In a series of articles on the state of general practice in the devolved nations, Katherine Price explores the workforce challenges in Wales
While the shortage of GPs is a problem being experienced across the UK, Wales is both leaking trainees into England while also suffering from an ageing GP workforce.
The latest figures show that GP numbers in Wales have fallen by 15% in the last 10 years, with 1,563 full-time equivalent (FTE) GPs recorded in June last year compared with 1,846 in 2012. And in the six months to June 2022, 49 FTE GPs alone were lost to the profession, described by GP leaders at the time as a ‘deeply worrying trajectory’.
Chair of RCGP Cymru Wales and GP principal at Wye Valley practice in Monmouthshire Dr Rowena Christmas says a major challenge for the country is the departure of international medical graduates into England.
At present, overseas trainees are sponsored and employed by NHS Wales Shared Services Partnership. They can apply for indefinite leave to remain after working in the country on a skilled worker visa for five years. But after gaining their certificate of completion – which due to the length of the GP training programme is usually three years, they need to be sponsored by an employer, leaving a two-year gap. And because GP practices tend to be smaller in Wales than in England, Dr Christmas says, very few have gone through the visa sponsor process with the UK Home Office.
The impact of this is reflected in data from the BMA. It shows that in August 2022, more than 30 GP trainees – almost half of the total cohort – faced being lost to the Welsh system because they needed a sponsor. And according to the GMC’s 2022 workforce report, almost half of Wales’ medical graduates relocate to England due to the greater availability of foundation posts. And 16% of those who have completed GP or other specialist training also make the move.
The GMC’s report also showed that over a third (35%) of licensed doctors in Wales gained their primary medical qualification (PMQ) outside of the UK. And yet, 28% of international medical graduates who qualified in Wales moved to another UK country, and 8% left altogether.
‘We’re losing fantastic Welsh-trained GPs who actually want to stay in Wales, and we’re losing them to England because of the visa issue,’ says Dr Christmas.
The issue is compounded by the lack of investment in premises to provide space for students, which is preventing some practices from taking on trainees. ‘They keep telling us there’s no money for estates, which is a big concern when we’ve got all these new doctors coming in to be trained. Quite how that’s going to work I’m not sure,’ she adds.
Ageing workforce
At the other end of the spectrum, Wales is facing another significant problem: a high proportion of GPs are close to retirement age. The BMA’s GPC Wales chair Dr Gareth Oelmann says GMC data shows Wales has the highest percentage of GPs over the age of 60 than any other part of the UK.
Meanwhile, Welsh Government workforce figures suggest around a third of GPs were at or approaching retirement age in December 2021.
Dr Oelmann says urgent proposals are needed from the Welsh Government on GP recruitment, but some work has started already. This includes reviewing existing incentive schemes such as seniority and partnership premium schemes, which have just recently been extended to include non-GPs who are partners in a practice.
‘We’re also already working with Welsh Government and the health boards to look at reforms to the all-Wales medical performers list, streamlining the process for joining and remaining on the list,’ he adds.
In February, the Welsh Government published its National Workforce Implementation plan, which aimed to set out ‘immediate practical actions to address some of the key issues’ facing the NHS in Wales. GP leaders warned at the time that the pressures in general practice felt ‘a long way from the ideals’ it set out, but there is also a specific Primary Care Plan in the works, which they hope will deliver a specific recruitment and retention strategy for general practice.
‘They are saying the right things…It [the National Workforce Implementation plan] does feel a bit like a glossy brochure and here we are at the coalface. There’s a great disconnect between the reality and what they’re talking about,’ Dr Christmas says.
She suggests that more flexibility is needed to retain the general practice workforce, which was traditionally seen as ‘family friendly’ but she has become less so in recent years.
‘That’s our USP, so that’s what we need to get back to somehow. We need a compassionate leadership ethos where we say “yes” if we possibly can and work around people.’
Dr Christmas’ own surgery has taken this approach. They’ve retained a semi-retired GP to see 12 patients, and employ a partner who only works during the school term. She also suggests that GPs who have retired or are close to retiring can be mobilised to support with aspects such as quality improvement work, mentorship and training, instead of losing that knowledgeable and experienced segment of the workforce altogether.
‘It’s about thinking differently, rather than saying, “this is the model it has to be, you have to see 16 patients, you have to do 10 telephone consults on top of that, you have to do three visits and all the bloods and letters”. People might then say, “no, I’m not doing that”, and then we lose them. Every little bit of GP talent we have, we have to nurture and try and maintain it.’
everywhere we look things are dire and getting worse. NHSE are trying all sorts of tinkering around the edges but the basic take away message is that the GP system is buckling and broken. We need to look back at the 80s and 90s and work out why general practice was effective then and try to get back to that way of working. The one glaring change that I have observed is the imposition of guidelines and templates and the legalistic extensive note recording as if every case will end up in court. This is hugely time consuming and has NOT reduced complaints. It does however suck the pleasure out of the job and makes us so slow we cannot cope with the demand in the way we used to.
Perhaps if so much GP time was not wasted on pointless bureaucracy, there might be enough GPs for the useful work?
And perhaps GPs might enjoy the job and want to keep doing it?