so started proactively planning for the whole of 2024.
‘We had seen our locum cost increase from £34,000 in 2016, to almost £80,000 in 2023. In addition, like most practices, we were replacing like for like i.e. a full-day clinician for a full-day clinician but as we have a strong continuity of care model, we also saw that a locum was not always fully booked either.’
Another practice manager in Frimley points out the impact on other staff of not being to afford to recruit GPs. She says: ‘The unrealistic stressful environment of general practice has caused many GPs to exit the role of salaried GP and determine their own working hours and workload by working as a locum GP.
‘Due to a severe underinvestment in general practice, it became impossible to afford locum services, thus meaning that the ones bearing the brunt of this mismanagement had to work many hours to stay afloat. It made a joke of all the "staff wellness" rhetoric.’
The general practice funding shortfall leaves practices facing unwelcome decisions. A joint survey conducted by Management in Practice and Pulse in September 2024 showed that around 6% of practices said they have had to make redundancies, while a further 20% said they had decided not to replace departing staff.
As part of that survey, one GP partner in the West Midlands commented: ‘We made the nurse associate role redundant and we have not been able to pick up the slack with any other roles.
‘We have had two salaried GPs leave and we now have two partners remaining – we used to be four partners in 2016. We have to offer one of the highest wages in our county to attract staff, which has meant personal losses for two consecutive years for us partners.’
They said that their ratio of staff expenses to contract income is 90%, which is ‘very high’, and with rising costs, they were unable to offer pay rises.
The GP partner added: ‘The employers’ National Insurance rises will mean some more of our staff may end up being made redundant or let go, which is a difficult decision if we want to carry on working as a GP surgery. It seems that instead of helping us attract partners, the Government’s decisions are punishing us for helping our patients.
‘We would ideally want to have two more full-time GPs, ideally partners, and one to two more nurses and a pharmacist. However, we are actually squeezed and worse than we were in 2016 in terms of numbers, equivalents and what we can offer.’
Lack of premises space
Even if practices did have money, the state of GP premises often means there is nowhere for additional staff to practise. GP premises are in dire need of modernising – a major 2023 RCGP report found they were ‘inadequate’, concluding that the allied healthcare professional staff had ‘expanded greatly in recent years, without a parallel expansion of clinical space for them to work in’. While the Budget in November 2024 did commit £100m to modernising GP premises, it specified that this would be limited to 200 surgeries.
The managing partner in Blackpool says: ‘We are a large practice in a large primary care centre, we have recently changed some storerooms into additional clinical rooms, and we still don’t have enough space. We have no expansion land as the NHS sold it off years ago. We have nowhere else to go to get more rooms. This affects who we can hire and what days they can work as we find clinicians have to room share or change rooms daily depending on who is in. It is a strain on the practice and the rotas.’
One GP in Northamptonshire says: ‘We do not have any more space in our building to recruit additional clinical or administrative staff, and this has led to us running at a far higher number of patients per full-time equivalent staff that we would ideally have. In our recent round of recruitment to salaried GP roles, we had many more suitable candidates that we have the space to employ and undertook competitive interviews to select our current employees including ARRS-subsidised recently qualified GP roles.
‘We really need to find an additional or alternative site but options for funding this are limited or unattractive. We already undertake remote working where it is possible to do so safely, and most of our ARRS staff are based in other GP surgery buildings within our PCN. Some clinical rooms are even shared between clinical staff within a session, with a staff member using a room while another has left to undertake a care home round.’
Of course, there is crossover between a lack of funding and a lack of space. Alex Kimber, a managing partner in Dorset, says she is ‘in the process of converting a toilet and cupboard into a telephone consultation room’ (see box below).
She adds: 'Expanding the premises by an extension with additional rooms is what we actually need. But capital funding is not there and as partners we don’t have the capital or wish to increase our practice debt to do this even if it was available, as it’s not affordable by the business to do so.’
It seems that, in fact, a lack of space is more a consequence of a lack of funding rather than its own separate issue. But how badly practices are affected by the funding squeeze, and how that impacts their recruitment, is also dependent on other factors – including deprivation. And we will be looking into that in our next piece in the series.
The pressure on GP surgery space: ‘Anywhere non-clinical is turning into clinical space’
I am in the process of converting a toilet and cupboard into a telephone consultation room, which isn’t ideal but needs must. Anywhere non-clinical on the ground floor is turning into clinical space. We’ve had to make a waiting room smaller to create another clinical room and are being creative in the way rooms are shared.
Meanwhile, my non-clinical team is being shoehorned into smaller spaces upstairs with many more per office than they were designed for.
The ARRS staff are great but we have to house them in our building for our PCN, as the other practices are smaller and just don’t have the space for them. Not only do they need desk space, they need access to clinical space to see patients.
We were able to get small premises grants from the ICB but they are particular about which hoops we need to jump through to get them and rather specific on what we can use them for. I’ve done the floors, taps, refurbished nurses rooms, etc. Expanding the premises by an extension with additional rooms is what we actually need. But capital funding is not there and as partners we don’t have the capital or wish to increase our practice debt to do this even if it was available, as it’s not affordable by the business to do so.
We used to be able to let other agencies use our rooms, for instance health visitors or Citizens Advice counsellors and even local small private services beneficial to our patients, such as foot care and podiatry – but we now need all the space for our own staff so those links between agencies on the ground have been lost.
We have space we could utilise that is taken up by having to hold paper notes. Yes, we could pay to digitise them, and then we would still need to pay to store the paper records offsite. I could fit two treatment rooms for the nursing team in the space these currently occupy. But it’s a cost I can’t add to the practice finances.
Alex Kimber is a managing partner in Dorset
Cogora’s General Practice Workforce white paper can be accessed in full here.
