Investigation: Not enough space, not enough money – Why GP practices can’t recruit

We have seen how GPs can’t find jobs and practices cannot recruit sufficient numbers of GPs. In the third part of our series, Jaimie Kaffash further explores this contradiction

There is both a shortage of GPs in the system, and a shortage of jobs for GPs, which could be seen as a ludicrous situation. A survey by our sister title Management in Practice of 387 practice managers found there are two reasons for this: first, a lack of funding; second, practice premises are often inadequate to accommodate GPs (see chart, below).

GP practices’ financial squeeze

In 2019, as part of the five-year contract, the BMA GP Committee and NHS England agreed to set annual increases of around 2% a year. At the time, many saw this as helpful for GPs – and there were even suggestions that other parts of the NHS were envious. Up until 2021/22, GP practices were seeing a real-terms increase in funding. Part of this would have been the money they received for carrying out Covid vaccinations. But 2022/23 saw a real-terms funding decrease (see chart, further down page). Since then, we have seen huge inflation and the cost-of-living crisis, yet the funding uplift remained at around 2% a year. This means that there has been a drastic cut in practices’ real-terms funding.

The Labour Government’s first Budget has exacerbated matters with the increase to employers’ National Insurance Contributions (NICs), which was intended to raise money for the NHS. GP practices were considered the big losers in this policy; they were not guaranteed public funding from the increase because they were considered ‘private sector’, yet GP practices do not benefit from tax breaks for smaller businesses because they are considered ‘public sector’ for this purpose, according to the chief secretary to the Treasury on Question Time (see from 37:20).

If you are unable to hire GPs, what are the main reasons?

Since then, Wes Streeting has announced the increase in funding of £889m a year – roughly 6%. This funding has been welcomed by the profession, although cautiously. One analysis suggested the increase in National Insurance will cost practice £260m. Furthermore, the details of how the funding will be provided to practices – and, crucially, what extra work they will be expected to do – won’t become clear until 2025/26 contract negotiations with the BMA’s GP Committee England are concluded (which is likely to be imminent).

But practices are currently facing a funding squeeze that has the effect of making ARRS staff look more attractive, even if the available roles are not the most appropriate for patient care. These staff are not only paid lower salaries but their costs are at least partly reimbursed by the NHS.

Dr Ian Sweetenham, a GP partner in Cambridgeshire, says: ‘We couldn’t find GPs two years ago. Now that I have them coming out of my ears, I have no money to employ them.’

The general practice funding shortfall leaves practices facing unwelcome decisions. As we reported yesterday, around 6% of practices said they have had to make redundancies, while a further 20% said they had to decide not to replace departing staff. 

This is affecting care. A GP partner in Leicestershire says: ‘As a practice we are always short of appointments, patient demand is tremendous. However, purely for financial reasons and the fact that the practice is struggling to function at a profit, when our three-session salaried GP resigned we made the decision not to replace them. Instead, we decided to try to manage as best as we could without these sessions. This was in spite of the fact that when we advertised to recruit a replacement for another departing GP in the last year, we had more than 20 applicants, so would have had no difficulty finding a good-quality candidate to fill the sessions had we chosen to. ‘In addition to this, we have also chosen not to replace two reception staff members who left – again, in the hope to save money. I reiterate, not for profit, but hoping to break even.’

Investment in general practice in England

In this context, cheaper non-GP staff look more attractive. One GP partner in Buckinghamshire said their practice had to ‘restructure [to] keep our doors open and allow us to continue to provide a service including not replacing all the clinical sessions a retiring GP used to offer. More GP sessions are being replaced by cheaper clinicians’.

GP pay is often highlighted when practice funding is under scrutiny. In 2022, following such scrutiny, the Government amended the GP contract so that partners earning more than £150,000 would be forced to declare their earnings. But simply reducing earnings would not enable them to hire more GPs. The GP partner from Warwickshire says: ‘I earn good money as a part-time partner, and there’s an argument that my partners and I could earn less and there would be money for another GP. 

‘However, it isn’t as simple as that. We’re being offered two days of an advanced care practitioner anyway by the PCN, and it seems silly not to use this. One of our nurses has just completed her ACP training, so we’ll have her for another two-and-a-half days. I’d rather have another GP, but we’re reluctant to have both. We’re unsure what Wes Streeting plans for general practice, and we don’t want to commit to another GP unless we know our funding will continue at the same level.’

Have you had to make any redundancies in the past 12 months?

Lack of premises space

Even if practices did have money, the state of GP premises often means there is nowhere for additional staff to practise. GP premises are in dire need of modernising – a major 2023 RCGP report found they were ‘inadequate’, concluding that the allied healthcare professional staff had ‘expanded greatly in recent years, without a parallel expansion of clinical space for them to work in’. While the Budget in November 2024 did commit £100m to modernising GP premises, it specified that this would be limited to 200 surgeries.

One GP in Northamptonshire says: ‘We do not have any more space in our building to recruit additional clinical or administrative staff, and this has led to us running at a far higher number of patients per FTE staff that we would ideally have. In our recent round of recruitment to salaried GP roles, we had many more suitable candidates that we have the space to employ and undertook competitive interviews to select our current employees including ARRS-subsidised recently qualified GP roles. 

 ‘We really need to find an additional or alternative site but options for funding this are limited or unattractive. We already undertake remote working where it is possible to do so safely, and most of our ARRS staff are based in other GP surgery buildings within our PCN. Some clinical rooms are even shared between clinical staff within a session, with a staff member using a room while another has left to undertake a care home round.’

This is a common problem. Dr Grant Ingrams, chief executive of Leicester, Leicestershire and Rutland LMC, says his practice ‘has GPs working from home at times but there are continued problems finding space for people to work from’. Another GP in West London says they ‘could certainly do with additional nurses but are already struggling with space for existing staff, who are having to cope with hot-desking’. A GP partner in Lancashire says: ‘In 2023, we changed some storerooms into additional clinical rooms and we still don’t have enough space. We have no expansion land as the NHS sold it off years ago. We have nowhere else to go to get more rooms. This impacts who we can hire and what days they can work, as we find clinicians have to room-share or change rooms daily depending on who is in.’

Of course, there is crossover between a lack of funding and a lack of space. Alex Kimber, a managing partner in Dorset, says she is ‘in the process of converting a toilet and cupboard into a telephone consultation room’. She adds: ‘Anywhere non-clinical on the ground floor is turning into clinical space. We’ve had to make a waiting room smaller to create another clinical room and are being creative in the way rooms are shared.

‘Expanding the premises by an extension with additional rooms is what we actually need but capital funding is not there and as partners we don’t have the capital or wish to increase our practice debt to do this even if it was available, as it’s not affordable by the business to do so.’

‘We have space we could utilise which is taken up by having to hold paper notes. Yes, we could pay to digitise them, and then we would still need to pay to store the paper records offsite. I could fit two treatment rooms for the nursing team in the space these currently occupy. But it’s a cost I can’t add to the practice finances.’

It seems that, in fact, a lack of space is more a consequence of a lack of funding rather than its own separate issue. But how badly practices are affected by the funding squeeze, and how that impacts their recruitment, is also dependent on other factors – including deprivation. And we will be looking into that tomorrow.

To download the full Cogora report, which includes all the data and the methodology, click here