We can all agree that cancer does not go on holiday. Yet during the winter months, referrals for suspected skin cancer in England decline steeply.
The National Health Service (NHS) collects extensive data that presents a golden opportunity for improvement and targeted interventions. For instance, by examining the data on skin cancer referrals, we can identify a long-standing pattern that presents a significant opportunity and exemplifies the potential of routinely collected data to enhance outcomes.
In the case of skin cancer, this opportunity translates to 170 livesa year that may have been saved through earlier cancer detection.
Skin cancer referrals: unlocking opportunities through a 10-year trend
The NHS Digital Cancer Waiting Times records provide valuable insights into skin cancer referrals. A simple glance at the time trend reveals a stark cyclical pattern.
The difference between the lowest point in referrals in January and the peak in August is astonishing, with August witnessing a 60% increase compared to January.
If we were to expect referral volumes to be relatively constant across the year, 36,000 patients might have presented sooner than they did in 2022. Given the skin cancer conversion rate of 8%, that’s nearly 3,000 potentially delayed diagnoses.
Moreover, the number of 2WW referrals aligns rather consistently with the number of patients awaiting cancer treatment. Therefore, fewer referrals are a result of fewer cancers presenting and being detected, rather than an artificial summer spike in referrals.
It is not news either – the pattern was present in 2016 and is just as prevalent today as it was then. This is an area that would benefit from targeted intervention.
A Chance to Improve Patient Outcomes
The decline in winter referrals for skin cancer likely occurs because people tend to notice skin changes less often during this season, and others may also point them out less frequently (for instance, as suggested by Walter et al. ). This effect has been observed for several years, not only in the UK but also in countries like Italy and France.
What is notable about the UK, however, is that it lags behind much of Europe for cancer survival rates – this includes skin cancer, though to a lesser extent, given the generally higher survival rates compared to others.
Early detection represents the greatest opportunity for addressing this disparity. Patients who delay their presentation to a GP until the summer may be diagnosed with cancer at a stage later than otherwise.
While skin cancer survival rates are relatively high, late-stage detection significantly reduces chances of survival. For patients diagnosed at stage 1 cancer (55.5% of diagnoses), the 5-year survival rate is 100%. This, however, drops 84% for stage 2 (21% of diagnoses) and 73% for stage 3 (8% of diagnoses). Detecting melanoma at stage 1 versus later stages could save 560 lives for every 10,000 patients. For 2022, that means an extra 170 lives could have been saved out of the 3,000 potentially delayed diagnoses.
Addressing Service Challenges
The surge in summer referrals for skin cancer also strains the capacity of healthcare providers, leading to delays in diagnosis and treatment for all dermatology patients. This issue has become even more significant in the aftermath of the pandemic, as healthcare services struggle to cope with mounting waiting lists.
The following chart highlights this challenge – as the volume of 2WW referrals increases, so do the 62-day target to treatment breaches. Although the time lag between the two is not substantial, it has widened since the pandemic, likely due to the extra burden posed on services by the elective backlog.
Patients referred just before the peak experience the most significant impact, as the capacity for 2WW referrals competes with the capacity for treatment. This indicates a healthcare system under pressure, where there simply isn’t enough capacity to handle a sudden rise in referrals. To address this issue, targeted solutions are needed.
What can we learn from this?
There is a strong case for gaining more insights across various cancer types, examining inequalities, geographies, pathways, and populations to align them with the Core20Plus5 priorities.
This knowledge can help to focus on a broader range of interventions and measure their impact.
For skin cancer, two clear opportunities emerge:
Implementing winter skin check campaigns, akin to successful breast cancer awareness efforts. Targeted outreach could encourage earlier presentation, improving outcomes.
Provider strategies to manage summer surges, such as Teledermatology and cross-site collaborations. New approaches may expand capacity for minor procedures and biopsies, speeding up diagnosis and care.
Data-driven insights can focus and maximize initiatives by revealing where needs and inequities lie. They also offer opportunities to monitor progress and assess effectiveness.
Learning to harness information will be crucial to the future of the NHS. The skin cancer example serves as a testament to how data can uncover life-saving possibilities and point the way toward realising them.
Happy International Women’s Day! This year’s theme “DigitALL: Innovation and technology for gender equality” is especially close to our heart. At Edge Health, we are lucky to boast a team of 13 incredible women, all bringing invaluable contribution to innovation and technology in healthcare analytics and consulting.
We have asked them for their thoughts on today’s celebration, and share with everyone their nuggets of wisdom.
How can we build on our past successes to create a better future for all women? 1. Advocate for equal access to education and training for women in tech. 2. Work towards equal pay. 3. Create a more supportive and inclusive work environment for women in tech. 4. Recognise and celebrate the achievements of women in tech and their contributions to the industry.
How can we ensure that women of all backgrounds and experiences are included and represented in conversations about women in technology and innovation? 1. Create inclusive environments that recognise and value diversity. 2. Providing opportunities for these women to participate in and lead conversations and initiatives related to technology and innovation. 3. Include and consider the perspective of women from all backgrounds and groups.
Marta Berglund, Analyst
How do you think healthcare consulting and data analytics can help improve healthcare outcomes for women and girls specifically? 1. Impartially shining a light on health inequalities, using data. 2. Building business cases to equitable allocate funding for services where it will optimise health outcomes
What changes do you hope to see in the industry over the next 5-10 years, and how do you see yourself contributing to those changes? I would love to see more women in leadership roles – specifically in the entrepreneurial space. I hope that I could help normalise this for others. At a policy level, I think things like stronger government policies for parental leave even in SMEs could help.
Jennifer Connolly, Senior Consultant
Why do you think IWD is important? IWD sheds light on all the important work that women have done that may not have been recognised in the past, and acts as a conversation starter on how we ought to be supporting women around the world in every industry going forwards.
Can you share a moment where you felt empowered as a woman, and what made that moment so meaningful to you? Growing up my mom was a strong female presence in my life. She started her own business when pregnant with me, and still runs that business today on her own. I feel both empowered and inspired when hearing stories of her working with other women from my home town to create a network of strong female entrepreneurs. As well, I’ve had the opportunity to work with her all-female team on projects in the past and was empowered through receiving recognition from clients on our great work as women in the industry.
Kate Cooper, Analyst
What are ways men can be good allies? What do we need to do to engage and inspire male advocates? I believe men can be good allies by recognising their privilege and using it to empower and support women. I think what needs to change for this to happen is the narrative around gender equality. The fight for equality concerns all genders and ultimately will benefit all genders. This needs to be taught to children in schools starting when they’re very young.
What would you change about the world for women if you could? I would love for all women across the world to have access to healthcare and education. Health is the essential building block, while education provides you with the knowledge and skills to pursue your goals and dreams.
Virginia Dall’Ó, Senior Analyst
How do you think we can encourage employment of women in consulting and data analytics? Show them that it’s the new normal, and women excel at this kind of work – events like IWD are the perfect occasion for this. In our day to day, we should show that we value and respect their views – include them in decision-making, place on them the same level of trust and responsibility than on men, and be careful to avoid discriminating remarks in the workplace (a colleague – not at Edge! – once kept calling me “young lady”; which demeans the individual both personally and in the eyes of others).
How do you balance your personal and professional life, especially in a field that can be demanding and high-pressure? I feel very lucky to live in a society where I am no longer pressured into giving up my career to look after family & home. Women, however, still do most of the caring (and may wish to do so). My main advice would be to take pride and joy in your career, find what excites you about it and then ditch perfectionism and unrealistic expectations. Use work as a way to express yourself, rather than a way to prove or define yourself. Don’t be afraid to ask for help, and be kind to yourself.
Lucia De Santis, Analyst and MD
What would you say to young girls to inspire them to look towards data as a career? Show them what women have achieved in the field and emphasize that careers in data can cover nearly every interest one has. You do not need a degree in computer science or mathematics to excel in data careers but instead can apply different background knowledge to help solve problems.
What challenges have you faced, as a woman, entering this industry? 1. Lack of female role models and mentors in the field 2. Perception of it being a male-dominated field with a gender bias 3. Lack of educational institutions encouraging girls to pursue a career in the field
Laura Dell’Antonio, Analyst
What is the most satisfying aspect of your work as an Analyst/Consultant? In general having the opportunity to improve healthcare for everyone! This includes women’s health, but also reducing health inequalities for other patient groups and striving to ensure everyone has access to the same quality of healthcare.
If you could have dinner with three inspirational women, dead or alive, who would they be and why? 1. Rosalind Franklin – her research was central to the discovery of the molecular structure of DNA, although credit for the discovery was originally given to Francis Crick and James Watson, who were awarded a Nobel Prize in 1962. It would be amazing to hear her perspective of working in such a male-dominated field at the time, and also appreciate how far we have come since then. 2. Emma Watson – partly as a Harry Potter fan, but also she has been a great advocate for women’s rights and has been actively involved in promoting gender equality and women’s health for many years. In her role as UN Women Goodwill ambassador she ran a campaign aiming to engage men and boys in the fight for gender equality, which I think is really important. 3. Michelle Obama – an obvious choice, but definitely an inspirational woman!
Catriona Mackay, Senior Analyst
What do you think will help combat gender stereotypes? I think that education is the most important tool to combat gender stereotypes as they are often present from childhood. By treating all children in school the same regardless of their gender and encouraging girls to pursue careers than are stereotypically chosen by men, children will be less likely to pick up gender stereotypes.
This year’s IWD theme is “DigitALL: Innovation and technology for gender equality”, what does this mean to you? Women are often left out from the design of innovative or technological tool. This leads to gender inequalities being rooted at the very base of such tools. They often don’t take into account how a women’s experience could be different from that of a man. Innovation and technology can help reduce gender inequalities if it gives similar opportunities to everyone.
Julia Mayer, Analyst
Can you share an example of a project or initiative you have worked on that has had a positive impact on healthcare outcomes for women? I am currently working on a regional audit of breast pain clinics. These clinics aim to improve the experience of patients (most commonly women) presenting to primary care with breast pain as their only symptom as well as patients entering urgent breast cancer pathways. Research has indicated that the risk of breast cancer in patients with breast pain as their only symptom is very low and, even where the patient is found to have cancer, is only coincidental. However, breast pain remains a frequent reason for referral from Primary to Secondary Care, often on an urgent (2-week wait) pathway. The referral often causes significant patient anxiety and subjects them to numerous scans, including ultrasounds and mammograms. It also adds pressure to already strained 2WW pathways, delaying treatment for those most in need. Therefore, using data to prove these breast pain clinics offer patient, staff and health system benefits, will be a step towards improving the health outcomes and care experiences of women across the country.
What perspective can a woman bring to the data world? Unfortunately women in data analytics and data science remain underrepresented. This is concerning as female perspectives in health data will help to ensure that women’s health issues get the attention they deserve. There is a growing understanding of the historic biases within health research which has limited the understanding of women’s health and led to reduced health outcomes for women. We need to do more to help change this and one key way that’s possible is to get women into the data field and bringing their perspectives and lived experiences to the job.
Lucy Pirkle, Senior Analyst
What will be the biggest challenge for the generation of women after you? I think it is important that women don’t become complacent, and maintain an international vigilance to ensure equality for every woman. I personally have witnessed many positive changes in equality- but am also living through misjustice targeted at women- we must make sure that the energy and passion to make positive change is consistent.
What can we do to ensure that the accomplishments of women throughout history are not forgotten? Keep talking! Learn and share- it is important we keep the stories alive and remember to share the new accomplishments too. We need to search for, and share the stories of women’s achievements and ensure they are not mis/under represented.
Sarah Shelley, Office Manager
How have you seen gender equality evolve throughout your life, and what changes do you hope to see in the future? Having spent my childhood in India, I witnessed a shift in the role women played in society: moving from traditional domestic roles to professional roles especially in the information technology industry. This has not only increased representation of women in the professional sector but has also led to women becoming financially independent and be heard when raising concerns about their rights. Even though the UK is more liberal, I would still like to see even more women in STEM roles (especially women of colour).
When you were 8, what/who did you want to be as a grown up? I wanted to become an architect. I loved building structures with my LEGO so I pictured myself as an architect which as an 8 year old seemed like a glorified version of a LEGO builder!
Aditi Shetty, Analyst
What do you hope to achieve in your career in healthcare consulting and data analytics, and how do you see yourself making a difference in the lives of women and girls? As cliché as it sounds, working in healthcare I would hope that I can make a difference to the lives of those around me, through using data to improve access to and quality of healthcare. On a more personal level, I am hoping that I can inspire girls and young women to step into the roles and fields that are not necessarily characterised by high representation of women. The work we do is important, valuable, exciting, and fun! It is important for girls and women to know that they can thrive in a field like this, should they choose to give it a try.
What is your International Women’s Day message? I would encourage all of us to take stock of the part women played in history, how far we have come, and how far further there is yet to go. In 1928, women and men were given equal voting rights for the first time. A lot has happened in less than a hundred years that followed. And so much more will happen in the next hundred years. The realisation that it is up to us to make it happen now takes a second to sink in.
Maria Starovoitova, Consultant
Solving the Emergency: Improving Ambulance Response Times through Strategic Planning
After what seemed to be a potential recovery of ambulance response times in November 2022, the latest data release from NHS Digital shows that response times have taken a significant downturn, hitting the highest on record.
Since 2020 there has been a large increase in mean response times across all incident categories. C2 incidents (serious conditions that are not immediately life threatening, such a strokes and chest pain) have suffered the most with mean response times reaching 93 minutes in December 2022, 5 times higher than 18 minutes pledge time. Waiting this long for transport to care will have drastic impacts on a patient’s outcome, not just for life threatening issues, but also for urgent conditions needing acute care, such as C3 incidents that have seen their pledge time exceeded by 455%.
When breaking down these figures into regions in England, significant differences emerge, with C1 calls in the South West waiting an average of 13.2 minutes, 32% higher than North West and the Midlands’ average response time of 10 minutes. Despite diverting 68% of calls out of 999 (compared to 19% in November 2022) and allocating an extra 9,000 ambulances (a 45% increase) to attend C1 calls, only 2/3 of them arrived on site, meaning the other third was stuck elsewhere.
Ambulances mean response times by region, December 2022
What is behind this huge disparity across regions?
Calls to ambulances have seen a significant increase since the start of 2021, growing by 20% nationally. And although the total number of calls resulting in an ambulance being dispatched (an “incident”) have decreased, the proportion of incidents attributed to C1 calls has grown to 18% (from 9% in 2019) the total number of C1 incidents has increased significantly, up by 23% compared to last year (Dec 2021), and the number of C1 incidents has seen a sharp rise. This is particularly significant in the South West, where C1 incidents have nearly doubled since 2021, suggesting that patients are becoming sicker, not just more willing to pick up the phone.
The situation in the South West should not be seen in isolation, but rather as a premonition of what might be coming for other regions if resources are not planned adequately. The remoteness of locations in the South West should not be the main culprit in the rising ambulance times – pre-pandemic they were performing in line with other regions -, but rather evidence of the strain that population health factors place on acute and community services, and the need to plan accordingly.
On the one hand, the population of the South West is amongst the oldest in England, which naturally leads to higher levels of demand across the entire health as well as the social care spectrum. Our recent work with NHSE/I on demand for secondary care shows that significant planning is required to deal with the demand associated with ageing.
Issues with capacity and bed utilisation are on the other side: 6 out of 8 ICBs in the South West have average G&A bed occupancy of above 92% (the recommended maximum), well above the national average of 88%. Last week, 20% of their entire G&A bed capacity was taken up by patients who are medically fit for discharge.
Being unable to shift patients out of hospital results in A&E departments too busy to take handovers from ambulances. In December, the average time lost to ambulances due to delays in handover more than doubled – in fact, time lost due to delays in handover was the equivalent of 40% of the total time spent dealing with incidents.
C2 ambulance response times and G&A bed occupancy, England
A new NHSE delivery plan for recovering urgent and emergency care sets specific funding to both increasing capacity of beds, ambulances and same-day emergency care services (£1bn), speed up discharge (£1.6bn), with further mentions for growing workforce, expanding community services and tackling unwarranted variation that did not receive specific funding mentions.
This is a step in the right direction, though it will now be up to ICBs, once the funding has been streamlined, to figure out how this can be used most effectively. Too narrow a focus risks creating bottlenecks downstream, rather than solving the issue, and solutions will need to both address patient flow while targeting the whole pathway, spanning from community care to addressing workforce.
At Edge Health we are experts in using forensic data analysis to target new capacity to solve the flow problem, not just move it. In our experience, full-spectrum capacity planning is what enables effective use and distribution of resources, and we have supported trust-wide planning and reconfigurations that have enabled trusts to recover the 4-hour A&E target. To find out how we can help you, get in touch.
NHS Planning Guidance ICB dashboard: six metrics, one glance
The NHS planning guidance released at the end of last year has placed particular emphasis on acute care, elective recovery, primary care and mental health.
In order to support ICBs in responding effectively to the targets, Edge Health has created an interactive dashboard that summarises six key metrics covering community and secondary care making use of data publicly shared through NHS Digital, that allow a quick overview across systems and targets.
We welcome thoughts and feedback on our beta version that you can access through this link: https://tinyurl.com/edgehealthICB, so that we can create a tool that is as useful as possible.
10% fewer GPs, record high appointments: how remote consultations are transforming healthcare
The pandemic has powered new ways of working across the NHS, and remote care has seen an unprecedented rise in both primary and secondary care. It allowed care to continue in the midst of a pandemic, and now, in the aftermath that has left the system heavily stretched, it provides a way to reach more patients despite a depleted workforce.
The data shows that the ratio of face-to-face appointments per GP across England has not changed. GPs are providing just as much face-to-face activity per person as they were pre-pandemic, though at first glance this may be easily missed.
Compared to the beginning of 2018, there are now 2,500 fewer fully qualified GP FTEs. With the current yearly ratio of appointments:GP, we would have expected them to carry out approximately 15m appointments. Despite this significant workforce loss, primary care is delivering more appointments than ever, and the number of monthlyappointments per GP has increasedby 30% since 2018 (first year for publicly available data on appointments in primary care).
GPs have undoubtedly been working harder, as they tell us, and one of the benefits of remote care shows in the chart below. GPs are now performing roughly the same number of face-to-face appointments per GP that they were at the end of 2018 (this is strictly GP-led appointments, rather than across primary care). Additional capacity is coming from the rise in telephone and video appointments and triage.
Moreover, despite the negative press that often surrounds primary care, the average wait per appointment to see a GP has decreased by 25% compared to 2018. Again, given the fall in the GP numbers, a more positive narrative is that this is a tremendous achievement despite having lost 10% of their workforce in four years. The majority of patients are also satisfied with the service provided, given that only 10% of patients would rather see a GP face-to-face.
How long primary care will be able to plug the holes and work harder is a key question. We have applied public health drivers to forecast demand in primary care, and it paints a dire picture: by 2032, we’d need 39,000 GPs to match demand. There is no quick fix, and a strategy is needed on several fronts, including addressing public health drivers, training and retention. In this scenario, we should expect and welcome the emergence of new ways of working, as innovation may help GPs find time for more patients when there are only 24 hours in a day.
Technology can’t replace GPs (yet), but it can save them time
There has been an unprecedented focus in Primary Care to make better use of digital resources, providing virtual and remote consultations. Changing consultation modes will not provide the answers we need when looking at the growing GP workforce gap, which requires focussed planning on training, retention and addressing demand. We estimate that the benefit of innovation on workforce numbers will be relatively low compared to other strategies and that is by design – innovation should support, rather than replace, the workforce, though there is scope for potential productivity gains.
Closing the 2032 GP workforce gap, aiming for 8.5 % vacancy Number of GPs expressed as Full Time Equivalent (FTE)
With that in mind, we should not put innovation on the back burner, for at least two considerations. One, that discovering new ways of working relies on innovation, which may yet provide us with strategies to tackle need; secondly, that innovative ways of work can have ripple benefits on other areas, such as workforce and patient satisfaction and increase the potential to attract and retain doctors in primary care.
What’s out there?
Innovative solutions are widespread in Primary Care, and some have demonstrated promising changes the way healthcare is provided, particularly through bridging primary and secondary care, and making care more accessible. Consultant Connect, a service developed for North Central London CCG that allowed GPs to directly message specialists for advice and guidance, reduced secondary care referrals in 64% of contacts as specialists could provide advice to be implemented in primary care rather than requiring a referral.
The virtual boost promoted by compelling need during the pandemic has allowed e-consultations to flourish and transform the way time is spent in primary care: e-consultations in North London have allowed non-clinical queries to be directed to staff other than GPs, and GPs were able to deal with e-consultations much faster than in person, reducing face to face consultations by 25%.
Our previous work has highlighted the vast impact of video consultations beyond healthcare savings – such as savings on inpatient travel resulting in lower greenhouse gas emissions as well as £108m savings in lost productivity through avoiding 3m lost work hours.
Productivity gains through harnessing innovation can be very material – virtual consultations have saved PCNs approximately 17,200 hours – scaled nationally, this is equivalent to freeing enough capital to employ 900 GPs –, and eConsult has shown to reduce missed GP appointments by 60%, with large time and cost savings. These strategies could give a substantial boost to our 2032 workforce concerns, though it is important to recognise the technology supports and enables the workforce, it does not (yet) replace it.
How can innovation become a reality?
Innovating does not always equate to revolutionising systems – sharinglearning and making best use of resources in effective and innovative ways can be the best route to having a large impact. Working with Kaleidoscope and Cambridge and Peterborough STP, Edge Health supported the implementation of a digital first pathway for diabetic patients that enabled, through shared priorities and consistent approach to care, to improve care for diabetic patients and increase the uptake of the National Diabetes Prevention Programme without generating more work for GPs. Key to the success of the programme was the sharing of evidence that supported innovation within the STP, as well as the engagement with frontline staff that directly experienced the benefits of the innovative intervention.
We could draw four take home points from this successful implementation of innovation at scale:
Ideas should be generated locally, where need is clearly understood
Successful innovation relies on collaboration across practices – this promotes not only sharing of best practices, but also agreement on care delivery strategies that have the potential to level up working habits
Taking on from the example of practices, collaboration across ICBs will also enable effective innovation to reach other areas through cross-communication; central channels need to be available for this to happen
Innovation must involve frontline staff rather than be exclusively top-down, for effective implementation and longevity
The last consideration is particularly important in the context of workforce – attempting to implement innovative strategies will undoubtedly be a challenge amidst an overstretched, disenchanted workforce. Taking decisive steps towards tackling the workforce gap will be a necessary step to promote further innovation, and in return, innovation could hold the keys to better healthcare that makes best use of resources.
30% of GP appointments are due to musculoskeletal (MSK) conditions – nearly 49million in 2021. The solutions that GPs can provide is often limited – self-management and analgesia, referrals to secondary care or physiotherapy.
By contrast, physiotherapists working in primary care can avoid unnecessary referrals, reducing admin and bureaucracy, providing cost-effective services that can reduce both primary and secondary care workloads, while empowering patients to take ownership of their health.
The role of direct patient care practitioners (DPCs, which includes physiotherapists) and nurses in primary care is expanding – and rightly so. 55.6% of primary care patients have more than one chronic condition; they need holistic, person-centred care. This can hardly be provided in 10-minutes GP appointments, where patients would like to have 2.5 issues resolved, but are told to only bring one. Multidisciplinary teams have already proven highly successful in secondary care and are key to empower patients to manage their conditions from multiple angles – covering education, nutrition, physical activity – without relying on over-medicalisation. Widening the healthcare team can achieve not only higher patient satisfaction, but also equal if not better care for patients than doctors alone. Expanding their role also offers solutions to addressing GP workforce demand which, as we have seen in our previous posts, poses significant challenges for the future.
Catch up with previous chapters of our blog series here.
Closing the 2032 GP workforce gap, aiming for 8.5 % vacancy Number of GPs expressed as Full Time Equivalent (FTE)
So how many do we need?
Our projections suggest that by 2032, primary care demand will rise to 382million appointments a year. As outlined in our first post, providing today’s level of care requires closing a gap of nearly 30,000 GPs as well as employing 11,000 extra DPCs and nurses, who see just under half of all primary care appointments.
The valuable role played by DPCs is reflected in their growth of 8% a year since 2015 – though nurses numbers have remained largely stationary. Continuing the current trend will fulfil the demand requirement, though it might rely on continued funding through the Additional Roles Reimbursement Scheme (ARRS) which currently subsidises practices employing a list of professionals (including physiotherapists, dietitians, social prescribers and pharmacists). We are also faced with a choice: to continue “as is”, on a healthcare provision path that is facing significant challenges, or aim for a change. Could the role of DPCs be expanded to more consistently take over some of the functions that are traditionally the remit of GPs, mitigating to some extent the challenges in GP supply?
Collaborating with community pharmacists can save each GP practice £7,000, and spare patients from taking unnecessary, costly medications that may worsen rather than ameliorate their health. If physiotherapists could lead more MSK consultations, for instance taking over half of all MSK consultations carried out by GPs (24m), the saving in direct cost per appointment would be £375m a year, not accounting for potential costs saved from unnecessary tests, secondary care referrals and more. That would be enough to employ 9,000 full time equivalent physiotherapists in primary care.
Given the difficulties in matching GP supply to demand, DPCs could help reduce the overall requirement for GP time by 2032, while providing even greater benefits on population health through models of care more focused on prevention than our current.
There are two ways to achieve this:
Increase the number of DPCs to slightly more than the required 11,000, to provide some buffer to the system in case GP training and recruitment efforts don’t bear fruit. Keeping the current ratio of professional to appointments, an extra 2,000 DPCs could free 1,800 GPs’ time by taking over the appointments that would be otherwise carried out by them (where appropriate). This time gain could be re-invested in providing training or clinical support to DPCs, keeping the system sustainable. The saving in direct employment costs would be £43m.
Identify more appointments that could be appropriately carried out by DPCs and do not require a GP in the first instance, increasing the average appointments seen by DPCs, and slightly reducing GP consultations. Adding 2 extra appointments to each DPC’s working day could free 18million GP-led appointments. This requires appropriate triage, DPC training and collaboration amongst the practice team, so that patients are being seen by the most appropriate professional, with support from the wider team. For this option, the saving in direct employment costs would be £130m.
Primary care networks would be the optimum environment to lead on DPC training and expertise, as resources could be pooled amongst practices, allowing even the smaller ones to benefit from multidisciplinary teams.
Are there any drawbacks?
The body of evidence highlighting the clinical benefits – and to some extent, the economic benefit – of DPC staff and primary care nurses is growing. However, some sources have pointed out that roles may not be readily replaceable, and that patient education is needed to ensure satisfaction is maintained.
Innovating our models of care require two important considerations. First, that the increase in non-medical staff needs to be matched by adequate patient education on the diverse roles in primary care and that many concerns can be addressed by professionals other than a GP – for instance, that practice nurses are excellent educators for chronic conditions where many GPs may fall short and that pharmacists are experts in medication review and management. And secondly, that there will never be a 1:1 replacement ratio amongst any healthcare practitioner – what would be the point in a different job title and education, otherwise? It is the contribution provided by team members in a varied workforce that will reduce the burden placed on GPs and help with retention, while providing better, more holistic care for patients. However, for as long as primary care is seen as an exclusively doctor-led world, innovation and change in its structure will inevitably lead to unmatched public expectations, and discontent. Some practiceshave achieved this with success – much can be learned if these experiences are widely shared, and effective initiatives should be trialled across more centres under the direction of PCNs.
To support primary care through the future, one must think of the future. Outdated models of care are uncovering deep cracks in our system. It’s time to bring innovation into primary care, both to benefit patients and to improve primary care working conditions. More on this next week, for our last post of the series.
Three zero cost solutions for retaining more GPs than are trained each year
If the PRUComm National GP Worklife Survey (funded by the NIHR) and the latest member survey by the RCGP are right, we stand to lose between 9,000 and 11,500 GPs in the next 5 years, with those figures doubling over a decade, to 18,000 by 2032.
Over 1,000 of these each year are retiring doctors – set to increase as our workforce ages. However, that leaves 7,500GPs that may leave for reasons other than retirement: the ones we should do everything we can to keep. Training GPs is valuable, but not an insignificant expense, making the imperative of keeping the ones we have a no-brainer.
At the end of 2021, 1,428 GPs had retired because of age, voluntary early retirement, or ill-health (NHSBSA FOI 24471). We would have expected an extra 1,672 qualified GPs from the 2018 cohort completing their training and joining the qualified ranks in 2022. Instead, qualified GP numbers dropped by 517, an effective loss of 761 GPs. So where did they go?
The answer is – we don’t know. One of the biggest issues in addressing retention is data. Although the GMC has figures on doctors who give up their license to practice, there is no data collection on why they have done so. That also still leaves an incognito regarding doctors who leave their jobs but keep their licence.
Closing the 2032 GP workforce gap, aiming for 8.5 % vacancy Number of GPs expressed as Full Time Equivalent (FTE)
Why do GPs leave the profession (and where do they go)?
Just like in any other profession, doctors may leave because of personal choices or career design. However, we cannot ignore surveys raising a number of opportunities that could be targeted to retain at least half of the leaving cohort who will not be retiring (approximately 2,500 GPs): workload, job dissatisfaction, worry over high-stakes decision making and public expectations.
According to the PRUComm questionnaire, the top reported job stressors were:
Increasing workload – 86% of respondents
Increased demands from patients – 84% of respondents
Having insufficient time to do justice to the job – 79% of respondents
With “adverse publicity by the media” being the stressor with the biggest change since 2008.
So where have our GPs gone? In reality – most have not gone anywhere. Besides the ones who retired, the majority have reduced their full-time hours to cope with increasing workload and demand, as reflected in the dropping ratio of headcount to FTE. In September 2022, GPs carried out 667million appointments per working day – the equivalent of 24 appointments per day, per every GP FTE – meaning some would have seen far higher numbers each day. With the addition of home visits, reviewing results, ordering tests, filling forms, training and carrying out other practice admin tasks, our GPs’ days look increasingly exhausting, and we are not doing anything to help, as our primary care utilisation keeps growing every year.
What can be done to improve retention?
That retention across primary care is a major concern is reflected in the number of interventions that have been set up across HEE and NHSE. Although some have encouraging evidence backing them, others have yet to be validated and have not been in existence for long; there is also the issue of schemes not being taken up equally across the country.
A comprehensive review collated by the Health Foundation has raised two actionable themes when it comes to evidence-based retention: the success of local, de-centralised interventions and the need for better collection of data on workforce, both to assess effectiveness of retention schemes, but also to accurately identify why staff are leaving and what can be done about it.
The three recommendations that follow are the result of a brief survey we conducted amongst GPs and GP trainees – and although may not be fully representative, they resonate with the RCGP’s recommendations to the UK government. The Department of Health (DoH), NHSE and the new Integrated Care Boards can all contribute to improving retention through these actions.
Step 1 – Change public perceptions and NHS-wide narrative
Primary care is supposedly the “the bedrock of the NHS”, however, the media discourse fuels discontent amongst the public, which affects morale and wounds the patient-doctor relationship, and our representatives spread misinformation further damaging the profile of primary care amongst the public. This negative narrative seeps through the NHS itself – more than once, as a doctor, I witnessed colleagues show little sympathy for primary care. It’s time for the DoH to invest in public image campaigns for primary care to both change the narrative as well as set patient expectations. Primary care appointment numbers increased by 7% from 2019 to 2021, despite the COVID pandemic, despite GP numbers falling. The successes of primary care should be celebrated more widely, while reminding the public that its failings are a symptom of system-wide problems, not an excuse to point the finger at GPs. It’s time that policy makers were honest with the public – if the NHS is not allowed to meet demand, then expectations need to be readjusted.
Step 2 – Widen the primary care MDT and work collaboratively to reduce GP burden
Our GPs tell us their workload has become unmanageable, and that they are increasingly isolated while dealing with more and more complex patients. Two ways to tackle this are: increasing MDT roles in primary care to share workload and bridge the gap between primary and secondary care.
Pharmacists, physiotherapists, specialist and practice nurses and other non-medical professionals have made increasing appointment numbers possible. Going forward, they should play a more prominent role in managing patients as the need for holistic care and preventative medicine intensifies.
ICBs are the new key resource in creating a cohesive health system. Initiatives to allow secondary and primary care to collaborate, such as specialist nurses and consultants leading clinics in primary care, streamlining referral pathways, sharing of IT systems and access to care notes are key to improve not just working environments but also patient satisfaction. More collaboration at the level of primary care networks is also needed: they are the optimum ground to share excellence and learning, including how the best staffed practices manage to retain their workforce, and the place to identify local challenges. The voice of GP practices can be brough forward to ICBs and NHSE to collaboratively address local pressure-points and design effective solutions.
Step 3 – Value trainees and expert practitioners, and ask them what they want
A number of schemes have been designed to attract clinicians to low-doctored areas, support newly qualified GPs to start working independently and provide funds to set up new practices. These could be further improved if representative bodies collaborated with policymakers to guide further initiatives and show trainees and expert GPs that we value their opinion. For instance, a poll for GPs who choose to take early retirement could enquire on what practical steps may persuade them to stay longer. Our survey respondents unanimously voted in favour of a “retirement fellowship” scheme, where GPs nearing retirement could cut their clinical hours to 2 sessions a week and spend a further two days training and sharing their expertise with more junior and non-medical colleagues. The only way of knowing for certain why doctors don’t stay is by asking them. I was surprised that, when relinquishing my licence to practice, no efforts were made by the GMC to find out exactly why I had left. Not keeping track of our skilled workforce has another major downside – in the face of another pandemic they may be needed to provide support; we should not wait till we are cornered again to start planning.
If we are to expand and sustain our primary care workforce, we cannot overlook the issue of retention. By engaging GPs and systems, we can put forward realistic solutions that will demonstrate to the public how much we value primary care through actions besides words.
Next week we’ll take a deeper look into how non-medical patient facing staff can have a huge impact on primary care and support GPs in providing great care.
Could 50 additional GP training places per year be enough to sustain primary care?
The single biggest challenge in closing the GP workforce gap is the issue of supply. With numbers of qualified GPs effectively decreasing each year due to retirement, changes in working patterns and leavers, we need a strategy that will replenish our workforce faster than retirement rate. This needs a coordinated effort on two fronts: training and retention.
If you want to catch up on previous posts, click here: part 1, part 2.
Closing the 2032 GP workforce gap, aiming for 8.5 % vacancy Number of GPs expressed as Full Time Equivalent (FTE)
Our forecast of GP workforce has suggested that by 2032 we will need 39,000GPs FTE. With an already significant vacancy rate, GPs retiring, potential leavers and demand increasing, we will not be able to rely on the current 27,500 GPs to make up the majority of that figure. To prepare us for the future, we need a long-term strategy on training and on relieving system pressures where possible.
GP training has already seen some significant changes in the last few years – such as more time during training spent entirely in primary care and rising numbers of GP-training places being filled. These have resulted in a record-high 9,714 doctors in training in 2021/22, 45% of which are international medical graduates. The contribution of overseas doctors to the NHS is both admirable and invaluable, such as their support in the COVID pandemic, but we may question the sustainability of this approach. Foreign doctors often come from lower-income countries (NHS Digital) and there may be ethical issues in question when they leave in large numbers to sustain our health system. Addressing our static medical school numbers (OECD) will be a matter of priority to support a future sustainable workforce.
How much reliance will be placed on training new GPs to fill the workforce gap will depend on how far other factors can be addressed, such as demand drivers, retention and better use of the primary care MDT. In order to illustrate this challenge, we have created three scenarios, outlined below:
PMQ: primary medical qualification
We have added two moderating factors to our trainee scenarios in order to produce realistic figures: that up to 15% of trainees may not complete training, and that once qualified many will not work full-time in general practice, resulting in 75% as many FTE as headcount.
Strategy 1 – A multi-faceted approach to the future, focusing on reducing demand, retention and training
In a scenario where we address drivers of demand and focus on retaining the current workforce, a modest but sustained increase the number of GP trainees by50 every year, effectively creating an additional 2,750 training spaces over the 10 years would provide 23,200 GPs to close the 2032 workforce gap.
This option would allow for the greatest proportion of UK-trained doctors as part of the GP-cohort, seeing medical schools slowly increasing their graduates to at least 13,000 – a figure that echoes the 2021 plea from the Medical Schools Council. It would bring the ratio of UK-trained vs international-trained doctors from the current 55%-45% split to 59%-41%, in line with secondary care figures.
Achieving this scenario, however, relies on effective retention planning and addressing the sources of demand, where possible, both through public health measures and innovative care strategies. The potential long-term benefit on the nation’s health is vast, and decisive effort should be placed on focusing on system sustainability, as the risk of relying exclusively on training high numbers is that if posts are unfilled, an even bigger gap awaits.
Strategy 2 – Efforts on addressing demand are not effective, but retention strategies bear fruit. The focus on training is increased
In this scenario, no decisive action is taken towards demand drivers and therefore demand continues to grow as projected. The 2,000 GPs we estimated could be saved from addressing demand drivers in part 2 of this series now need to be accounted for by supplementing training numbers. This requires GP training places to grow (and be taken up) by 210 a year, rather than 50. The 2032 cohort would be the largest, with 11,834 doctors in training – and approximately a third of them qualifying that year. This is 1,800 more than with our first scenario, meaning that we will need robust infrastructure in place to sustain this number of trainees, including support for GP practices, adequate training facilities and opportunities and chances for all trainees to be exposed to varied practice and patient settings.
In order for this strategy to work, significant efforts need to be placed on retaining the current workforce, as well as on increasing the attractiveness of general practice to medical students. We estimate that currently only 17% of medical school graduates choose GP training and without increasing the medical school places to at least 15,000 – rather than the 13,000 needed in scenario 1 -, or increasing the proportion of students who take up GP as a specialty, we will not be able to reduce our reliance on international-trained doctors.
Strategy 3 – Demand drivers are not addressed and retention strategies are not effective in preventing GPs to leave their posts. Future workforce is mainly supplemented by training
The requirement for FTE GPs that need to be produced solely through training now is 27,690 – it includes both the 2,000 that could be averted by addressing demand as well as the 2,500 GPs part of the potential leavers cohort we hoped we could retain (more on this next week).
This increases our training requirement to an extra 425 places year on year – this means that by 2032 we need to be able to support 13,964 doctors in GP training at any one time, compared to the 9,714 of 2022. As there are currently 6,495 GP practices in England, a 20% drop since 2013 (GP online), that would equate to 2 trainees per every GP practice across England. Currently, only 3,422 practices support trainees as they must be able to meet a number of criteria to provide training; we can expect that the added training pressure on practices would represent a significant challenge in this scenario.
This option also has the biggest potential to have unfilled training posts over time. We would need much higher proportions of the medical student cohort to take up primary care as a specialty, as our current university infrastructure would not be able to educate high enough numbers of students. To mitigate for this, we would need international doctors to make up nearly 60% of the GP training cohort, with 7,938 overseas doctors in training by 2032.
These scenarios reinforce that a cohesive future strategy will be needed to address the GP workforce gap over the next 10 years. Retention will play a key part in this plan – join us next week to hear more about this.
Lucia is a Senior Analyst and NHS-trained medical doctor. She is passionate about engaging workforce in healthcare improvements. Her unique insights add depth and human element to data analysis, literature review and visualisation.