Investigation: The GP recruitment crisis continues while staffing numbers explode

In the second part of Pulse’s major new series on general practice workforce, Jaimie Kaffash explains how the recruitment crisis remains despite GPs being out of work and overall staffing numbers exploding

You’d be forgiven for thinking that, with GPs being out of work, it would at least signal the end of the recruitment crisis. Unfortunately, this isn’t the case.

The cycle of recruitment crisis (not enough staff for jobs) to unemployment crises (not enough jobs for staff) has been a staple of general practice. Indeed, when Pulse stopped publishing a print issue in January 2024. For the final edition, we revisited our back catalogue, going as far back as 1960, and headline oscillated between the two ever since. But this may be the first time we have faced both simultaneously.

This current recruitment crisis has been a particularly long one, beginning in the early 2010s, with successive health secretaries promising to increase numbers – most famously Jeremy Hunt’s pledge to increase full-time equivalent GP numbers by 5,000 within five years. As everyone will know by now, numbers went down during that duration.

The first thing to say is that, despite the difficulties with personnel and workload, the total number of GPs is steadily increasing.

Total number of GPs in England (headcount)

This is partly due to governments’ undoubted success in increasing the number of GP trainees through Health Education England, which was later incorporated into NHS England.

The NHS has also looked to recruit trained GPs from abroad. The latest GMC statistics show 23% of fully trained GPs are from overseas.

That all said, the overall story in terms of GP numbers is one of continuing failure. The pledges made by Hunt and Javid were not around GP headcount – they were based on fully trained full time-equivalent (FTE) GPs. By these measures, their governments failed miserably.

Total full-time equivalent GPs

The fall in the number of FTE GPs alongside an increase in GP headcount is partly explained by GPs working fewer hours. According to NHS Digital figures, GPs are increasingly working less than 37.5 hours per week. This is more or less in line with Pulse’s September 2024 survey, which showed GPs are working an average 35 hours per week, and just under six sessions. There are a number of reasons for this. The NHS has actively promoted the merits of more flexible working, which has appealed to working parents as well as GPs who wish to develop portfolio GPs. There are also questions around under-reporting of these working hours. But a bigger reason for this shift is more likely to be the increasing intensity of general practice sessions, which has forced GPs to – as the GMC puts it – ‘take matters into their own hands’ by reducing hours to improve their own wellbeing and reduce potential risks to patient care.

Regardless of the reasons for greater LTFT working, it has resulted in fewer fully qualified FTE GPs. To compound matters, this has come at a time of increasing patient numbers. This leaves the ratio of GPs to patients well below that called for by professional bodies. The BMA has set out an aim to have one FTE GP per 1,000 patients by 2050. In 2009, there were 1,520 patients per GP; that figure is now more than 2,100.

Patients per FTE GP

This compares poorly with other developed countries, with the UK having 16% fewer GPs per patient than the Organisation for Economic Co-operation and Development average.

GPs per 1,000 population across the world

Not only are patient numbers per GP increasing, but the demand per patient per year is increasing as well – a trend that began before the Covid-19 pandemic. There could be many reasons for this – an ageing population, greater co-morbidity or demand stoked by ministers and the NHS. But attempts to ease these demand – including Pharmacy First and self-referrals – don’t seem to have worked, with total appointment numbers continuing to increase. To sum this all up – we are still short of GPs.

Other staffing numbers explode

Successive Conservative governments seemed to concede defeat on GP numbers. They, and the NHS, pivoted to another strategy – increasing the number of non-GP healthcare professionals in general practice. The roots of this strategy had been in the early 2010s, but it was really in 2019 that there was a revolution in staffing with the introduction of the additional roles reimbursement scheme.

Now, in terms of ministers’ and the NHS’s own metrics, the scheme has been an undoubted success. Staffing numbers in general practice have increased exponentially.

Total FTE practice staff

Of course, there are caveats to this – since the introduction of the ARRS, we have gone through Covid and a major economic downturn. But this has been the key policy for all recent health secretaries and NHS England, and it is likely this would have been the direction of travel regardless of these disruptions.

There has been an obvious effect on provision of patient care. In 2024, for the first time, only half of appointments in general practice were with GPs. This shift is likely to continue, with many ARRS staff being upskilled. For example, from 2026, all new graduate pharmacists will be qualified to prescribe.

But this has not negated the need for increased numbers of GPs. There remain two burning questions around multidisciplinary working. The first is whether the roles are clinically appropriate – and safe – for the tasks associated with them. Here, much of the debate has focused on the role of physician associates (PAs). GP groups are united in wanting to limit their scope of practice to exclude tasks that should be done by fully trained GPs, such as managing undifferentiated patients. But PAs do not have a huge role in general practice, making up 6% of the workforce. The NHS workforce plan commits to expanding their number to 10,000 by 2036 without saying how many will be in general practice. Importantly, health secretary Wes Streeting has launched a review into the role.

However, our sister magazine Nursing in Practice has found that nurses feel they are taking on too much responsibility as a result of this change to the workforce.  Asha Parmar, an advanced care practitioner in London, points to covering two practices with populations of 10,000 and 5,000: ‘All the liability of all things nursing relies on you – immunisations, infection control, smears, diabetic physical checks, wound dressings, stock, fridge responsibility.’ Nadine Laidlaw, a lead practice nurse in Newcastle, says she is ‘single-handedly managing chronic diseases with some of the most complex patients in our practice [including patients who] speak no English and have no health literacy, let alone any idea how to navigate the healthcare system’. This involves ‘following national guidelines, addressing holistic issues with social care or domestic issues, alongside “routine jobs” like cervical screening, immunisations and health promotion’

GPs still in demand

The second burning question is less concerned with patient safety than the usefulness of ARRS staff. Dr Bethany Anthony, a research officer at Bangor University who wrote a paper on the ARRS, says: ‘There was some evidence that substituting GPs with nurses for common minor health problems is cost-effective. A separate qualitative systematic review uncovered a number of barriers and facilitators to pharmacists and PAs providing general medical services instead of GPs.’

And when discussing this, it is clear that GPs are still in demand. A joint Pulse and Management in Practice survey found practices would like a 19% increase in the number of GPs if recruitment issues were not a problem. Furthermore, only 35% of practice managers said they had no need to hire GPs (see full report).

What are the vacancy rates in your practice?

Partners say there is no substitute for GPs. One GP partner in Warwickshire says: 'We would like more GPs. I don’t want an advanced care practitioner on a high salary seeing a patient every 15 minutes for a single issue when I’m still legally responsible for them even though I’ve not seen their patients.’ The partner says the PCN-employed ACP is very competent, but ‘can’t prescribe and asks to review five patients a day with a GP’, adding: ‘I want a GP who can deal with complex cases, triage effectively, see non-differentiated patients safely.’

This vacancy rate is most likely a major underestimation because many practices have simply given up on the idea of hiring a GP, with their work having been absorbed into the team over the years when finding GPs was impossible.

On top of this, many practices still struggle to find GPs. One GP in Buckinghamshire says: ‘Despite the talk of GPs being out of work, we recently had two days when we needed a locum at short notice and have had difficulty finding one. We have just advertised an ARRS GP job with maximum flexibility, mentoring, scope for special interests, but the only two applicants were two recent ex-registrars from practices in our PCN. Which again is fine, but you get the picture.’

Another partner in Cornwall says: ‘We have a fairly stable cohort of regular locums which I think speaks volumes that they are happy to return to us and see our patients time and again. But if we approach locums with the prospect of even just an employed role they decline being happier in the peripatetic role, with no ties, freedom to hold a portfolio career and the option to take leave as it suits. It’s a way of life and is not for everyone, but I am constantly on the make for our own succession planning.’

There is a particular problem finding partners, he says. ‘I think there are a myriad reasons for GP not wanting to be partners, not least the financial risk, the responsibility and, let’s say, stress of both running a business and being an effective, compassionate and efficient doctor. It’s like spinning plates, it’s a skill that can be learned but not everyone wants to be bothered with spinning plates all the time, all the while NHSE adding more plates to spin.’

So with GP numbers per patient falling, non-GP staff proving not as useful as GPs, and practices still requiring GPs, how are we in a situation where GPs are out of work? Tomorrow, we will explore why there is this contradiction, and on Wednesday we will examine what effect characteristics such as funding and deprivation have on practices’ workforces.

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