The GMC’s chief executive Charlie Massey delivers a speech at Pulse LIVE on ‘the role of the regulator in building a sustainable workforce‘
Introduction
The GP workforce, and primary care, is under immense strain.
Across a worrying breadth of measures, GPs report more negative experiences at work than their colleagues.
Our data tell us that, year on year, GPs report greater pressure, with more than three quarters of their days being described as ‘high intensity’. This is a significantly higher proportion than specialists[1].
GPs are also the most likely to be at a high risk of burnout, with nearly a third falling into this group[2].
Yet despite their best efforts, GPs are also most likely to report challenges in meeting patient needs. Our research shows that they are much more likely to highlight patient dissatisfaction as a key concern, reflecting the frustrations of the public and profession alike[3].
These figures have a real world impact – for the GPs struggling to cope with the unprecedented demand for care, and for the patients desperately seeking it.
These pressures might explain why, across the board, the proportion of doctors taking hard steps to leave the profession has increased[4]. This, in turn, feeds the vicious cycle of draining the workforce of talent just as the need for care is mounting.
The sad truth is that across multiple measures, we’re only seeing trends worsen. And whilst that is true for all groups of doctors, it is clear from our data that GPs are suffering more than those working in other specialties.
So it is not surprising that in recent years general practice has had the lowest proportion of doctors feeling satisfied in their work and the greatest proportion at high risk of burnout.
And this is driving a structural problem. The GP workforce has not only been the slowest growing register group over the last ten years. But we are now also seeing more and more GPs moving away from full-time working simply to cope with mounting pressures, rather than as a positive choice.
The state of play today is intolerable – both for patients, who feel that their needs aren’t being met, and for GPs themselves, who are unable to provide the quality of care they want to provide for their communities.
All of this tells us that just expecting more GPs to plug the gap will not give us the sustainable and long term answers we need. Instead it risks killing our primary care model altogether.
So a new approach required. And it has to start with a re-think of the roles and responsibilities of primary care teams.
SAS doctors as part of the solution
It’s true that there isn’t a ready-made pool from which we can pluck enough GPs to fill the primary care gap.
But what we do have is a sizeable source of experienced talent in the form of SAS doctors, many of whom are itching to do more with their skills.
While the growth in the GP workforce has been sluggish at best over the last five years, the number of SAS and LE doctors has grown by a whopping 40%[5]. That’s six times the rate of GPs. In fact, if current trends continue, by 2030 they will be the largest group in the medical workforce.
The SAS cohort is diverse, in terms of specialties but also background. But what they all have in common is their high level of experience and skill. In our 2019 survey, 83% of SAS doctors had been in clinical practice for 10 or more years[6].
Despite their number and ability, bureaucratic barriers mean SAS doctors are unable to deploy their skills to maximum effect. This includes the restrictions that block them from working in primary care.
This is anachronistic on several fronts.
For SAS doctors, who have expertise and experience directly relevant to primary care but who find themselves stuck in roles that don’t make the most of their talents.
For the wider GP workforce, where the mismatch of supply and demand is taking a huge personal and professional toll.
And for patients, who are struggling to access the care they need, at the time they need it.
The reality is that the medical workforce is changing but the rules that govern it aren’t keeping pace. Dated ideas are holding SAS doctors back and patients are being denied their skills in the process.
Embracing reform
I believe the key to tackling the challenges confronting the service is to make the most of what we already have, both in terms of GPs and the wider medical workforce.
There is no ready-made batch of GPs waiting to be plucked off the shelf to ease the pressures on the workforce. So we need to give the talent we already have the opportunity to maximise their skills and experience.
The good news is that there are things we can do about this today, benefiting primary care patients and practitioners alike.
The first is reform to the Performers List, which determines which doctors can work in primary care. Changing the criteria could allow SAS doctors to work alongside GPs in complementary roles.
Exactly what that mix looks like would be down to primary care leaders, and would vary according to the needs of different locations.
I need to emphasise that this isn’t about SAS doctors substituting for GPs. And I’m certainly not suggesting that GPs don’t have a particular and expert set of skills and knowledge. Instead, what I am arguing for is that the rules should be changed to allow other doctors with relevant expertise to work alongside GPs and the primary care team.
This new SAS grade in primary care would not only help alleviate pressure on the existing workforce. It would also expand career options for the SAS cohort and provide new opportunities for those who want them. This would have the additional upside of giving SAS doctors more reason to stay in UK practice, no small thing given this group is more likely to leave the workforce than any other.
So it’s vital NHS England and others enable these changes, so we can realise the benefits to both the public and profession.
Embedding compassionate culture
Altering the composition of the primary care workforce in this way is, of course, not without its challenges.
The devil is in the detail, and the mechanics of how these changes play out on the ground will require careful thought and attention. That includes how SAS doctors will be supported and supervised by experienced GPs, without increasing their workload.
It is not for the GMC to work out the answers to all of these questions. But there is reason to believe that primary care is well placed for this sort of reform. Early results from our 2022 Barometer survey show that more GPs than other doctors agreed that their organisation encourages a culture of teamwork[7]. This suggests fertile ground for pioneering a new type of multidisciplinary working.
Working in this sort of supportive and inclusive environment makes a tangible difference not just to the day-to-day experiences of doctors but also to the care their patients receive, as copious research affirms.
But too often this is not the experience of many doctors who join UK practice from overseas.
Our data tell us that the small growth in the GP workforce we have seen in recent years has been driven largely by IMGs[8]. But we know shamefully high numbers continue to experience discrimination and disadvantage in their daily working lives.
For all doctors, compassionate cultures that allow them to speak up, ask questions and raise concerns are as fundamental to their practice as their medical skill and knowledge. It is the experience a doctor has when they come into work every day that determines the quality of care they’re able to provide. For doctors new to UK practice, navigating a new society as well as a new workplace, these issues are fundamental.
These factors can also be the difference between a doctor choosing to stay or leave. Our 2021 Completing the picture survey showed that IMGs were more likely to cite bullying and harassment as key factors in why they left UK practice than doctors[9] who qualified in the UK.
This comes back, again, to retention and the paradox of medicine today – that while we continue to see large numbers of doctors joining the register, huge numbers are also leaving.
Conclusion
To conclude, there’s no doubt that general practice is under huge strain – and the effects of that are pernicious to patients and practitioners alike.
Sadly there is no magic switch we can flick to resolve all the problems in one go. But that doesn’t mean there aren’t solutions.
Realising such a shift in approach requires the cooperation of all of us in the system – including the hard working GPs giving their all to care for their communities.
Evidence tells us that primary care is in dire need of such a change. Doing things as we’ve always done will not create the sustainable workforce we need. It threatens the very survival of our primary care model.
To sustain general practice fresh thinking is needed. We at the GMC, working with partners across the system, are committed to playing our part.
Thank you.
[1] p. 24 The state of medical education and practice in the UK 2021 (gmc-uk.org)
[2] p. 31
[3] p. 41
[4] p. 94
[5] p. 07 The state of medical education and practice in the UK: The workforce report 2022 (gmc-uk.org)
[6] p. 25 https://www.gmc-uk.org/-/media/documents/sas-and-le-doctors-survey-initial-findings-report-060120_pdf-81152021.pdf
[7] These are findings from the 2022 Barometer survey, to be included in the new SoMEP
[9] p. 29 completing-the-picture-survey_pdf-87815271.pdf (gmc-uk.org)
