18.In our previous report on access to general practice in March 2016 we highlighted that problems with recruitment and retention mean there are not enough GPs to meet demand. Against a target to provide 5,000 additional doctors working in general practice by 2020, the Department and NHS England acknowledged at the time that faster action was needed. Since then official data have been published that show the number of GPs has decreased rather than increased, from 34,592 full-time equivalent doctors in September 2015 to 34,495 in September 2016.
19.On the recruitment of trainee GPs, Health Education England filled 3,019 places in 2016–17, 250 more than in 2015–16 but still only 93% of the 3,250 available places. Health Education England explained that applications for GP training after the first round of recruitment in 2017–18 are up 4.7% compared with 2016–17. It told us that a scheme to attract trainees to hard-to-fill placements, predominantly in rural areas, had filled 105 of 122 posts. It is also looking to make recruitment options more flexible, by allowing trainees to move across the country to train together, and by looking at opportunities for people to study part-time medical degrees.
20.However, challenges remain in expanding recruitment further. Health Education England said that in some parts of the country being a GP is not seen as being as good a career choice as other specialties, and cited research it has commissioned into perceptions of general practice of new doctors coming out of medical school. It told us that the amount of time that medical students spend in the community is directly correlated to how likely they are to choose general practice as a career. We asked the witnesses how overseas recruitment may be affected by Brexit. Health Education England suggested that there has been no impact so far with the proportion of postgraduate applications from EEA nationals having remained the same after the referendum on Brexit. Doctors trained outside the UK but within the EEA only account for 4% of the GP workforce.
21.Since 2010 nearly as many GPs have left as have joined. NHS England explained it has examined the reasons for people leaving, and found that the number one issue is workload. It said that, as part of an extensive programme to support commissioners and providers, it is supporting practices to redesign their services and reduce their workload. NHS England told us that it is helping practices to analyse their demand and so find a more productive way of managing workload, such as using other members of the workforce or the voluntary sector. To improve retention, Health Education England said it was exploring whether it should lock new GPs into providing at least four years’ service in general practice. NHS England highlighted a scheme it is trialling to support experienced doctors who are thinking of leaving general practice, by employing them to provide leadership and mentoring support to practices. We were concerned about the impact that pension arrangements are having on the retention of GPs. The Department told us the arrangements have contributed to GPs leaving the profession, though this has not been the main reason behind more GPs retiring early.
22.Often patients will expect to see a GP, but Health Education England told us that a wide range of other professionals can help to deliver general practice services, and that GPs should be allowed to spend the majority of time doing things that only GPs can do. In April 2016, NHS England, alongside Health Education England and the Royal College of General Practitioners, published its General Practice Forward View which committed to supplement increases in doctors in general practice with 3,000 mental health therapists, 1,500 clinical pharmacists, and 1,000 physician associates. NHS England told us it is providing partial funding to practices to recruit clinical pharmacists, and has been able to demonstrate how these can save GPs time and improve the use of medicines. Health Education England explained that it had just published a report on expanding and developing the general practice nursing workforce.
23.We were keen to hear how these initiatives to expand the number of GPs and other professionals in general practice fit within an overarching workforce plan covering the whole of primary care. NHS England explained that it and Health Education England are creating community training hubs to help plan future staffing needs in general practice. NHS England also said it was keen for patients and NHS staff to make better use of community pharmacists as there was a good supply coming out of training. We remain concerned about the challenges in making the best use of available staff, particularly in rural or small practices. NHS England recognised the challenge of accessing specialist care in rural areas where there is insufficient demand to sustain a service. It also accepted there needed to be more capital investment into general practice as limitations of existing premises are preventing practices from being able to employ a wider staff mix. NHS England said it was investing £1 billion over four years for general practice premises, technology and other related infrastructure, but suggested that a lot more will be needed.
24.The level and variation in staffing is likely to be affected by funding. NHS England is improving the equity of primary care funding allocations to local areas. In 2016–17, 48 of 209 clinical commissioning groups will be 5% or more above their target, and 53 will be 5% or more below their target. By 2020–21, 20 are expected to be 5% or more above and none to be 5% or more below. For payments to individual practices, NHS England is creating a fairer system through phasing out the minimum practice income guarantee and through reviewing PMS funding. But NHS England said it must tread with care in changing the payment formula to individual practices, the Carr-Hill formula. It has agreed with the British Medical Association not to introduce an updated formula before April 2018 so it can protect practices from financial stability or uncertainty.
37 NHS Digital, General and Personal Medical Services, England September 2015—September 2016, Provisional Experimental statistics, 25 January 2017
38 , para 3.15
39 Qq108, 111
40 Qq112, 125
42 Qq114, 122
43 , para 8
44 Qq39, 90, 123–124, 129
46 Qq94, 125
47 Q93; , para 9
48 Qq95–96, 101, 150
50 Qq97, 100, 152
51 Qq92, 104, 132
54 , para 3.4
55 Q70; , paras 3.6–3.7
25 April 2017