Although it was ultimately omitted from their 2015 general election manifesto, the Conservative party’s pledge to deliver ‘at least 5,000 new GPs’ by 2020 was widely reported. Those of us on the ground actively involved in recruiting and training GPs were skeptical to say the least about our chances of achieving this in the current climate. Given the length of time taken to train a GP and the pressures on the existing workforce, meeting this target seemed impossible. Had anyone asked, we would have all said so.
It does seem this realisation is beginning to dawn on others and we have seen the wording of the promise gradually and subtly change. When giving evidence to the Parliamentary Health Select Committee, Health Education England (HEE) chief executive Ian Cumming indicated that this may not be calculated in the way we might have naturally expected. It should be pretty simple: count GPs in 2015, count GPs in 2020 and find out the difference, but this gave us our first sight of some potential trickery.
Something puzzling remains: whilst those of us on the ground remain so very unconvinced, no-one from NHS England or HEE seems to have any doubt at all that the target will be met. So how might they claim to have achieved this?
So when is 5,000 not 5,000?
When it is not a NET increase
Perhaps the simplest way to ‘achieve’ the target would be to not take into account those leaving the workforce and to deal in gross, rather than net figures. This is surely too blatant a misdirection to be advisable.
When it’s not ‘GPs’, it’s ‘doctors working in primary care’
This is the key change, and where we see the language quietly shifting. It is clear now that newly recruited GP trainees will be counted (and not just the increase in their numbers over baseline). Don’t be surprised if we also start to count ‘pre-speciality trainees’. These doctors, rejected at GP selection, are placed into hospital jobs with some GP training scheme input, in the hope they apply again and are successful. But with no guarantee they will be.
Even more worrying would be if they counted any new ‘Foundation for GP’ posts. These are applicants who can’t get through selection for general practice because they are unable to demonstrate foundation competence. Again, they are placed in a hospital job to allow them to demonstrate Foundation competence prior to hopefully applying for and being successful at GP selection.
These schemes are an important part of our recruitment and should result in more GP trainees. But they are not GPs and are working in hospitals, not in primary care.
When it depends how you count GPs
Counting the number of GPs practising is actually quite difficult – for example how do you capture the number of locums working? How do you account for portfolio careers? The Health and Social Care Information Centre produces figures, but new measures are being used and they say themselves, ‘As a new collection its results must be further understood, as such these statistics are experimental and subject to change’.
Don’t be too surprised if a way is found to count GPs that results in an apparent increase in the workforce.
When it is 4,000 plus 1,000
Ian Cumming told the select committee that the 5,000 ‘new doctors in primary care’ would be made up of 4,000 new doctors and 1,000 who would otherwise have retired.
There is no sign of the pressure on GPs easing and with seven-day working on the horizon and the increasing burden of administration and regulation, the result is that means many of those in the twilights of their careers are leaving.
Reducing the exodus from the profession by delaying people’s retirement, whether through incentives or other means is not only likely to be very difficult, it is a seriously short-term solution. We need to improve the working conditions of general practice so that the job is one you can survive past 55.
When you axe broad-based training
Broad-based training was a small initiative that allowed some trainees to spend two years in various specialties before deciding on one and entering at ST2, very much in line with the Shape of Training report. It was extremely popular and well-evaluated, but has recently been scrapped in a bid to concentrate on recruiting to the 5,000 target.
When you actually need 7,500 to get 5,000
Attrition, wastage, participation. I heard recently that to produce one full time GP for the workforce you need to take at least 1.5 GP trainees into the start of training. Due to failure to progress, illness or career choice, attrition over three years of GP training can conservatively be estimated at 8%.
Then, when GPs are awarded CCTs, many of them don’t work in GP in the UK, choosing to have career breaks or work abroad. Many leave medicine or general practice altogether.
Finally, the level of participation means that many GPs choose not to work what would have traditionally been thought of as full time.
So, to produce 5,000 nine session FTE GPs (after three to three and a half years), I estimate you need to take into training at least 7,500.
When it should be 8,000
At the 2015 election, the political parties differed in their estimations of the required numbers of extra GPs, with most agreeing with the RCGP’s carefully calculated and evidence based figure of 8,000 new GPs required. Of course 8,000 is even more unachievable, but at least it more accurately represents what we actually need.
We would all love to see a net increase of 5,000 GPs by 2020, but we have to acknowledge that in the sense we all understand that, it isn’t going to happen. But that doesn’t mean we should stop trying.
Let us be careful not to say we’ve achieved this when we haven’t. And let us remember the reason we aren’t going to achieve it is that UK primary care is failing.
We must all focus our efforts not just on recruiting, returning and retaining GPs, but fixing the reason why doing so is so difficult.
The author is a GP who works for HEE