1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health (the Department) and NHS England. We also took evidence from the Royal College of General Practitioners and Healthwatch England.
2.Most of the contact that people have with the NHS is with their general practice, with an estimated 372 million consultations in 2014–15. There are around 37,000 full-time equivalent GPs working in 7,875 practices across England. GPs work with nurses and other staff to provide advice and treatment on a wide range of health issues. General practices are independent companies, owned by an individual GP or a group of GPs, that provide care to a registered list of patients. NHS England contracts with practices to provide a range of services, and in 2014–15 it spent £7.7 billion (8% of its budget) on general practice. Until April 2015, NHS England commissioned all general practice services but in many areas clinical commissioning groups now have a role in commissioning these services.
3.The Department is ultimately accountable for securing value for money from spending on health services, including general practice. It sets NHS England objectives through an annual mandate and holds it to account for the outcomes the NHS achieves. The Department also holds Health Education England to account for ensuring that the future general practice workforce has the right numbers and skills.
4.Generally patients have a positive experience of getting and booking general practice appointments, with 89% reporting in 2014–15 that they could get an appointment when they had last tried. However, the proportion of patients reporting problems has gradually but consistently increased in recent years. In 2014–15, 27% of patients said it was not easy to get through to their GP practice on the telephone, up from 19% in 2011–12. The proportion of patients reporting a poor experience of making an appointment increased from 8% in 2011–12 to 12% in 2014–15.
5.Demand for general practice services has risen faster than capacity in recent years. The best available estimates indicate that between 2004–05 and 2014–15 the number of consultations grew by about 3.5% a year on average, compared with 2% average annual growth in general practice staffing. The Royal College of General Practitioners told us that the rise in the number of GPs had not kept pace with demand for a number of reasons—an increasing proportion of patients were older and had multiple, ongoing illnesses so their needs were more complex; at the same time, the number of GPs per head of population had fallen. Therefore general practice was struggling to provide the level of access that people expected. NHS England told us that the number of GPs had in fact risen by 5,900 over the last decade, but that had not been enough to keep up with extra demands; there would need to be almost an equivalent increase over the next five years to make good on the shortage that had developed. NHS England considered that the system had kept going largely by relying on good will on the part of GPs and the affection that patients had for their practices.
6.The Department and NHS England have committed to having 5,000 more doctors working in general practice by 2020. To achieve this they want to: recruit more trainee GPs, make it more attractive for GPs to stay in general practice, and support those who wish to return after time away. NHS England, together with Health Education England, the Royal College of General Practitioners and the British Medical Association, published a 10-point workforce action plan in January 2015 covering each of these three areas. NHS England expects that 1,000 of the 5,000 extra doctors working in general practice will need to come from staff returning to general practice and from improved retention. The Department said that it remained a challenge to make sure the GP workforce grew quickly enough to meet growing demand, and accepted that it needed to take faster action to meet the target of 5,000 extra doctors by 2020.
7.Increasing proportions of GPs in every age group are leaving the profession. In particular, between 2005 and 2014 the proportion of GPs aged 55 to 64 that left approximately doubled. This represents a drain on overall numbers and a loss of experience. The proportion of younger GPs leaving has also been increasing, although at a slower rate. NHS England acknowledged that the large numbers of GPs leaving the profession was a cause for concern across the NHS.
8.The Royal College of General Practitioners told us that the reason more GPs were leaving the profession was due to extreme workload pressures and a feeling that GPs were undervalued. While patients valued general practice, the morale of GPs was regularly undermined, for example by the way they were portrayed in the media. The National Audit Office report highlighted that job satisfaction is at its lowest since 2001. NHS England referred to a survey by the British Medical Association last year to which 15,000 GPs responded. The survey found that workload was the most important issue. The Royal College of General Practitioners told us that increasing administrative burdens were adding to the workload of GPs.
9.The Department said that GPs were often frustrated by their interactions with other parts of the health system. It told us that the work being done as part of the new care model vanguard sites to bring general practice together with community nursing and other health services was helping to break down the boundaries between different parts of the NHS. NHS England told us that to help reduce the workload of GPs it was important to develop the wider general practice workforce and to make better use of technology so that practices could do more online and on the telephone.
10.NHS England told us that, with the Royal College of General Practitioners, it was interviewing older GPs to identify what might encourage them to stay in general practice. Early findings from these interviews indicate that not having such a full workload or doing more mentoring might help to retain older GPs. We note that new pension arrangements may also be encouraging GPs to retire early if they have maximised their pension fund before the age of 60.
11.The Royal College of General Practitioners told us that it was difficult, time-consuming and costly for GPs to return to general practice after working abroad or taking a break for family reasons. It cited the example of GPs in Scotland waiting up to a year to transfer to become GPs in England. Despite efforts to improve the process, the Royal College of General Practitioners said that it was still too bureaucratic.
12.NHS England maintains the ‘National Medical Performers List’ of all GPs registered and approved to work in England. The Department told us that there were 54,050 people on the Performers List but only 40,580 GPs were working in general practice, some of whom worked part-time. Some locum GPs and GPs who work only in out-of-hours services are not counted as working in general practice. In addition, the Performers List does not include GPs who have stopped practising altogether or have moved to practise abroad.
13.NHS England and Health Education England are struggling to attract sufficient new doctors to become GPs. The number of available training places increased from 2,719 in 2009–10 to 3,049 in 2014–15, but the number of trainees recruited remained fairly constant at approximately 2,700 a year. As a result, a declining proportion of GP training places were filled: in 2014–15, 12% of places were unfilled. The Royal College of General Practitioners told us that a lack of funding and support for general practice were making it more difficult to attract recruits.
14.The Department told us that it wanted to make general practice a more attractive career option. It highlighted that Health Education England had run regional roadshows to promote general practice to foundation-year doctors who were coming to the point of having to make a career choice. Following these roadshows Health Education England and the Royal College of General Practitioners had launched a marketing campaign in September 2015 called ‘Nothing general about general practice’. NHS England also said it and Health Education England were looking to offer greater flexibility, for example through part-time training.
15.The Department told us that there were some early indications that the number of GP trainees was increasing, with 100 more people taking up training places in 2015–16 compared with the previous year. NHS England said that this progress would need to be sustained for general practice to attract the 3,250 trainees each year that would be needed to meet the target of 5,000 more doctors working in general practice by 2020.
1 Stocktake of access to general practice England
10 Building the Workforce—the New Deal for General Practice
Prepared 3 March 2016