There is no greater source of pressure in the NHS at the moment than staff shortages. Rising demand, growing complexity and lengthening waitlists, combined with high turnover, absence and staff leaving the NHS post-Covid, have created a gap between demand and supply of staff.

Understanding and responding to this gap is a complex problem across the health system. Doing so requires a detailed understanding of future workforce requirements and innovation in model and roles. By partnering with Dearden HR, award winning HR and OD consultants, we are able to combine our robust analytics and understanding of data with bespoke people and OD solutions.

West London, Surrey & Sussex Radiotherapy Operational Delivery Network

One example of our work together was with the West London Surrey & Sussex (WLSS) Radiotherapy Operational Delivery Network (ODN). The ODN, which comprises 4 radiotherapy providers, sought to understand their future workforce requirements and opportunities to innovate and implement a new workforce model to meet demand.

Approach

Our approach revolved around three workstreams. The first two supported the development of a rich evidence base, through modelling of future demand and activity and gaining a detailed understanding of the ODN’s current workforce status. These efforts formed the groundwork for assessing the future workforce requirement and developing an action plan for meeting this requirement. Our approach was designed to ensure that the final outputs are rigorous in detail and evidence, innovative in approach, built off existing best practice and co-developed with providers and ODN leadership.

The modelling was built on anonymised attendance-level data collected from each provider. This level of detail allowed for robust modelling of the workforce requirements of current and future activity, considering changes in complexity, treatment type and pathway. This was supported by workforce data and staff engagement, including a questionnaire and interviews to better understand each Trust’s workforce model, as well as staff motivation and job satisfaction at each of the Trusts.  This multi-faceted approach ensured a comprehensive understanding of the present workforce landscape and laid the groundwork for informed workforce planning and recommendations.

Future demand was modelled based on a range of scenarios, considering changing population, demographics, population health and cancer treatment. This modelling informed future workforce requirement scenarios. An interactive workforce planning tool was developed alongside the final report, enabling scenario analysis for future workforce shortfalls or surpluses based on Trust-specific assumptions.

“Partnering with Edge Health allows us to develop recommendations and an implementation plan which is based on clear and rigorous data analysis.”

Michelle Hodgkinson, Director, Dearden HR   

Outputs

Based on the demand and capacity modelling and our understanding of current staffing levels, we calculated the additional establishment and in-post WTE required to meet the recommended level of staffing. The work also developed a series of recruitment and retention interventions, including regarding:

• Apprenticeships
• International recruitment
• Active retention and support
• Development roles
• Flexible working

The combination of quantified workforce gaps and recommended interventions has provided the ODN and each Trust with a strategy for addressing future workforce pressures. This is currently being taken forward within the ODN.

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 monthly appointments per GP has increased by 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.

Closing the GP Workforce gap – part 6

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 – sharing learning 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.

Closing the GP Workforce gap – part 5

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 practices have 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.

– Closing the GP Workforce gap (part 4)

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 7,500 GPs 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)

If you want to catch up on previous posts, click on these links: part 1, part 2, part 3.

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.

– Closing the GP Workforce gap (part 3)

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 39,000 GPs 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 by 50 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.

– Closing the GP Workforce gap (part 2)

Last week we provided an overview of our analysis of the GP workforce gap and the steps that can be taken, starting today, to prepare primary care for 2032. In this post, we highlight the potential benefits – both on workforce and more – that can be gained from addressing demand drivers.

Closing the 2032 GP workforce gap, aiming for 8.5 % vacancy
Number of GPs expressed as Full Time Equivalent (FTE)

Recent trends in care utilisation, ageing and the rise in chronic health conditions are projected to place an unprecedented demand on healthcare. Not all demand will be avoidable, but opportunities to address what is possible should be sought. This is because, despite representing a relatively small margin of intervention compared to supply issues, the cost-benefit of targeted strategies is highly advantageous, and in addition to benefiting workforce numbers it has far-reaching consequences for the wider nation’s health.

We have developed a machine learning model to predict future appointment numbers that accounts for past trends, the effects of ageing as well as rising prevalence of diabetes and obesity. Our model projects that in 2032 GPs in England will have to carry out 382million appointments (nearly 100million more than the current 285million figure), growing at an average of 2.7% a year.

If we expect our workforce to grow by the same extent, we will need an extra 9,450 fully qualified GPs* compared to 2022 (27,500 GPs) to meet demand alone, in addition to the 2,300 needed to halve the current vacancy rate (reported at 17%).

With primary care appointments per patient suffering from obesity or diabetes reported at 2.96 annually and 2.68 per quarter respectively, we can expect an extra 31million appointments in 2032 when taking into account the projected prevalences of diabetes and obesity (9.6% – Public Health England – and 36.7% – Cancer Research UK– respectively).

If we made use of targeted strategies to slow down the rise of obesity and diabetes, and we considered the effects that interventions for obesity and diabetes could have on other conditions such as hypertension, atherosclerosis, chronic kidney disease which exert a large primary care burden, it would not be unreasonable to suggest that we could save at least 18million appointments in 2032.

This equates to freeing up 2,000 GPs as well as savings of up to £700million in direct costs for 2032 and up to 3.8billion over the 10 years (with appointments priced at £39 each), the equivalent of £300 for each of the estimated 13 million patients who are either obese or diabetic. This, however, is only a reflection of appointment costs in primary care and does not account for even greater expenses such as prescriptions, secondary care costs, wider economic consequences and loss of QUALYs associated with a raised BMI (adding up, as a whole, to £58billion).

The new ICBs are placed in a prime position to take action, as the roof under which NHS organisations, primary care and local authorities now work together to improve health. Although the most cost-effective interventions are top-down and national-level, such as reducing mass-media advertising and implementing taxes on sugary and fatty foods (NICE, ACE-Obesity), we should exploit the new ICBs to attempt something that has never successfully been done before – provide a consistent message and pathways across healthcare, schools and local communities that reinforces healthy eating and physical activity, inspired by the NIHR multi-system plan to target obesity.

Tackling underlying demand drivers will play a key part in the long-term strategy for the health of our nation, but it addresses a relatively small amount of the projected primary care demand at just over 5%. Planning on delivering an adequate supply of workforce will be the game changing factor to guarantee a dependable, resilient primary care in 2032, as we will explore next week on our upcoming post on training.

It takes 10 years to train a GP. Therefore, interventions we put in place today may not bear fruit until as late as 2032.

We estimate that by 2032 we will need 39,000 fully-qualified full-time equivalent GPs* to meet the growing demand, if we aim to halve the current vacancy rate of 17%, as reported by the annual survey by Pulse, or approximately 4,700 GPs.
A strategy to replenish and retain the current workforce (27,500 fully-qualified GPs) will be paramount, as 10,700 GPs are forecast to retire over the next decade and more have expressed a wish to leave, as highlighted by the eleventh National GP Worklife Survey and the Royal College of GPs’ latest survey (33% and 42% of respondents respectively).

In this upcoming series of blog posts, we will take you through five practical steps that the Department of Health and NHS England could take to address the growing gap and support primary care and the wider nation’s health through the future.

Our analysis of primary care workforce and demand has highlighted that:

• Demand is growing, public health strategies are necessary to slow down its rise
• Workforce growth will not keep up with demand, at current rates, and needs to be supported by a sustainable, long-term strategy focusing on retention, training and accounting for changes in working patterns
• Innovative approaches to healthcare, a greater contribution of non-medical direct care staff and better use of powerful data can guide the health service through the next decade

We believe this gap can be addressed through the following pragmatic and actionable five steps:

1. Addressing public health factors that drive primary care demand by targeting the prevalence of obesity and diabetes
2. Retain as much as possible of the current workforce by addressing reasons for leaving
3. Sustain trainee numbers by increasing UK-medical school graduate numbers as well as continuing to support international hiring (but taper this down overtime to promote sustainability)
4. Increase numbers of primary care nurses and non-medical patient facing staff to free up GPs’ time
5. Enact innovative strategies to support future primary care

We will be discussing each of these individually in follow-up blogs, where we will explore the methodology and strategy in more detail.
Until then, you can reach out to us with any questions or further thoughts.

* We will be using Full-Time Equivalent (FTE) numbers when referring to GPs during our analysis

Appendix:

Gap estimates obtained as follows:
Current gap estimated from reported vacancy of 17% (Pulse) – setting a target of reducing this to 8.5%.
Demand gap: from in-house demand model trained on attended appointment volumes from 2018 to 2021 (NHS Digital), ageing, obesity and diabetes prevalence rates and projections (QOF and ONS).
Retirees: maintaining the last 10 year’s trend of 1300 retirees (headcount) per year (NHSBSA).
Other leavers: estimated at 33% every 5 years (PRUComm National GP Worklife Survey), minus retirees.
PMQ: primary medical qualification.

Published 8 September 2021

Specialist cancer nurses play a vital role in supporting people with cancer, but their numbers have not kept pace with growing demands. As cancer incidence increases across the UK, there is an urgent/ongoing need to expand the number of specialist cancer nurses working in the NHS.

Macmillan Cancer Support has been supporting nurses to become specialist cancer nurses for many years, but the NHS will need considerable additional investment from UK governments to expand the workforce to the extent needed. To help understand the scale of the need, Macmillan Cancer Support commissioned Edge Health to undertake modelling on the number of additional specialist cancer nurses required by 2030 and the funding needed for training.

Our modelling shows that an additional 3,371 specialist cancer nurses are needed in England by 2030, the training for which would cost £124 million. You can find more details of the work on Macmillan Cancer Support’s website here.

For further information please contact George on 07980804956 or [email protected]