Three zero cost solutions for retaining more GPs than are trained each year

– 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.