Practices are finding it increasingly harder to recruit GPs. It has often been thought that some areas of England are struggling more than others, but this is not always the case
Recruiting GPs is fast becoming a nightmare for practice managers around the country, particularly for those in deprived areas where it is less attractive to live and work.
This problem is recognised at the top with the Conservatives having pledged an extra 5,000 GPs by 2020. Given the scepticism with which this was received and the time it takes to train a GP secretary of state for health, Jeremy Hunt later revised this promise down to a maximum of 5,000 GPs post election.
Attracting, training and retaining GPs is no small matter.
The Royal College of General Practitioners (RCGP), the British Medical Association (BMA), NHS England and Health Education England (HEE) have come together to tackle workforce issues in primary care.
The collective plan has been outlined in the joint document Building the Workforce – the New Deal for General Practice.
Promoting general practice to newly qualified doctors is a large part of the push. Mark Porter, British Medical Association (BMA) chair says attitudes need to change towards general practice. Porter says: “There are some major problems. One of them is that training in general practice is shorter than training as a hospital doctor and this [difference] has an inevitable feedback into the status that things have.
“Everyone knows that GPs and consultants have equivalent status in the health service but in actual fact there is still quite a hangover from that old attitude that hospitals are where it is at.”
According to Porter it has been suggested that there should be more exposure to the routine of general practice, with the hope that more people would see general practice as viable a career path as working in a hospital. “I think there is quite a lot to be done in that [area],” he says, “but the most important factor is something that is supported by the BMA, which is extending the general practice training scheme by one year in order to give more time for people to become more confident in working as a GP”.
Porter highlighted a problem that perhaps the profession has created for itself. He says: “I’m very conscious of the fact that when we talk about things like this we give young medical students coming through university an impression that general practice is rooted in problems and stresses of today rather than the possibilities an opportunities of tomorrow.”
Certainly hearing about burnout and being overworked is not a great message in terms of recruitment.
While training and attracting medical students to general practice is key it doesn’t help with the immediate problems faced by practice managers trying to fill vacancies today. It is well known that there are certain areas of the UK that are struggling to recruit GPs. This is compounded by the increasing workload making it difficult not only to attract medics to general practice but also to retain current GPs.
According to the RCGP in 2014 the north west and north east are the most under-doctored regions of England, with 63.4 and 63.6 GPs per 100,000 population.
Val Hempsey, practice manager of Bridges Medical Practice, Gateshead, Tyne and Wear is aware of the problem in her area. But her practice operates under an unusual structure where she is the only partner. She has no problem in attracting salaried GPs and has therefore avoided recruitment issues. Despite this rare model holding its own Hempsey is still aware of the fact that her doctors are up against it. As a result some of her salaried doctors do not want to work full time in the practice when they can work elsewhere which will ease the pressure on their work life. She says: “The workload is increasing and increasing and it’s not the number of patients GPs are seeing that is the problem it is everything else. They are taking laptops home and working really late at night on tests and investigations letters. They’ve got so much mandatory training to do: online nutrition advice, respiratory advice and so on. The number of patients has probably remained static if not decreased.”
This has been echoed by Dr Mike Dixon, partner at College Surgery partnership, Devon. He says his patient list “has not frankly changed in 30 years, so I’m having two or three times the workload as when I started 30 years ago but the same number of patients”. He says: “There needs to be more time really sorting out some of the more complex patients, a larger team to do more for the mental health patients and those with long-term disease.”
Even in a desirable location such as Devon where recruitment is not such an issue Dixon, also chair of the NHS Alliance, has still struggled. He says he survived, “by virtue of being a fairly high profile practice and always only taking on partners”.
“We have a reputation of going beyond core general practice and having a futuristic view of things, like very active patient groups. I suppose the attraction for the people that have applied is [that we are] creating a sustainable model of general practice in terms of being future proof for survival,” he says.
Despite Dixon having applicants for his practice he recognised that unfortunately they all came from other practices. “There is an absolute dearth of new young trainees waiting to come into general practice,” he says.
Two practices on opposite sides of the country with very different models have both found ways to attract GPs.
But where has such a crisis stemmed from? Dr James Kingsland president of the National Association of Primary Care, and a GP based in Wirral, Merseyside reflects on the late Nineties. Kingsland feels that a lot of resources were injected into general practice in 1997 and then 2004 that perhaps weren’t used effectively. He says: “In 1997 we had a primary care act and we could have done all the current reforms then through that act and recognise that we were having recruitment and retention problems and there was a need to increase GPs in under-doctored areas.” Kingsland feels the National Health Service (primary care) Act 1997 gave practices the opportunity to improve recruitment but “here is where the contention is, they did not recruit partners and found it was better financially for the business to recruit salaried positions.
“Fast forward to 2004 where we are still probably having the fall out of a really great negotiated contract where again general practice was rightly rewarded. There was another opportunity to invest in the independent contractor partner type model but both these led to practices looking for salaried GPs.”
It is partners that many practice managers are looking for, because, as Andrew Kolenda, business manager of DMC healthcare explains, “you get more of a commitment”. Currently going through the recruitment process at his practice Kolenda echoes Dixon and Hempsey’s views that having a strong practice model is appealing to applicants. “I’m lucky the practice I’m at in Woking is very clinical commissioning group (CCG) board member focused so there is a lot of charisma that goes with it and I suppose if an [applicant] is career minded they want that. You’ve got to make your practice attractive.” Aware of the fact that doctors are applying to several surgeries Kolenda doesn’t waste time when it comes to interviews. “As soon as I get an applicant I ring them and invite them in informally for a walk round and ask some questions, rather than saying ‘we’ll see you in four weeks for an interview’. Some doctors have to give three even six months notice. It has taken now nearly two and a half months to appoint a doctor here, we have got to move quickly. At the end of the day, employment wise, doctors are in the driving seat.”
But there are ways to attract potential candidates to a practice in this competitive. Kolenda is aware of the power of advertising. He says: “I do a nice advert with all the partners on. When I look for work if I see a little box advert in the corner that’s a freebie I think, ‘well they aren’t very committed’. If you do a quarter page spread you think, ‘well, they mean business’.”
While recruiting partners maybe the preferred choice it is not always easy for practices in certain areas. Dr Peter Swinyard, a GP based in Swindon and president of the Family Doctor Association (FDA) recognises that the way people view careers has changed.
“Previously people wanted to stay in one place for a long time where as now the aim is to move and experience other practices. The FDA has taken an idea to NHS England that senior GPs should be employed on a standby basis to go in and help practice’s that are having difficulties because most have done the job for 30 years and understand the business. It could be really useful for some practices to use advice on offer,” he says.
Swinyard honed in on a glaring problem that practices are facing – retirement. “There is clearly a significant demographic problem in terms of GP numbers because GPs of my generation, I turn 60 this year, we are about to retire – some of them as fast as they possibly can,” he says.
According to the General Medical Council’s List of Registered Medical Practitioners, in 2014 there were 65,130 GPs in the UK. A recent BMA survey, The Future of General Practice, received responses from 15,560 GPs across the UK. It found that 82% of GPs over the age of 60 intend to retire within the next five years. With GPs retiring and a lack of young doctors wanting to go into general practice, what is being done to recruit doctors into general practice training?
After a successful pilot in Wales, 2014 the Welsh government has decided that trainee GPs will be employed by Welsh NHS rather than a practice. Charlotte Jones, chair of Wales General Practice Committe, says: “By having just one employer during this training period, it should make it easier to obtain mortgages and access other benefits such as childcare vouchers.
“We also hope that this development will attract additional GP specialty trainees to come and train in Wales.”
Dr Simon Gregory, director and dean of education and quality for the midlands and the east at Health Education England (HEE) sheds light on what is being done to ensure there are enough GPs coming through the system.
A GP of 20 years experience and now responsible for education for 30% of England Gregory explains three reasons why he thinks there is a shortage.
“The first is that the workload in general practice has increased during my time. As a GP the consultation rate has more than doubled as has the complexity.
“People no longer came with one problem they came with four or five and often they are things that in the past could have been dealt with in the hospital.
“Second, general practice has at times not had the best profile as a speciality in it’s own right. I think that perception still carries through in some medical schools and hospitals to this day. We still hear comments about things like ‘why have you given up medicine’ or ‘work hard or you’ll end up being a GP’.
“Third, we as a profession need to get positive. We need to highlight what a wonderful job it is. It is tough but the way to get it better is to get more resource into general practice.”
HEE has been “expanding GP training capacity significantly year on year” he says.
Initiatives to make general practice training more appealing include a pre GP training opportunity where medicine graduates who haven’t been successful in recruitment or are unfamiliar with general practice can have a year of targeted supported training to help them get into position where they would benefit from training as a GP.
Another option includes the transfer of trainee medics from speciality areas in secondary care to GP training.
“This is the first year we have had a number choose to do it. It takes time for people to realise that this is an option,” he says.
Making it easier for GPs to return to practice is also a key idea.
The Induction and Refresher/Returner scheme has been running in some areas of the country for a year. This initiative was relaunched in March this year with greater clarification around the way to return depending on circumstances such as working oversees or being out of practice.
“We need to get people in general practice but they need to be safe. Patients must be protected at all times. By June we had 60 GPs reply to return to practice and undertaking assistance,” he says.
Application numbers peaked in London at 18 while the east midlands and north east had the lowest with just one each.
Solving the recruitment crisis is not straightforward. It involves every level of the career pathway from training to retirement. Efforts are being made on all fronts; practices are recognising the need to be an attractive place of work. Time will tell whether these measures will result in positions being filled. l
Kimberley Hackett, deputy editor of Management in Practice, The Commissioning Review and Nursing in Practice