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NHS workforce plan relies on ‘significant’ substitution of qualified GPs, NAO warns

NHS workforce plan relies on ‘significant’ substitution of qualified GPs, NAO warns

NHS England’s workforce ambitions are based on ‘significant’ substitution of fully-qualified GPs with trainees and SAS doctors, the public spending watchdog has revealed.

In a new assessment of the NHS long-term workforce plan, the National Audit Office (NAO) found that NHS England’s modelling of the future workforce had ‘significant weaknesses’ and that some of its ‘assumptions’ may have been ‘optimistic’.

Last year, the national commissioner committed to doubling medical school places to 15,000 and increasing GP training places to 6,000 by 2031. 

This was based on modelling which predicted that, without these changes, the NHS could face a staffing shortfall of 360,000 and a GP shortfall of 15,000 by 2036.

The NAO’s report has examined the robustness of NHS England’s predictions, and made a number of recommendations which could influence the refreshed projections NHSE has committed to publishing every two years.

Scrutiny of GP workforce modelling formed a substantial part of the watchdog’s report, due to the mismatch in growth of GPs compared with other doctors.

The long-term workforce plan (LTWP) projected only a 4% increase in fully-qualified GPs between 2021 and 2036, compared to a 49% growth in consultants. 

‘The total supply of doctors in primary care is projected to increase substantially over the modelled period but the total number of fully qualified GPs is not,’ the report said. 

It found that NHSE’s projected supply growth in general practice ‘consists mainly of trainee GPs’, who accounted for 93%, as well as ‘making increased use of specialist and associate specialist (SAS) doctors in primary care’. 

The NHS and Government have committed to allowing SAS doctors to work in general practice, but had not yet given a timetable as to when this will happen. 

In the NAO’s analysis of NHSE’s modelling, SAS doctors begin to form part of the primary care from 2026-27. 

And the GP contract for this upcoming financial year will cement performers list flexibilities brought in during Covid, which seems to open up the path of SAS doctors to be employed by practices and PCNs.

But last year, NHSE’s national director of primary care told Pulse that plans to allow SAS doctors to work in general practice are not about replacing GPs.

The NAO report went on to say: ‘NHSE told us that general practice had already been changing in recent years to make use of a wider range of medical and clinical professionals, and that the plans in the LTWP would continue in that direction. 

‘The LTWP also states that NHSE wants trainee GPs to spend more of their time in primary care settings in future. 

‘Taken together, these changes constitute one of the most significant examples of workforce substitution in the modelling, whereby some of the work typically done by one type of health professional today is moved to another type of health professional in future. When modelling such shifts, the choice of substitution rates is significant.’

According to NHS England, one GP in training equated to 19% of a fully-qualified FTE GP – which accounts for the time a GP needs to supervise trainees – while one SAS doctor in primary care equates to 70% 

The NAO urged the national commissioner in future workforce planning to show how the ‘large increase’ in GP trainees up to 2036 ‘eventually converts’ to more fully-qualified GPs.

Other NAO findings:

  • The pledge to double medical school places is ‘at the top end of the maximum expansion NHS thought theoretically possible’;
  • NHS England’s analysis of growth in medical training did not take account of the ‘capacity constraints’ to an an ‘expansion’ of this scale;
  • In the modelling, international recruitment is expected to continue to fill gaps until the supply of domestic workers increased, but the workforce plan also aims to reduce the reliance on international recruitment – the report assessed that ‘this is not a reasonable modelling assumption’.

In response to the report, chair of the Public Accounts Committee (PAC) Meg Hillier said: ‘It is good to see that NHS England has for the first time produced this modelling, but it now needs to build on this and address the weaknesses the NAO report identified so its long-term decisions about the NHS’s future workforce are better informed and we know what money will need to be spent on it.’

Responding to the NAO’s findings on international medical graduates (IMG), head of medical at the MDDUS Dr Naeem Nazem said the report confirms that NHSE made ‘unrealistic assumptions about when the recruitment of overseas medical graduates can be phased out’.

‘We find this concerning, not only because it undermines the vital work international medical graduates (IMGs) are doing today in the NHS but it also risks undermining how their colleagues view them as we head into the second half of this decade,’ he added.

Dr Latifa Patel, chair of the representative body and workforce lead at the BMA, said: ‘Importantly, the report notes that the total supply of doctors in primary care is projected to increase substantially over the modelled period, but the total number of fully-qualified GPs is projected to be less than 2015. The NAO report underlines the need for independent assessments of future plans and the modelling underpinning them, as this report has brought to light key issues that need addressing.

​’At the very least, NHS England needs to be honest about the challenges facing the healthcare workforce and amend its plan accordingly, in the expected 2025 update. Going back and making changes isn’t a failure, but continuing on a course that many have said isn’t going to work surely will be.’

When the LTWP was published last year, GP leaders criticised the lack of specific plans to retain existing GPs, with one LMC leader saying we ‘cannot recruit our way out of the current workforce crisis’.

A Pulse analysis revealed that general practice would need to double the number of trainers by 2028 in order to accommodate NHS England’s workforce pledges.

Watchdog recommendations for future workforce modelling

  • NHSE’s modellers should consider whether it is reasonable to expect the same rate of increasing productivity from a workforce increasingly composed of newly qualified staff.
  • Future versions of the modelling would be improved by greater consultation and by taking better account of the factors that could limit the expansion of education and training, and of any reductions in service that might result from rapid increases in the amount of on-the-job training.
  • NHSE’s modelling should incorporate more realistic assumptions on the minimum level of international recruitment of doctors in future.
  • Ahead of the next version of the LTWP, NHSE modellers should consult further with a wide range of stakeholders, including Royal Colleges, healthcare providers and other health bodies about the appropriate substitution rates to use when meeting demand for one type of healthcare worker by employing another and should attempt to understand the real-world workload effects on general practice of changes in roles in primary care. NHSE should also be clear about how any proposed changes in skill mix fit with its wider agenda of progressively moving care out of hospital settings and into the community.



Please note, only GPs are permitted to add comments to articles

Turn out The Lights 22 March, 2024 10:26 am

Looks like they are building the foundations of the nhs on sand.No worries there then!

So the bird flew away 22 March, 2024 10:38 am

Another flag that NHS being moved towards USA style of first contact where there’s hardly any notion of a GP, ready for that US trade deal. Both mainstream parties have likely signed up for this, so even more important that GPs voices are heard by the public. Maybe there’s still time to send a message to the next Govt.
Even those GPs advocating going “Guernsey” option will find that once NHS is transmuted into a US style, private GP will quickly do a dodo.

David Church 22 March, 2024 12:10 pm

The estimate of FTE % for SAS doctors is faulty, as it does not account sufficiently for training time, and uses the wrong definition of FTE hours of work – which as we all know is 26 hours per week, spread between 8 am and 8 pm 5.5 days per week…….. whereas 3/4 time is only 19 hours, but takes longer too. Can NAO understand the hours differences enough to know what is FT and what is not, and how much training an SAS doctor would require, including fully-qualified GP supervision?

Dylan Summers 22 March, 2024 12:14 pm

Bringing SAS doctors into primary care is a great idea – but should be done by giving them GP training (perhaps shortened if appropriate) and then working as GPs.

Mr Marvellous 22 March, 2024 1:36 pm

This isn’t a mistake, it’s policy.

George Forrest 22 March, 2024 2:45 pm

The country urgently needs a realistic NHS workforce plan based on evidence – NHSE delivers a deleterious policy of politicised magical thinking
Just stick to the brief?

Northern Trainer 22 March, 2024 6:19 pm

Mr Marvellous is sadly absolutely correct. This was a transparent and planned policy laid out before our profession’s paid and elected leaders years ago. At the tail end of their careers they placed their own pole-climbing quest for honours ahead of the core values of General Practice and its future. They know who they are.

This set of critical mistakes will be analysed and written about for years as the impact is inevitably felt by all. If only “why don’t we just fund the service properly and ensure we have enough GPs” was a sentence uttered at the start of this car crash……..

Just Your Average Joe 24 March, 2024 7:56 pm

Its already hitting buffers as they haven’t put the money ion, and the expansion in medical school numbers less than needed for the coming year, so it will be behind schedule from day 1.

Plus you need to keep the doctors going into GP training, in the profession when they qualify , so you don’t lose the valuable product you spent almost a decade in training ( from A levels!), at the final hurdle.

S0 if currently 3500 in GP training you may falsely expect to get 3500 GPs – but they will not actually give you 3500 FTE working GPs – because in the current climate you may be lucky to get 2500FTE working GPs at most.