Has general practice reached a ‘tipping point’?

A recent study suggested that falling GP numbers could ‘lead to a tipping point’ where most general practice appointments are delivered not by a GP but by other practice staff. Beth Gault takes a closer look.

For a number of years, there has been a trend of declining GP numbers in general practice but an increase in the number of patients.

A study in the BMJ Open this month suggested that the number of GP practices in England fell by 20% between 2015 and 2022, with an average loss of 178 practices a year. It also found that the number of full-time equivalent (FTE) GPs per 1,000 patients dropped by 15% in the same period. The total number of qualified GPs also fell by 627.

Alongside this trend, there has been a shift towards larger practices with a wider breadth of multidisciplinary teams, particularly with the addition of PCNs and the ARRS scheme.

After an initial aim of 26,000 additional roles by 2024, the scheme has now hit 37,000 staff.

The BMJ Open study suggested these trends would likely lead to a ‘tipping point’ in the ‘near future’, where the majority of appointments are not delivered by a GP, but by other direct patient care staff.

The research covered the 10-year period between 2013-2023. In the latter half of this (2018-2023), the research found that GPs were providing around half of the appointments.

Pulse PCN’s own analysis, which looked at practice-level NHS appointment data from the past month, suggested that of the 6,210 practices that shared this, 3,250 reported less than 50% of appointments were now with GPs, and were instead delivered by other direct patient care staff. That is more than half (52%) of practices with more appointments delivered by ‘other’ staff rather than GPs, among the practices who provided this level of data to NHS England. Although it should be noted that this data is labelled ‘experimental’ by NHS England.

But when PCNs were first brought in, it was the aim of the government to fund an extra 50 million general practice appointments by 2024 and to increase the staff available across primary care in order to deliver these appointments. Social prescribers in particular were meant to handle around 900,000 patient appointments per year by 2023/24.

The scheme reached these 50 million extra appointments by November 2023, according to the Department of Health and Social Care (DHSC), with 358 million general practice appointments in the year to October 2023, up by 50.9 million from 2019 figures.

In the 12 months to the end of July 2024, according to Pulse PCN analysis of NHS appointment figures, the number of appointments had reached 364 million in England over a year.

However, NHS England does not break down the data on who exactly provided these appointments beyond those delivered by GPs or by other direct-to-patient staff, meaning it is not possible to extract just how many of these appointments were delivered by ARRS employees.

A spokesperson from NHS England told Pulse PCN: ‘Unfortunately, we are unable to identify ARRS roles within the data we hold, and therefore cannot say how many appointments have been delivered by the scheme.’

One of the authors of the BMJ Open report, Dr Luisa Pettigrew, also said the data should be interpreted with ‘some caution’ as the statistics are ‘experimental’.

But there is significance to who delivers these appointments, and a growing debate over which roles are able to deliver what care.

This is demonstrated by the recent furore around physician associates (PAs), which are the sixth largest employee group within the ARRS scheme, with around 1,183 currently employed by PCNs.

While the role of PA has been in general practice since 2003, it caught public and the profession’s attention after a handful of high-profile tragic cases, including Emily Chesterton, a 30-year-old patient who died at the end of 2022 after a pulmonary embolism. The coroner in the case concluded that the poor quality of care provided by the PA she saw contributed to her death.

In June, the RCGP urged that PCNs halt the recruitment of PAs, while in the same week, the BMA launched legal action over the regulation of the profession.

The union said plans would mean a ‘dangerous blurring of lines’ for patients between ‘highly skilled and experienced’ doctors and assistant roles.

This month, the RCGP voted to oppose the role of PAs in practices at its UK council.

The ARRS scheme in general has also faced flack from the profession, with some arguing the funding would be better spent in the core contract.

The BMA had been calling for GPs to be added to the ARRS scheme in January 2024, as an ‘obvious solution’ to practices’ workforce and financial issues. But in August, after GPs had been added to the scheme on a temporary measure, the union then called for funding to be given directly to practices rather than PCNs.

The move to add GPs was one of the first of the new Labour government, and it aimed to allow practices to hire recently qualified GPs who face potential unemployment this summer.

However, the updated PCN DES has only just been published despite the funding being available from October, raising concerns that there will be recruitment delays.

At most, it also only aims to offer 1,000 GPs across England, which is less than one FTE GP per PCN.

With the new government’s ambition to shift care into the community and its focus on prevention, the demands on primary care look set to increase, and its workforce will not only need to be plentiful but robust.

The authors of the BMJ Open study also referenced the ongoing challenges of continuity that are present with increasing multidisciplinary teams.

‘Maintaining relational continuity of care will be harder to achieve if there is a shortage of GP appointments and if patients need to see different clinicians for different problems, this will likely have implications for quality of care,’ it said.

In 2019, Rebecca Rosen, senior fellow in health policy at the Nuffield Trust, said in the BMJ that continuity of care was as important as access to GP services.

She said: ‘Improving access by shortening waiting times may seem a must-do for general practice, but equally important is providing access to the right person.’

No matter who delivers appointments, it’s the quality and outcomes of those interactions that will tip the balance for patients and that has to be the focus.