Human resources in General Practice in the UK

 

Introduction.

Healthcare in the United Kingdom (UK) is delivered mostly by the National Health Service (NHS).  The NHS is a model of healthcare owned by the state with the aim of delivering universal health coverage (UHC).  UHC is the concept of providing health services to all without their suffering financial hardship as a result.  Estimates suggest that most patient contacts in the NHS are in Primary Care with 90% of 330 million contacts in 2008 taking place in General Practice.  Patient contacts in the NHS have continued to rise with around 564 million contacts estimated to have taken place between 2018 and 2019 (The King’s Fund, 2020a).

The UK is wealthy with the 5th largest gross domestic product in the world.  In 2017, it spent $3943 per capita on healthcare with a budget of £114b. The private healthcare market in the UK is comparatively small and covers around 10.5% of the population.  Whilst real-terms spending by the state on general practice increased by 17.9% between 2010 and 2019 (NHSX, n.d.) the share of NHS spending allocated to general practice actually reduced between 2015 to 2019 (www.instituteforgovernment.org.uk, n.d.).

Between 1990 and 2010, life expectancy in England increased by 4.2 years with improvements in reducing premature deaths from heart and circulatory diseases.  As such, people in the UK are living longer with more long term conditions.  Over 15 million people in England now live with a long term condition.  Most of this care is provided in the community by general practice and thus will be the focus of this paper.

The NHS is the largest employer in England, with nearly 1.2 million full-time equivalent (FTE) staff.  NHS hospitals, mental health services and community providers are all reporting shortages of key staff.  Shortages of GPs and other staff working in primary care and community services are negatively impacting ambitions to increase the amount of care delivered outside of hospitals.  Further still, unfilled vacancies have resulted in increased pressure on existing staff, leading to high levels of stress, absenteeism and turnover, exacerbating the workforce challenges (NHSX, 2020a).

Demand for services.

Demand for general practice services has risen as the population has increased, and aged. There are now more patients who suffer from multiple chronic conditions.  Indeed, in 2012, the DoHSC estimated that people with long-term conditions accounted for 50% of general practice appointments (The King’s Fund, n.d.).

Further still, demand for GP consultations and prescriptions rose from 9% to 11.5% between 2010 and 2018 (DOHSC, 2011).  There was a 38% growth in the number of General Practice consultations between 1995 and 2008 (NHSX, 2009) and NHS Digital estimated a further 10% increase in consultations in the year ending in April 2019. At the same time patients’ expectations of general practice have increased.  Evidence suggests that patients now expect GPs to be more accessible and provide a wider range of services (West of England Academic Health Science Network, 2016).

Due to the increased workload and patient expectations, the average number of minutes per year that regular GPs had available per patient fell from 69.2 in September 2015 to 65.5 in March 2019 (NHSX, 2019a).

It is clear that the exponential rise in demand of General Practice has resulted in consequences for patients.  Between January 2020 and March 2020, 2.3 million postal questionnaires were sent out to adults registered with GP practices in England and around 740,000 patients responded.  Compared with 2019, the proportion of patients who rated their overall experience of their GP practice as good decreased by 1.2 to 82.9%, and the proportion of patients who rated their experience of making an appointment as good decreased by 1.9 to 67.4%.  For the NHS as a whole, compared with 2019, the proportion of patients who rated their experience as good decreased by 2.1 to 68.7%.  Sadly, around one in five patients (21.7%) say they tried to contact an NHS service in the past 12 months when they wanted to see a GP but their GP practice was closed.  This data shows a drop in satisfaction in NHS services including General Practice and is a suggestion that the system needs to adapt to ensure that supply can continue to meet demand (www.england.nhs.uk, 2020)

Staff numbers.

Between September 2010 and September 2014, the number of GPs, nurses and other staff in general practice increased.  However, GP numbers fell after 2015 whilst the number of other staff working in general practice continued to increase. Nurse numbers increased by 6.8% between 2015 and 2018.  The number of other staff involved in direct patient care such as clinical pharmacists and physiotherapists increased by 18.1% and the total number of staff working in general practice increased by 4.9%.

Meanwhile, the gap between GP demand and supply continues to grow.  Whilst the NHS had a target to increase the number of fulltime equivalent (FTE) GPs by 5,000 between 2014 and 2020 (www.england.nhs.uk, 2016)  the actual position was a fall in the number of GPs.  Indeed, there were 6% fewer FTE GPs in September 2018 than in 2015 (NHSX, 2020b).

Estimates project that if that trend continues, the supply gap of GPs would increase to 11,500 FTE GPs by 2028.  Without action to address this workforce shortage, there exists a fundamental threat to the sustainability of General Practice.

Given that a student starting medical school in 2019/20 will not finish their GP training by 2028/29, the long training lead times mean that the supply of GPs is unlikely to be the solution to the GP workforce crisis.

Non GP delivered primary care.

The demand for GP services has steadily increased over the years and the supply of GPs working in the NHS has fallen.  This has coincided with an increase in supply of allied healthcare professionals delivering services in primary care.  Indeed, NHS England has committed to funding for around 20,000 additional staff, including pharmacists and physiotherapists, as a part of the new GP contract.

Internationally, it is now common to include physiotherapists, nurse practitioners, pharmacists, social workers and psychiatric nurses within the primary care team (Hansen et al., 2015).  This is becoming increasing common in England with recent data showing that almost half of appointments in general practice are now taken by non-medical staff (NHSX, 2019b).

Interestingly, evidence shows added benefits from diversification of the workforce in addition to reducing the burden on GPs, patients are more likely to receive the care that they actually need (Peikes, 2016).

Allied healthcare professionals are quicker and cheaper to train than GPs and have lower wages.  Due to the less rigorous academic demands of these roles, it is also likely that they are easier to recruit to training schemes.  This model of creating clinicians to supply the demands of the NHS affords quicker access to a larger, more diverse workforce that is cheaper to sustain in terms of wages. 

There are less nurses.

Unfortunately, we cannot expect the nursing workforce to act as a substitute for GPs.  Aside from the obvious observation that nurses are not doctors, there are fewer of them now also.  The number of nurses and midwives from Europe leaving the Nursing and Midwifery Council’s register rose from 1,981 in 2015/16 to 2,838 in 2019/20 (Nmc.org.uk, 2019), while the number joining fell by 90% over the same timeframe.  One would expect the impact of Britain exiting the European Union to account for a significant proportion of that.  However, 28 per cent of nurses and health visitors leave the NHS within the first three years (The King’s Fund, 2020b) of their service suggesting that there may be other fundamental issues driving staff away from the nursing workforce.  Over recent years, work-life balance has increasingly been cited as a reason for leaving the NHS with nearly three times (NHSX, 2020a) more people stressing this over the last decade (The King’s Fund, 2019).

 

There are more pharmacists.

In 2018, there were more than 55,000 registered pharmacists in Great Britain working in a range of settings (www.pharmacyregulation.org, 2019).

The majority of pharmacists work in community pharmacies and in other large settings, such as hospitals.  It is recognised that the clinical skills of pharmacists are underutilised and there exists potential to transform the role of a pharmacist into a more patient-facing one with increased clinical responsibilities as a part of the wider primary care team (Smith, Picton and Dayan, 2013).  Indeed, evaluation of a pilot programme utilising pharmacists in this way suggests a positive effect when working at a ratio of one FTE pharmacist per 30,000 patients or fewer (Anderson et al., 2019).  Qualitative feedback however suggested that a ratio of 15,000 patients or greater per FTE pharmacist would compromise patient care and the ability of the clinician to effectively work within the practice team.

This is not a new concept.  The role of the clinical pharmacist working in General Practice can be traced back to the 1990s in the UK.  Despite this, the role remains largely underutilised and undeveloped until more recently where interest began again in 2018 (University and Saunders, 2018).

At that time, around 900 FTE pharmacists were employed in General Practice.  Modelling suggests that expanding this cohort by an additional 3,100 by 2023/24 would reduce the demand for GPs by approximately 1,600 FTE GPs and allow patients greater access to the specialist skills of pharmacists.

As the role of community pharmacy team members have evolved over the years, so too has the role of the pharmacist.  Where once, the pharmacist was a recognised expert in medicines, the modern pharmacist is a care giver, committed to person centred care by ensuring the high quality use of medicines (John, 2018).

This year, there are approximately 66,800 employed and self employed pharmacists in the UK with a net increase of just under a third over the last decade (Michas, 2020).  With an additional 19,311 registered pharmacy technicians being upskilled to deliver many of the functions of a modern pharmacy, pharmacists find themselves at juncture in their professional evolution pondering how best to capitalise on their capabilities.  Consequently, this supply of highly skilled healthcare professionals provides an opportunity with which to address the workforce demands of general practice. 

 

Solutions

The future of the NHS depends upon maintaining an effective and efficient primary care.  To achieve this the NHS requires a capable workforce which is sustainable in terms of recruitment and retention. 

Sustainability comes in part from diversity of suppliers to impart an element of protection against supply chain failures.  In theory, this is no different for human resources.  Over reliance upon any one supply of resource risks system failure at some point. 

Where the NHS has failed to train enough doctors to meet the workforce demand, it has sought to recruit expertise from outside of the UK.  Indeed, NHS England is currently supporting family doctors from the European Economic Area and Australia to work in England.  Whilst migration of health workers has always been a feature of health systems, it has been highlighted as a factor in undermining attempts to achieve health system improvement in developing countries (Buchan, 2005, Buchan and Dovlo, 2004).  Consequently, there is a strong ethical case for the UK to grow and utilise its own healthcare professionals (Benatar, 2007, Scott et al., 2004).

There will always be a need for General Practitioners.  While the role of the GP may have changed substantially over the years, GPs by and large remain contract holders, employers and leaders of primary care.  Whether they are required as a majority for the delivery of patient facing primary care is debateable with evidence to show that employing a nurse practitioner is likely to cost the same as a salaried GP.  Due to this, some still believe that GP delivered care is more cost effective in the long term due to the wider scope of practice of a GP compared to a nurse practitioner (Hollinghurst et al., 2006). 

To encourage recruitment of GPs we need to understand what motivates people to make this career choice.  Le Flock et al, looked at this across eight European countries in 2019 and identified a number of positive factors which give GPs job satisfaction. Their findings showed a focus on the human needs of a GP including the need to have freedom to choose working environments, to organise their practices to suit themselves, the need to access professional education to develop specific skills and to strengthen doctor-patient relationships. Le Flock et al highlight the need for stakeholders to consider these factors when seeking to increase the GP workforce (Le Floch et al., 2019).  Interestingly, financial remuneration was not highlighted as a factor for job satisfaction, which may come as a surprise to some.  However, GPs working in the UK were not included in this study and so their findings may need to be extrapolated and applied with caution.

With a major shift toward digital care and remote working catalysed by the Covid-19 pandemic it remains to be seen whether GP retention and recruitment will suffer as a consequence (Park, Premadasan and Salisbury, 2020).

Certainly, the shift from patient facing care to remote digital care seems at odds with the need to enhance job satisfaction utilising the evidence highlighted by Flock et al.

It seems that NHS England had appreciated the scale of this challenge even before the advent of Covid-19 pandemic, with the inclusion of the additional roles reimbursement scheme becoming a highlight of the 2019/20 and 2020/21 GP contracts providing funding for 26,000 extra staff as a part of the primary care workforce.  This is of course amongst a number of other measures aimed to address the serious shortage of GPs and nurses (Kings Fund, 2019).

With options running out on the training, recruitment and retention of clinicians who can respond to a wide scope of clinical needs, we could once again turn our attention to the pool of pharmacists who find themselves at a crossroads in their professional evolution.

The digital revolution has also affected the pharmaceutical industry with a move from community pharmacies to a hub and spoke model utilising robotic and automated processes.  The advent of robotic automatic dose dispensing has been reputed to improve medication safety and treatment adherence, particularly in older patients with multiple medications.   Further, additional anticipated benefits include reduced workload for dispensing staff in pharmacies and the avoidance of stockpiles of medication in patient homes (Rechel, 2018, Anderson et al., 2019, Cheung et al., 2014).

Further, technological advancements have caused a revolution in distance selling pharmacies and digital pharmacies who utilise the electronic prescriptions service and a plethora of new apps to ease processing of prescription requests, shifting patient activity from face to face to online.  Indeed, 2017-2018 saw a 23% growth in items dispensed by distance selling pharmacies.  Between 2015/16 to 2019/2020, there was a 207% rise in the number of distance selling pharmacies, whilst at the same time, bricks and mortar pharmacies fell in number by 1% (Gault, 2020)

Further, Ernst and Young in their 2020 report, predict a £497m deficit in funding to the current community pharmacy network with up to 85% of community pharmacy providers being financially unsustainable by 2024.  Clearly, something needs to change (www.npa.co.uk, 2020)

Whilst Ernst and Young look to provide solutions in their recommendations following analysis into the state of the community pharmacy, they fail to make remarks with due regard to the wider NHS and in particular the need to address the workforce crisis in General Practice.  However, this is unsurprising when one considers that the report was commissioned by the National Pharmacy Association, and so, one would expect the scope of the report to reflect the needs of community pharmacy in isolation.

When one considers the system as a whole, a solution presents itself.  The modernisation of pharmacy has created an excess of pharmacists who are no longer required in the same way by their industry.  At the same time, General Practice is experiencing an existential crisis surrounding recruitment and retention of a capable clinical workforce.  To embrace these changes would allow the modernisation of General Practice and Pharmacy.

Conclusion

The current digital revolution of the NHS presents a unique opportunity to redesign the workforce to meet the rising demands of the future.  By catalysing the growth of hub, spoke and distance selling pharmacies, the pharmacy sector could become more financially sustainable through utilisation of robotics, software applications and less reliance on a highly skilled workforce.  This workforce can then be redeployed into General Practice where evidence shows that diversity improves performance and outcomes for patients (Gomez and Bernet, 2019).

In adopting this position, there are a number of downstream consequences that one must consider.  Whilst the detailed discussion of such lies beyond the scope of this document they are of enough importance to highlight as considerations for future work.  Consequently, one must consider the implications of loss of at scale face to face community pharmacy.

Research suggests that Pharmacies in England carry out around 1 million consultations per week (PSNC, 2020) and that 41% of patients would opt to visit their GP if a pharmacist was unavailable for advice (Pharmacy in Practice, 2020).  Loss of this hidden value of community pharmacy could cause the need for an additional 492,000 appointments in General Practice per week (PSNC, 2020), should the demand for care by patients be shifted there.  However, once the skilled workforce settles and integrated into General Practice, resulting in the loss of bricks and mortar pharmacies, it would be hard to undo.

Before such an option is decided upon, once must be clear that the advantages outweigh the disadvantages.  In particular, it would be pertinent to undertake a detailed cost benefit analysis of the short and long term implications of mobilising and retraining the Pharmacy workforce to solve the crisis in General Practice and of catalysing the digital revolution of the Pharmacy sector.  

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