There is a workforce crisis in UK primary care. Analysis of the latest workforce data confirms a continuing drop in England’s number of general practitioners (GPs) – the equivalent of 2,133 fewer fully qualified, full-time GPs than in September 2015. One answer from policymakers has been the introduction of non-GP practitioners into surgeries, to alleviate pressure. Here, Dr Imelda McDermott and Dr Sharon Spooner discuss the practical impact of this policy on GPs’ workload and job satisfaction, and whether different policies to give GPs more choice in how their practices are run may be an alternative solution.

• While intended to reduce the pressure on GP appointments and release GP time, research from The University of Manchester shows that ‘skill mix’ actually increases the workload of GPs through the need for supervision.
• Although a wider mix of skills may be part of the solution, this needs to be supported with funding for training and development of non-GP practitioners, to enable them to safely work more independently.
• Against a national backdrop of falling GP numbers, a wider cultural shift is needed, including giving GPs a stronger voice in how national policy concerning their work contributes optimally to population health needs.

Skill mix – policy and research insights

In 2016, the government launched a strategy to strengthen primary care in England, which included plans to expand the non-medical primary care workforce. It was followed by funding for an additional 26,000 primary care staff through the newly developed primary care networks (PCNs), whereby groups of neighbouring GP practices can obtain limited funding to employ additional non-medical staff under the ‘Additional Role Reimbursement Scheme’ (ARRS). Funding was initially restricted to a small number of roles, such as clinical pharmacists, physician associates, physiotherapists, and paramedics, but was later broadened to include other roles such as dieticians and podiatrists.

Our research confirms that more diverse teams of practitioners are playing an increasing role in providing primary care in England. In our survey of GP practice managers’ preferences for staff roles and desired skill mix in England, we found that the most prominent factors motivating practices to employ staff in non-GP roles were: achieving a better match between what patients need and what the practitioner team can deliver, in particular through specialist nurses; increasing overall appointment availability; and releasing GP time. According to the 1,205 GP practice managers we surveyed, the ideal practice workforce would comprise over 70% of GPs and nurses, containing, on average, fewer GPs than the current workforce. Less than 20% of their ideal practice workforce would be comprised of the newer roles listed above, with pharmacists being the popular role.

However, our research shows that GPs’ overall workload and job satisfaction levels have not improved through implementation of skill mix change, which also risks reducing the continuity of a patient’s care. Our analysis of how practices accommodate skill mix change in their daily work reveals that to successfully adapt to skill mix change, practice staff and patients must negotiate additional layers of complexity. Patients request appointments in general practices to talk about relatively undifferentiated problems, and while GPs can typically deal with every different type of problem, the training and skills of many newer types of practitioners entering general practice does not prepare them for such broad or complex casework. The need for GPs to provide ongoing supervision and support for non-GP practitioners, some of whom have little or no experience of working in general practice, has created a new, and for many GPs, unexpected workload.

Workforce challenges – stress, relationship-based care, patients, recruitment, and retention

For many GPs, the seemingly endless demands on their time and overwhelming number of patient contacts are key components of work-related stress. In a recent survey of nearly 10,000 GPs across ten countries by the Health Foundation, 71% of UK GPs said their job was “extremely” or “very” stressful, the highest of all the countries surveyed.

Under severe time pressure, GPs often have fewer opportunities to engage directly with patients. The requirements to follow standardised care pathways and achieve specific performance targets have made it more difficult for GPs to have the time and flexibility to build relationships with patients and to provide the kind of individualised care that is often needed. The traditional role of GP as a “conductor” of the healthcare orchestra, coordinating the care of patients across different settings and providers, as opposed to merely a “gatekeeper”, is increasingly difficult to carry out.

Patients are also suffering because of the GP workforce crisis. The national GP patient survey has shown an unprecedented fall in patients’ overall experience of general practice, with patients living in the most deprived areas reporting the least-positive experiences. GPs themselves often express concern that their workforce pressures and heavy workloads are increasing the risk to patient safety. In the Royal College of GPs’ survey, 65% of respondents said that patient safety is being compromised due to appointments being too short.

The increasing levels of work-related stress and low morale is having a damaging effect on recruitment and retention of GPs across the UK. The Royal College of GPs has predicted a “mass exodus” of GPs and trainees in the UK over the next few years. Its 2022 survey of 1,262 GP and trainee respondents in England found that 42% were “likely” to quit the profession within the next five years. One in ten said they expected to leave within a year. The Health Foundation estimates that by 2031, around one in four projected GP posts will be vacant.

Recommendations

As academics working closely with GPs and listening to daily accounts of life on the ‘frontline’, we do not believe there is a single solution to the challenges they face – but our research, observations and experience point to the following key areas for action:

Make sustainable work schedules an integral part of the NHS Long Term Workforce Plan. The newly announced NHS Long Term Workforce Plan promises ambitious ideas for different approaches to train, retain and reform the NHS workforce. Sustainable work schedules should be an integral part of this plan, and should include adequate time for GPs to provide expert clinical support for colleagues.

Make general practice a more attractive career. Job satisfaction for GPs is closely linked to having the time and space to achieve the professional standards they aspire to – placing greater value on responding to the real-life needs of patients, than on achievement of incentivised targets that may be poorly aligned with patients’ needs.

Make future general practice deliverable. Under nationally agreed GP contracts, the contract holders, typically GP partners who make up just over half of all UK GP roles, bear the additional responsibility for their practice’s business operations. This includes balancing incoming payments that vary according to achievement of performance incentives with expenses such as those incurred in the employment of staff, provision of premises and other operational costs. This entails a large amount of additional work and stress as they deal with business risks. Increasing financial pressures and changing contractual obligations in recent years has been accompanied by a significant fall in the proportion of GPs becoming partners.

Measures to support the future viability of the GP partnership model and/or the delivery of primary care, should, as previously recommended, consider the introduction of new business models that reduce risk for individuals, enable flexible GP career choices, and ensure that practices have the funding and workforce resources necessary to deliver healthcare efficiently and effectively to their patient populations.