The culmination of our workforce series lays out six recommendations for policy makers and health leaders in strengthening the future of general practice
Report by Jaimie Kaffash
The Management in Practice series has been looking at how practice managers are affected by the twin problems of a recruitment crisis and GP unemployment in England as part of a wider report by our publishers, Cogora. We have looked into how practices still struggle to recruit despite GPs being out of work, how a lack of funding and premises is prohibiting them from taking on more staff, and the effect of deprivation on their skills mix.
In the final part of the series, we spell out the long-term action at macroeconomic level that needs to be taken by key decision makers to ensure a strong, sustainable workforce in general practice.
1.A greater injection of overall funding
By now it is abundantly clear that the underlying crisis is one of funding, with severe knock-on effects on staffing and employment. There are staff available, and there are positions that need filling. The main barrier is the funding to pay for this. This has come from years of 2% funding increases at a time of huge inflation and more expenses. Successive governments have rarely delivered on promises to shift more funding into primary care. The one time this did happen to a significant degree – when the 2004 GP contract was first implemented – led to the modern golden age of general practice. There is no way of improving recruitment without more money. Health secretary Wes Streeting’s commitment in December 2024 of an extra £889m ‘on top of the existing budget’ for general practice is welcome, but with the increase in employer National Insurance contributions and the previous below-inflation increases, it is unlikely to be enough.
2. More funding diverted to deprived practices
The way core practice funding is distributed needs to be reviewed. Currently the Carr-Hill formula, which dictates the baseline funding each practice receives per patient, doesn’t take enough account of deprivation, despite its adverse effects on health. As a result, deprived practices have less funding than those in more affluent areas that have an older population.
This increases inequalities, in part by the effect on staffing levels.
There is a new major GP contract being negotiated, which is likely to be implemented in three to four years’ time – the BMA’s GP Committee England has set a deadline for implementation as ‘2028 at the latest’. This might completely overhaul the way practices are funded – potentially even move away from paying them based on the number of patients they have. Regardless, there must be a funding mechanism that passes a greater share of the budget to practices in deprived areas.
3. Removal of restrictions from the ARRS
The introduction of GPs to the Additional Roles Reimbursement Scheme (ARRS) this year was a positive move but the effects are limited. There is uncertainty about long-term commitments and PCNs are only allowed to employ newly qualified GPs. But such restrictions no longer make sense. When the ARRS was first introduced, there was some justification for limiting the roles PCNs could employ, to protect other areas of the NHS from having staff taken away. The scheme originally promoted only those professions where there was deemed to be a surplus of staff (although community pharmacy has said that the inclusion of pharmacists has had a detrimental effect on that sector).
The time has come to give general practice owners free rein on who they now employ. Everyone agrees a strong general practice is essential for the NHS to function. If this requires a shift in staff, then so be it. There is also no reason this should be funnelled through primary care networks. It might be that practices feel this is the best way to organise themselves – but there is no reason it should be compulsory.
As well as increasing core funding and removing the restrictions on a staff reimbursement scheme, the Government should also consider increasing the proportion of the overall funding that is ringfenced for staffing costs. Governments have been reluctant to increase funding for practices in the past because they fear headlines about partners keeping the money for themselves. Increasing the ringfenced proportion would negate any such worries, and remove any concerns around increasing funding when it is necessary.
Again, Mr Streeting’s announcement around practice nurses being added to the ARRS is welcome. But all restrictions should be removed from the scheme.
4. Expanding premises and encouraging training
The 2024 Budget committed £100m for expanding the premises of 200 practices. How this will be allocated has yet to be decided. But the majority of GP premises need to be improved. Pre-2015 buildings didn’t take into account the expansion of non-GP roles that began around then; many practices are unable to accommodate new staff, whether that be GPs, nurses or other healthcare practitioners.
This has implications for long-term plans to increase the workforce, especially in terms of training. Training of any staff can’t take place without the physical space. But alongside this, fresh incentives are needed for experienced staff to become trainers. Again, this may only be possible when the workforce is increased.
5. Promoting general practice as a flexible career
It is true that one big reason for the fall in numbers of fully qualified full-time equivalent GPs is that more are working less than full time. But instead of seeing this as a weakness, all parties need to see it as a strength. The way to mitigate a shortfall of full-time GPs is to have a greater number of GPs coming into the system, and an effective way of doing this is to actively promote the positive elements of the job, such as flexible working.
Such a strategy might have implications for continuity of care. But continuity has been most affected by the lack of full-time GPs. With enough GPs – even working less than full time – strategies can be put in place to promote continuity. But without sufficient numbers, continuity will be impossible.
6. No short cuts
These proposed measures may seem obvious, and the biggest question is undoubtedly where the necessary funding will come from. But there are no short cuts to improving general practice workforce problems. Minor initiatives are no doubt well meaning, and may well bring about positive changes for a small number of practices. But they will not address the structural issues around the general practice workforce.
The fact that we have a recruitment problem and an unemployment problem running in tandem should be seen as a positive, because it provides fresh hope that we do have the staff available. But solving these twin crises will require a comprehensive, properly funded strategy. The time for sticking-plaster initiatives is over.
Cogora’s General Practice Workforce white paper, which includes more data and the full methodology, can be accessed in full here.
