Closing the GP workforce gap: not all about GPs

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.