The workforce problems faced by practice managers is in large part determined by their deprivation and funding levels. Jaimie Kaffash reports
Despite GPs being out of work, practice managers are still struggling with recruitment. Much of this is due to lack of funding and premises space. But these issues aren’t uniform across the country – there are regional variations. And the barriers faced are also affected by deprivation, and even the ethnicity of the patient population. An analysis of data on every GP practice in England, detailed in a white paper on the general practice workforce published by Cogora, highlights these differences.
Deprivation
A striking finding is that practices in more affluent areas have a higher number of GPs and clinical staff per patient than those in the most deprived areas.
Being located in a deprived area brings up a number of challenges for practices. The first is the health needs of the patient population. Even without including issues around access to healthcare, it is ‘well established that deprivation… is associated with poorer health, including mental health’ and patients in deprived areas are more likely to develop ‘serious mental illness, obesity, diabetes and learning disabilities’, says the Government. Patients in the most deprived areas face the onset of multimorbidity 10-15 years earlier than those in the most affluent areas.
Practices in deprived areas attest to the problems around health needs (which are exacerbated by a lack of support services). One practice manager in Blackpool says: ‘A large portion of our patient list has chronic diseases due to smoking, obesity, drug and alcohol abuse, etc. I believe Blackpool has the highest drug-related death toll in England. It is particularly difficult to manage these patients when they have poor living conditions, little money and no motivation to change their ways to improve their health. Our GPs, pharmacists, nurses and other staff all provide patient education to these patients, but we would ideally like to have more time with them. More GPs, nurses and pharmacists would mean we can bring them in more frequently and give them education on their illness and how to manage it.’
Case study: We are deepening inequalities in already vulnerable populations
Surgeries in deprived areas like South Ilford in east London face critical and unique challenges, exacerbated by being in the lowest quartile of NHS-funded practices. These challenges include persistent workforce pressures, difficulty recruiting skilled professionals, and high staff turnover. Such systemic issues threaten the sustainability of care delivery and amplify health inequalities.
In Redbridge, where the doctor-to-patient ratio is approximately one GP per 2,700 patients – far higher than the national average – recruitment is a significant hurdle. The demanding workload, combined with the multifaceted health and social care needs of the population, makes these roles less appealing. We are a partner-heavy practice that relies on the goodwill and altruism of our partners to survive. There is a significant risk of burnout among the partners and our senior leadership team.
These staff shortages particularly impact deprived populations like those we serve, where patients often have complex medical conditions influenced by socioeconomic factors.
Retention is equally problematic, staff turnover is significant. Staff report high levels of stress and dissatisfaction due to the mismatch between patient demand and available resources. Limited funding restricts the ability to offer competitive salaries, invest in support systems or provide professional development, compounding these challenges. This underfunding creates a cycle of workforce instability, leaving remaining staff overwhelmed and communities underserved. The result is a deepening of health inequalities in already vulnerable populations.
GP partner in Redbridge
A GP in a deprived area of Hampshire says: ‘We are by far the most deprived practice in our area, with a very young population, poor mental health and long-term conditions from a young age.’
This is where another problem for deprived practices comes in. The same GP adds: ‘The town in general is relatively wealthy, but we cover three large estates of social housing. Our demographics have a significant part to play in our lower funding, which results in a low weighted list and thus lower remuneration.’
Because despite these extra health needs, deprived practices do not necessarily get paid more – and, in many cases, their deprivation leads to lower funding. The Carr-Hill formula – which determines practice funding – is determined by patient age and sex, list turnover, rurality and ‘staff market forces factor’, which is based on geographical variations in staff costs. Deprivation is not an explicit factor. There is another element – ‘additional needs of patients’ – which looks at mortality and illness before the age of 65 and does, to an extent, benefit deprived practices. But these additional needs are based on data from before 2000. As deprived practices tend to have younger populations, they often end up with lower-than-average global sums.
On top of this, QOF and enhanced services targets are harder to meet for practices in deprived areas. For example, for childhood vaccinations, there are step increases for the final patients within the cohort they vaccinate. But for these practices, that is far harder to achieve. Their populations are more transient, more likely to have received their vaccinations overseas and more likely mistrust vaccination, especially minority ethnic families.
An analysis of the Cogora Data Dashboard, a tool built by the publisher that brings together data from 22 official sources for general practice, shows that practices with the top 20% most affluent patient populations receive £137.17 per patient (not including premises costs) compared with £135.93 for the 20% most deprived patient populations. This has been a problem highlighted constantly in the 20 years since the pivotal 2004 GP contract was introduced, most recently by the Nuffield Trust. As well as specific health needs, and often lower income, deprived practices face another recruitment problem – they need to pay more to attract staff.
One GP in Leicester says: ‘I think it has been forgotten that the inner city is a completely different world to the suburbs. Certainly in our region, inner-city practices often have to offer higher salaries to attract staff like practice nurses, pharmacists and GPs. Hence there is less funding for other aspects and these higher-funded staff may in some cases be less committed to long-term improvements of inner-city practices.’
Strangely, however, deprivation doesn’t seem to have had too much of an effect on practice manager numbers – indeed, the most deprived practices actually have fewer patients per PM, but there doesn’t seem to be a trend.
Funding
This is certainly not the case with funding, which has a major effect on practice manager numbers. There is a cause and effect dilemma here – do practice managers help practices bring in more funding, or can these practices simply afford more PMs?
Kay Keane, practice manager at Urban Village Medical Practice in Manchester and a director of the Institute of General Practice Management (IGPM) says its down to the former.
She tells Management in Practice: 'Gone are the days when a practice manager was responsible for putting appointments in the system and ensuring that reception was running smoothly, we are now running million pound businesses with complex income streams and funding opportunities. There is also opportunity to innovate and create new ways of working.
'Having a skilled professional leader is essential, and these statistics go further to prove that. The IGPM is critical to ensure that managers across general practice get the recognition and support they need to continue to lead what may well become even more complex organisations, as more care comes out of hospitals and into the community'.
The correlation between funding and staffing levels can be seen throughout the team, with those practices that receive the least funding having far lower levels of staffing. This is more explainable than the correlation between deprivation and staffing; the Carr-Hill formula is supposed to provide more funding for practices with greater demand, so in theory lower funded practices should have less need for staff.
But challenges not fully accounted for by the funding formula – including deprivation – cause particular problems with recruitment.
One GP partner, whose practice is in the bottom 20% when it comes to practice funding per patient, says: ‘We used to use a remote pharmacist to support the practice when one of us was on leave (we have never 100% backfilled GP sessions as it has never been affordable).
‘We now no longer do this, so when a colleague is on holiday, in addition to busier days, I have to do two hours or more in the evenings for repeat prescriptions. We took this decision after our profit share was down approximately £20,000 per partner from March 2022 to March 2023 (in hindsight, 2021-22 was artificially bolstered by Covid jabs).’
Another GP partner whose practice is in the 20% of lowest-funded practices, and is in a deprived area, says: ‘We have a young, deprived population – high-ish workload but not reflected in the weighting system (fewer elderly than average, no nursing homes, and our homeless people’s project is unfunded).’
The partner’s situation highlights the differences across the country. ‘Despite the talk of GPs being out of work, we recently had two days when we needed a locum at short notice and had difficulty finding one. We have just advertised an ARRS GP job with maximum flexibility, mentoring and scope for special interests, but the only two applicants were two recent ex-registrars from practices in our PCN.’
Case study: Finances are stopping us hiring new GPs
Case study: Finances are stopping us hiring new GPs
We are having to constantly balance staff morale and wellbeing with patient care and demand. This is more difficult when financially stretched. Our actual list is over 19,000 and weighted list is 16,000. We have unrecognised deprivation and are one of the highest practices for child protection. We have large numbers of patients with special needs, mental health issues and risky behaviours. There is unseen poverty, which is unrecognised.
In terms of staff, pharmacists get paid better elsewhere and don’t want to accept the pay being offered by PCNs.
There are locum agencies offering GPs for the PCN at £8,000 per session, but with holiday and CPD it is effectively £12,000. They may not enjoy working across three practices and essentially work as a locum so would be less helpful.
Our salaried GPs would like the 6% pay increase the Government promised staff this year, so we are trying to offer this while current practice finances stop us hiring new GPs, which can in the long run mean more spending on locums. Partners do the extended hours and evening duty. We only have six partners – one plans to retire in the next couple of years and three of us are now in our late 50s.
GP partner at practice in bottom 10% of income per patient
Ethnicity
An even stronger correlation exists between staffing levels and the proportion of a practice’ s population who describe themselves as ‘white’.
There are caveats to this data on ethnicity. This is based on the GP Patient Survey data, and the deciles indicate the number of patients who declare their ethnicity as ‘white’. It is also very likely that ethnicity is a confluence of a number of factors, including deprivation. But it is stark how much this data correlates with staffing levels.
Conclusion
It is clear that a practice’s characteristics, location, funding and patient demographics has an effect on their staffing levels – but it might be surprising just how much of a factor they are. It suggests that some practices have very little scope to improve recruitment because there are structural issues.
In the next in this series, we will take a look at what steps practices and PCNs are taking, in so far as they can.
Cogora’s General Practice Workforce white paper, which includes more data and the full methodology, can be accessed in full here.
