Performance Tracker 2023: General practice
Since then there has been an increase for both staff groups. GP partner pay increased by 12.0% in real terms between 2019/20 and 2020/21, and by a further 7.4% in 2021/22. In the first year of the pandemic, this was mostly due to Covid support money, increased income from the Covid vaccine programme (some of which continued into 2021/22) and a reduction in costs such as locum expenses during the first lockdown. Despite those large recent pay increases, GP partner pay was still 8% lower in real terms in 2021/22 than in 2006/07. This is likely to make GP partnership less attractive at a time when the number of GP partners is already falling – a trend which could lead to more practice closures, as explored in more depth below.
Pay for salaried GPs has also risen since the onset of the pandemic, by 2.0% in real terms between 2019/20 and 2021/22.[1] The agreed pay deals in 2022/23 and 2023/24 will further increase pay in real terms, but will still leave it 7.6% lower in real terms than in 2006/07. Other than in 2023/24, when part of the uplift for salaried GPs was funded, GP practices have had to pay for recent pay uplifts out of the GP contract.
The forecast increase in 2023/24 for salaried GPs comes following a government decision to increase their pay by 6% in that year,
1
Department of Health and Social Care, ‘NHS staff receive pay rise’, press release, 13 July 2023, retrieved 18 October 2023, https://www.gov.uk/government/news/nhs-staff-receive-pay-rise
after initially recommending a 2.1% pay increase.
2
NHS England, ‘Submission to the Review Body on Doctors’ and Dentists’ Remuneration: Evidence for the 2023/24 pay round’, 11 January 2023, p.46, https://www.england.nhs.uk/wp-content/uploads/2023/02/B2025-nhs-england-submission-to-the-review-body-on-doctors-and-dentists-2023-24.pdf
Importantly, the GP contract will be uplifted to account for this higher pay settlement, though it does not seem that this is additional funding for the NHS from the government, but rather money that is being reallocated from other parts of general practice.
3
Department of Health and Social Care, ‘NHS staff receive pay rise’, press release, 13 July 2023, retrieved 18 October 2023, https://www.gov.uk/government/news/nhs-staff-receive-pay-rise
The prospects for other practice staff are not so positive. The GP contract allows for a 2.1% pay rise for other practice staff in 2022/23 and 2023/24
4
Colivicchi A, ‘Salaried GPs and practice staff can only expect 2.1% pay rise this year, NHS England warns’, Pulse Today, 6 February 2023, retrieved 18 October 2023, https://www.pulsetoday.co.uk/news/practice-personal-finance/salaried-gps-and-practice-staff-can-only-expect-2-1-pay-rise-this-year-nhs-england-warns/
– however this is against private sector wages increasing by around 7% in 2022
5
Office for National Statistics, ‘Average weekly earnings in Great Britain: March 2023’, 14 March 2023, retrieved 18 October 2023, https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employmentandemployeetypes/bulletins/averageweeklyearningsingreatbritain/march2023
and a forecast 5.5% in 2023.
6
Bank of England, ‘Monetary Policy Report - May 2023’, 11 May 2023, retrieved 18 October 2023, https://www.bankofengland.co.uk/monetary-policy-report/2023/may-2023
More comparable, though, are the increases that the government has given to non-medical staff who work in hospitals. Those staff have received pay increases of 4.7% in 2022/23 and will receive a 5.2% increase on average in 2023/24, in addition to one-off payments worth 6% of their salary in 2022/23.
7
Hoddinott S, ‘A welcome NHS pay deal has taken too long to reach’, blog, Institute for Government, 17 March 2023, retrieved 18 October 2023, https://www.instituteforgovernment.org.uk/comment/nhs-pay-deal
In short, pay increases in general practice are not competitive with either the wider economy or other parts of the NHS, posing a risk to staff retention. This means that funding for general practice is not sufficient to provide all staff with competitive pay increases without imposing cuts on other areas of primary care.
Dissatisfaction with the GP contract has led the BMA to threaten balloting GPs on industrial action,
8
Colivicchi A, ‘BMA gives Government list of demands to meet to avoid GP industrial action’, Pulse Today, 22 March 2023, retrieved 18 October 2023, https://www.pulsetoday.co.uk/news/breaking-news/bma-gives-government-list-of-demands-to-meet-to-avoid-gp-industrial-action/
though it has since backed down from that position in anticipation of a new contract in 2024/25.
9
Lind S, ‘BMA will not ballot GPs on industrial action over contract imposition’, Pulse Today, 27 April 2023, retrieved 18 October 2023, https://www.pulsetoday.co.uk/news/breaking-news/bma-will-not-ballot-gps-on-industrial-action-over-contract-imposition/
Still, the possibility of industrial action hangs over general practice, especially as colleagues in other NHS services continue to take to the picket lines. A likely general election in 2024 adds further complications to negotiations. GP leaders will want to agree a contract with a new government, with reports that this could mean that they will push for a one-year holding contract to bridge the gap between 2023/24 and 2025/26, when the longer-term contract would start.
10
Bower E, ‘New GPC chair sets out ambitions for expected one-year GP contract in 2024/25’, GP Online, 11 August 2023, retrieved 18 October 2023, https://www.gponline.com/new-gpc-chair-sets-ambitions-expected-one-year-gp-contract-2024-25/article/1833019
GPs often work in cramped and poorly maintained premises with outdated IT
It is more difficult to assess the sufficiency of capital spending in general practice than in other services, as there is little publicly available data to show the quality of the estate, IT systems, or equipment.
11
Department of Health and Social Care, ‘NHS Property and Estates: Why the estate matters for patients’, GOV.UK, March 2017, p.11, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/607725/Naylor_review.pdf
Much of the estate is not owned by the NHS itself: the May 2022 Fuller Stocktake reported that only 14% of premises are owned by NHS Property Services, with the rest owned by GPs themselves and third parties.
12
NHS England, ‘Next steps for integrating primary care: Fuller stocktake report’, May 2022, p.23, https://www.england.nhs.uk/wp-content/uploads/2022/05/next-steps-for-integrating-primary-care-fuller-stocktake-report.pdf
Despite the difficulties in accessing good data, the indications from information that is publicly available and our own interviews are that capital investment in general practice has been insufficient to ensure the primary care estate meets the requirements of a modern health service.
A survey of clinicians shows that one in four GPs are treating patients in premises that are not fit for purpose.
13
Royal College of General Practitioners, ‘4 in 10 GPs working in premises ‘not fit for purpose’, says College survey’, press release, 17 May 2023, retrieved 18 October 2023, https://www.rcgp.org.uk/News/Practice-Premises-Survey
Lack of space seems to be a particular issue: 88% of GPs say that there are not enough consulting rooms;
14
Royal College of General Practitioners, ‘4 in 10 GPs working in premises ‘not fit for purpose’, says College survey’, press release, 17 May 2023, retrieved 18 October 2023, https://www.rcgp.org.uk/News/Practice-Premises-Survey
66% say that the lack of space makes it harder to train new GPs;
15
Royal College of General Practitioners, ‘4 in 10 GPs working in premises ‘not fit for purpose’, says College survey’, press release, 17 May 2023, retrieved 18 October 2023, https://www.rcgp.org.uk/News/Practice-Premises-Survey
and 84% report that estate space restricts how many GP trainees they can take on.
16
Royal College of General Practitioners, ‘Fit for the future: Reshaping general practice infrastructure in England’, RCGP.ORG.UK, 17 May 2023, p.10, https://www.rcgp.org.uk/getmedia/2aa7365f-ef3e-4262-aabc-6e73bcd2656f/infrastructure-report-may-2023.pdf
One GP responding to a Royal College of General Practitioners (RCGP) survey said: “Lack of space is our biggest constraint.
There is no funding to address accommodating physios, mental health, and social care practitioners, [this] has led to GPs working in cupboards – it’s hopeless”.
17
Royal College of General Practitioners, ‘Fit for the future: Reshaping general practice infrastructure in England’, RCGP.ORG.UK, 17 May 2023, p.7, https://www.rcgp.org.uk/getmedia/2aa7365f-ef3e-4262-aabc-6e73bcd2656f/infrastructure-report-may-2023.pdf
The lack of capital investment is not, however, limited to the estate. IT systems in general practice are often out of date. Almost half (46%) of respondents to the RCGP’s survey say that PC or laptop software is not fit for purpose
18
Royal College of General Practitioners, ‘Fit for the future: Reshaping general practice infrastructure in England’, RCGP.ORG.UK, 17 May 2023, p.12, https://www.rcgp.org.uk/getmedia/2aa7365f-ef3e-4262-aabc-6e73bcd2656f/infrastructure-report-may-2023.pdf
and more than a third of general practice staff say that their broadband is not of an acceptable standard.
19
Royal College of General Practitioners, ‘Fit for the future: Reshaping general practice infrastructure in England’, RCGP.ORG.UK, 17 May 2023, p.12, https://www.rcgp.org.uk/getmedia/2aa7365f-ef3e-4262-aabc-6e73bcd2656f/infrastructure-report-may-2023.pdf
It is not just the quality of IT within practices that prevents more efficient working – close to two thirds (65%) of staff say that their ability to exchange information with the wider health service is not fit for purpose, driven by underinvestment in software that makes it easier to share information.
20
Royal College of General Practitioners, ‘Fit for the future: Reshaping general practice infrastructure in England’, RCGP.ORG.UK, 17 May 2023, p.13, https://www.rcgp.org.uk/getmedia/2aa7365f-ef3e-4262-aabc-6e73bcd2656f/infrastructure-report-may-2023.pdf
The reasons for this are complex. The NHS argues that responsibility for capital investment in primary care lies with GPs, given their status as independent contractors. As such, GPs should provide and maintain an appropriate estate and ensure IT systems are fit for purpose. While this is technically true, the reality is more nuanced. GPs are not well suited – either financially or from a logistical perspective – to make the required level of capital investment in general practice.
On financing, the GP contract is a poor mechanism for allocating capital investment. First, unlike how funding is allocated to government departments, there is no ring-fencing for capital investment in the amount provided to GPs, meaning that capital directly competes with other funding pressures, such as a requirement to increase practice staff wages. The result is that, as a government review of general practice premises policy found, there is “a lack of clarity or understanding around the responsibilities of all parties involved in estate ownership and occupancy” which can mean that property is not maintained to the level it should be.
21
NHS England and Improvement, ‘General Practice Premises Policy Review’, June 2019, p.11, https://www.england.nhs.uk/wp-content/uploads/2019/06/general-practice-premises-policy-review.pdf
It could be argued that GP partners – as the holders of GP contracts – should reduce their earnings to fund investment. But on an individual practice scale, that may not generate enough cash for the type of investment required[1] and would likely further harm GP partner recruitment and retention at a time of declining numbers, as discussed below.
GPs are also somewhat at the mercy of national policy making. For example, the problem of limited and inappropriate estate space has been compounded by the expansion of multi-disciplinary teams (MDTs), which includes the addition of 29,103 direct patient care (DPC) staff (discussed more below). But that policy has not been accompanied by concomitant intention or funding to expand the estate, with de facto responsibility falling to practices to accommodate them. 22 Baird B, Lamming L, Bhatt R and others, Integrating additional roles into primary care networks, The King’s Fund, February 2022, p.16, https://www.kingsfund.org.uk/sites/default/files/2022-02/Integrating%20additional%20roles%20in%20general%20practice%20report%28web%29.pdf This means that the government is not using those new staff as effectively as they might otherwise be, eroding value for money.
The Fuller stocktake asserts that when it comes to utilising multi-disciplinary teams, the primary care estate is “not up to scratch”
23
NHS England, ‘Next steps for integrating primary care: Fuller stocktake report’, May 2022, p.23, https://www.england.nhs.uk/wp-content/uploads/2022/05/next-steps-for-integrating-primary-care-fuller-stocktake-report.pdf
and that the NHS needs to develop “hubs within each neighbourhood and place to co-locate integrated neighbourhood teams… for the provision of more integrated services”.
24
NHS England, ‘Next steps for integrating primary care: Fuller stocktake report’, May 2022, p.27, https://www.england.nhs.uk/wp-content/uploads/2022/05/next-steps-for-integrating-primary-care-fuller-stocktake-report.pdf
As an example of the kind of investment needed, it uses the case study of a health centre that was developed in Waltham Forest through a partnership between the local authority and the local NHS, at a cost of £1.4m.
25
NHS England, ‘Next steps for integrating primary care: Fuller stocktake report’, May 2022, p.24, https://www.england.nhs.uk/wp-content/uploads/2022/05/next-steps-for-integrating-primary-care-fuller-stocktake-report.pdf
That scale of investment and coordination of stakeholders is far beyond the ability of any practice – or even small group of practices – to deliver, either financially or logistically.
The same argument holds for investment in IT. Practices are responsible for providing hardware for their employees, and often as noted fail to provide an adequate standard. But it is beyond their ability to provide systems that, for example, enable data sharing between different parts of the NHS – an outcome that requires large scale investment and coordination. Even when individual practices can purchase their own IT systems, this is unlikely to represent good value for money; the Fuller stocktake again argues that, when procuring IT systems, integrated care systems could “leverage their larger scale and purchasing power to improve value for money and quality of service”.
26
NHS England, ‘Next steps for integrating primary care: Fuller stocktake report’, May 2022, p.26, https://www.england.nhs.uk/wp-content/uploads/2022/05/next-steps-for-integrating-primary-care-fuller-stocktake-report.pdf
The government has recognised this and taken some steps to address the issue. On estates, it has proposed investing in six “Cavell centres”, intended to provide appropriate space for the integration of primary, community, and social care services. But the Health Services Journal reported in March 2023 that NHSE had ordered that work on the centres be stopped until a national business case had been approved.
27
Launder M, ‘Exclusive: NHSE halts ‘pioneer’ health centres due to lack of capital’, Health Services Journal, 21 March 2023, retrieved 18 October 2023, https://www.hsj.co.uk/primary-care/exclusive-nhse-halts-pioneer-health-centres-due-to-lack-of-capital/7034482.article
On IT systems, the government used the Delivery Plan for Recovery Access to Primary Care to allocate £240m over 2023/24 and 2025/25 “for new technologies and support offers for primary care networks”,
28
NHS England, ‘Delivery plan for recovering access to primary care’, 9 May 2023, retrieved 18 October 2023, https://www.england.nhs.uk/long-read/delivery-plan-for-recovering-access-to-primary-care-2/
which includes some portion going to improved cloud telephony for practices. This is welcome, but is targeted at a very narrow, patient-facing part of the service and will not address many of the IT issues laid out above. It also comes at the expense of spending elsewhere in the health and care sector, as the government chose to “retarget” funding rather than make new money available.
29
NHS England, ‘Delivery plan for recovering access to primary care’, 9 May 2023, retrieved 18 October 2023, https://www.england.nhs.uk/long-read/delivery-plan-for-recovering-access-to-primary-care-2/
One interviewee suggested that decision making for capital investment in primary care could be improved if it was shifted upwards from GP partnerships to integrated care boards (ICBs), who would be best placed to make decisions about how to coordinate care between community care, primary care, mental health, and adult social care providers. This would also allow ICBs to leverage their size to achieve better value for money.
General practice does not have enough capacity to meet demand
Anecdotally, demand for GP services has never been higher. The so-called “8am rush” for GP appointments has featured prominently in the press over the last year.
30
Calver T, ‘Is this the end of the full-time family doctor?’, The Times, 22 July 2022, retrieved 18 October 2023, https://www.thetimes.co.uk/article/is-this-the-end-of-the-full-time-family-doctor-tvffppcnm
,
31
Letters to the editor, ‘My son could have flown to Spain and seen a doctor sooner’: your experiences of the NHS in 2022’, The Telegraph, 22 December 2022, retrieved 18 October 2023, https://www.telegraph.co.uk/opinion/2022/12/22/son-could-have-flown-spain-seen-doctor-sooner-telegraph-readers/
Supporting the anecdotal evidence with data is harder. It is possible to observe the number of appointments that general practice delivers: this increased by 12.4% between 2019/20 and 2022/23, an average of 4.0% per year. But that amount is necessarily limited by general practice capacity. There is therefore an unobservable number of people who try and fail to book an appointment on any given day (though there is evidence that people are finding it harder to book appointments, more on which below).
Demographic changes appear to have increased demand on general practice. While the overall population in England grew by 0.6% per year on average between April 2013 and April 2023, the over-65 population grew at 1.1% per year – the same proportion as rise seen in the number of patients registered with GPs. 32 NHS Digital, ‘Patients Registered at a GP Practice’, 12 October 2023, retrieved 18 October 2023, https://digital.nhs.uk/data-and-information/publications/statistical/patients-registered-at-a-gp-practice
That older population often has more complex needs – and the proportion of people aged 75 and over with two or more long term conditions is also increasing. 33 Raymond A, Bazeer N, Barclay C and others, Our ageing population, The Health Foundation, December 2021, p.20, https://www.health.org.uk/publications/our-ageing-population We heard throughout our interviews that patients are presenting with more complex conditions and therefore higher need for care across all health and social care services. This has again proved difficult to evidence, but if true would imply that it is not only the quantity of demand that has changed, but also the complexity.
Respondents to the GP Patients Survey also show decreasing satisfaction on questions related to access.
34
https://gp-patient.co.uk/surveysandreports
For example, the proportion of people who are satisfied with the experience of making an appointment and who found it easy to talk to someone on the phone dropped to 54.4% and 49.8% respectively in 2023, both the lowest scores on record. This has fed through to the lowest patient satisfaction on record with 71.3% reporting a positive experience of general practice in 2023, down from 82.9% in 2019. It could be argued that these results show a general frustration with the service. But polling shows that those who access the general practice are more satisfied with the service than those who do not.
35
Morris J, Schlepper L, Dayan M and others, Public satisfaction with the NHS and social care in 2022, The King’s Fund, March 2023, figure 21, https://www.kingsfund.org.uk/publications/public-satisfaction-nhs-and-social-care-2022
These results imply that people are struggling to access general practice when they need to.
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