In the first part of Management in Practice’s major series examining the general practice workforce, we explain how practice managers are having to tackle recruitment crises among surgery staff – while in the midst of one themselves
Report by Jaimie Kaffash and Rima Evans
In the past year and a half, we have seen a strange phenomena in general practice in England. Management in Practice and our sister title Pulse have been reporting on GPs being out of work. You’d be forgiven for thinking that a small consolation of such an unwelcome trend would be that practices’ recruitment problems would be over. Sadly, this is not the case.
A major new white paper by Cogora, the publishers of Management in Practice, has revealed how we are stuck in both a recruitment crisis across a number of professions at the same time as seeing an unemployment crisis for GPs.
Practice managers are at the heart of alleviating these issues. But, as we will see, they having to deal with this while short in numbers themselves.
Recruiting traditional roles
For practices, the shortfall in GP numbers has been one of the – if not the – biggest issues over the past decade. This led to the introduction of the additional roles reimbursement scheme (ARRS) and was a major driver for practices having to join primary care networks.
The crisis has been ongoing since the early 2010s, with successive health secretaries vowing to sort the problem. Contrary to popular belief, the total number of GPs is steadily increasing (see graph below).
This is partly due to governments’ undoubted success in increasing the number of GP trainees through Health Education England, which was later incorporated into NHS England.
The NHS has also looked to recruit trained GPs from abroad. The latest GMC statistics show 23% of fully trained GPs are from overseas.
That all said, the overall story in terms of GP numbers is one of continuing failure. The pledges made by former health secretaries Jeremy Hunt and Sajid Javid were not around GP headcount – they were based on fully trained full time-equivalent (FTE) GPs. By these measures, their governments failed miserably.
The fall in the number of FTE GPs (see graph above) alongside an increase in GP headcount is partly explained by GPs working fewer hours. According to NHS Digital figures, GPs are increasingly working less than 37.5 hours per week. This is more or less in line with a survey by Pulse in September 2024, which showed GPs are working an average 35 hours per week, and just under six sessions. But much of this is due to GPs ‘taking matters into their own hands’, as the GMC put it, by reducing shifts to alleviate burnout, or by pursuing more flexible careers – something that has been encouraged by the NHS.
Regardless of the reasons, this fall in the number of fully qualified FTE GPs has come at a time of increasing patient numbers. This leaves the ratio of GPs to patients well below that called for by professional bodies. The BMA has set out an aim to have one FTE GP per 1,000 patients by 2050. In 2009, there were 1,520 patients per GP; that figure is now more than 2,100 (see graph below).
This compares poorly with other developed countries, with the UK having 16% fewer GPs per patient than the Organisation for Economic Co-operation and Development average.
Not only are patient numbers per GP increasing, but the demand per patient per year is increasing as well – a trend that began before the Covid-19 pandemic. There could be many reasons for this – an ageing population, greater co-morbidity or demand stoked by ministers and the NHS. But attempts to ease this demand – including Pharmacy First and self-referrals – don’t seem to have worked, with total appointment numbers continuing to increase. To sum this all up, we are still short of GPs.
A survey by Management in Practice and Pulse of 640 distinct practices in England backs this up. It reveals that they are still in need of GPs, reporting that 16% of required roles are vacant. However, they are even more in need of nurses and pharmacists.
As one practice manager in Humber and North Yorkshire put it: ‘We have been working on investing in pharmacy for relieving more GP prescription admin and reviews. However, clinical pharmacists are like hen's teeth and hard/impossible to recruit to. Pharmacy technicians are invaluable but the max reimbursement for pharm techs is Band 5.’
A practice manager in Blackpool says they can’t afford to match salaries for nurses and pharmacists. ‘We currently have four practice nurses; they do the bulk of our chronic disease management and are worth their weight in gold. Nurses are particularly difficult to recruit, mainly because the local out-of-hours provider pays significantly more than we can ever offer.
‘We had an advert out for a pharmacist for six months without a single applicant. Ideally four pharmacists would work for us.’
This competition leaves practices and PCNs vulnerable to them leaving. A GP partner in the Home Counties says: ‘We have taken on several ARRS paramedics and clinical pharmacists, spent two to three hours per week of my time training them in the ways of primary care, only to have them leave for jobs in other PCNs.’
Other staffing numbers explode
At the same time as practices are in need of GPs, pharmacists and nurses, there has been an explosion in other staff. As successive Conservative governments seemed to concede defeat on GP numbers, they and the NHS pivoted to another strategy – increasing the number of non-GP healthcare professionals in general practice. The roots of this strategy had been in the early 2010s, but it was really in 2019 that there was a revolution in staffing with the introduction of the additional roles reimbursement scheme.
Now, in terms of ministers’ and the NHS’s own metrics, the scheme has been an undoubted success. Staffing numbers in general practice have increased exponentially (see below).
Of course, there are caveats to this – since the introduction of the ARRS, we have gone through Covid and a major economic downturn. But this has been the key policy for all recent health secretaries and NHS England, and it is likely this would have been the direction of travel regardless of these disruptions.
There has been an obvious effect on provision of patient care. In 2024, for the first time, only half of appointments in general practice were with GPs. This shift is likely to continue, with many ARRS staff being upskilled. For example, from 2026, all new graduate pharmacists will be qualified to prescribe.
But there remain two burning questions around multidisciplinary working. The first is whether the roles are clinically appropriate – and safe – for the tasks associated with them. Here, much of the debate has focused on the role of physician associates (PAs). GP groups are united in wanting to limit their scope of practice to exclude tasks that should be done by fully trained GPs, such as managing undifferentiated patients. But PAs do not have a huge role in general practice, making up 6% of the workforce. The NHS workforce plan commits to expanding their number to 10,000 by 2036 without saying how many will be in general practice. Importantly, health secretary Wes Streeting has launched a review into the role.
However, our sister magazine Nursing in Practice has found that nurses feel they are taking on too much responsibility as a result of this change to the workforce. Asha Parmar, an advanced care practitioner in London, points to covering two practices with populations of 10,000 and 5,000: ‘All the liability of all things nursing relies on you – immunisations, infection control, smears, diabetic physical checks, wound dressings, stock, fridge responsibility.’
Nadine Laidlaw, a lead practice nurse in Newcastle, says she is ‘single-handedly managing chronic diseases with some of the most complex patients in our practice [including patients who] speak no English and have no health literacy, let alone any idea how to navigate the healthcare system’. This involves ‘following national guidelines, addressing holistic issues with social care or domestic issues, alongside “routine jobs” like cervical screening, immunisations and health promotion’
The second burning question is less concerned with patient safety than the usefulness of ARRS staff. Dr Bethany Anthony, a research officer at Bangor University who wrote a paper on the ARRS, says: ‘There was some evidence that substituting GPs with nurses for common minor health problems is cost-effective. A separate qualitative systematic review uncovered a number of barriers and facilitators to pharmacists and PAs providing general medical services instead of GPs.’
On this, some practice managers query whether the ARRS is good value for money. One practice manager in Yorkshire says: 'We do have access to some ARRS staff including ANPs and paramedics, although in our view the vast sums spent on the ARRS Care Home Team vastly outweigh the need – in cost terms the money is wasted when money would be better spent on our wider patient population employing GPs. Money needs to come to general practice and not the PCN.’
Kay Keane, practice manager at Ancoats Primary Care Centre in Manchester, agrees this way of funding is seen by many as just 'a sticking plaster' but nevertheless points out that some managers have been resourceful and used ARRS money to provide services that 'make a real difference to the health and wellbeing of local populations.' She describes examples such as federations working to set up services like pharmacy support or social prescribing, or areas with a high number of housebound patients that have joined to create an acute home visiting service using skilled nursing and paramedic colleagues, taking the pressure off GP teams and helping reduce hospital admissions.
'ARRS does work well for some, particularly those practices who would be too small to employ a whole time equivalent staff member,' Ms Keane adds.
Practice manager numbers
But navigating all these challenges and having to be innovative comes at a time when practice manager numbers are barely increasing, and indeed are going down per patient.
Practice managers report a 14% vacancy rate themselves. Ms Keane, also a director at the Institute of General Practice Management points out that this vacancy rate is even more damaging than for other professions.
She says: ‘We can see that the vacancy rate for practice managers (PMs) currently sits at about 14%. However, unlike a GP if a PM is absent or the role isn’t filled, it’s rarely possible to get locum cover or someone else to step in. And we have so many hats: we look after HR, recruitment, budgeting, finances, business development, technology, payroll, even deal with mundane issues like running out of toilet paper and much more.
'This all means that at practices without a PM, there really is no one else doing that job, just a gap with practice staff just having to make do. This eventually has an impact on the efficiency of the practice, adds to workload of all team members and erodes staff morale.
‘This is worsened by the fact that the person who would usually look after the recruitment processes to keep resourcing levels up isn’t there, so it can become a vicious circle.
‘The non-clinical managerial roles are just as vital to keeping surgery doors open as the clinical roles but this issue gets underplayed,' Ms Keane stresses.
The outlook isn’t that reassuring in the medium term. Ms Keane says: ‘We also know that over 50% of PM’s are considering leaving the profession in the next five years’.
However, the IGPM sees the accreditation and regulation of managers in general practice as a solution to attracting future talent to plug the gap. Its own accreditation framework both for practice managers and PCN managers has attracted over 200 applicants (who now have MIGPM accreditation) since its launch in 2022.
Ali Daff, the institute's business manager, points out that not only is this training helping to raise standards in general practice management, benefitting how surgeries are run and services are delivered, it is helping ‘professionalise’ the practice manager role itself so it’s regarded as being on a par with doctors, nurses and other healthcare professionals.
She explains: ‘Crucially, it’s also about career development, and mapping out what a practice manager role can offer in terms of prospects to help attract people to the job. We need to ensure the next generation see ours as a fulfilling career so we can stem PM shortages.'
Currently, the IGPM is also working on an innovative project with Lincolnshire LMC to create an apprenticeship for PMs.
'We want people to understand that this is a great career, it's varied and autonomous,' says Ms Keane. 'We need to attract the best leaders into practice management, as well as nurture those within our teams.
'That’s why we have worked with Lincolnshire LMC to devise an apprenticeship programme that works alongside their existing training provision and our accreditation. Once completed, individuals gain their level 5 management qualification, have an industry specific registration, and get to use those all-important letters MIGPM after their name.'
Ultimately, practice management needs to be supported by those outside of the profession too, notably policy makers and the Government.
‘General practice fails without a competent, highly skilled leader in place,‘ says Ms Keane. ‘Practice management must be part of local and national workforce planning within the NHS and we have to ensure we are consulted on and considered in future strategies.’
Cogora’s General Practice Workforce white paper can be accessed in full here.
