Number of general practices shrinking but patient lists ballooning in England

Over the past decade the number of NHS general practices in England has shrunk by 20%, but patient list sizes have expanded by 40% to just under 10,000, on average, finds an analysis of three national primary care datasets, published in the open access journal BMJ Open.

And while the total NHS general practice workforce grew 20% between 2015 and 2022, as a result of increases in admin staff and other practitioners, the number of GPs per 1,000 patients fell by 15% over the same period, when accounting for working hours, the analysis shows.

Major structural and organizational changes have taken place in general practice in England over the past decade,but it’s difficult to get an overall picture because information about different aspects of general practice is dispersed across multiple datasets, explain the researchers.

They therefore combined information from different national data sources to describe changes in the organizational structure, workforce, and appointments provided by different types of staff in English general practice, and to consider the implications of these trends.

They drew on general practice data collected by NHS England, the Office for Health Improvement and Disparities, and the Care Quality Commission, covering periods of between five and 10 years from 2013 to 2023.

They found that the numbers of people registered with an NHS general practice in England grew by 11% from 56,042,361 to 62,418,295 between 2013 and 2023. And the average proportion of patients aged 65 and over rose from just over 16% to 18%.

But the total number of practices fell from 8,044 to 6,419, equivalent to 178 fewer practices a year and an overall reduction of 20%, while the average practice list size increased by 40% from 6,967 to 9,724 patients, equivalent to 291 more a year.

The number of large practices with lists exceeding 20,000 patients also rose from 1% (81) of practices in 2013 to 6% (355) in 2023.

Between September 2015 and September 2022, the total number of qualified GPs working in NHS general practice in England rose from 34,474 to 36,492. But after taking working hours into account, the number of those working the equivalent of full time fell from 27,948 to 27,321.

The average number of GPs fell from 0.53 to 0.45 for every 1,000 patients, representing a fall of 15%, with the fall significantly steeper among male GPs: 23% vs. 4% of female GPs.

The proportion of practices reporting a GP trainee rose from just over a third (35%) to half (50%) between 2018 and 2022. But there’s no guarantee that, once qualified, GP trainees will work full time in general practice or stay in it, the researchers point out. And the NHS continues to rely on doctors who qualified overseas: they make up a quarter of GPs in NHS general practice.

As to other staff, the average number of nurses remained relatively stable between 2015 and 2022, with, on average, 97% of practices employing a nurse. But the average number of other roles, which include pharmacists, social prescribers, physician associates and paramedics, rose by 67%, with the proportion of practices directly employing these other staff rising from 72% to 89%.

Admin roles also rose by 14% over this period, making up over half of the NHS general practice workforce by September 2022.

Using new national data, the researchers estimated that between 2018 and 2023 there were between 63 and 119 (average of 98) general practice appointments/week for every 1,000 patients, carried out by all types of practitioner. Appointments peaked between September and November each year, and dipped between April and August 2020 in the wake of the first COVID-19 lockdown.

GP appointments ranged from 35 to 57/week/1,000 patients, with no clear trend over time, after accounting for population increases. Appointments with nurses ranged between 18 and 28 /week/1,000 patients. Appointments with other practitioners ranged between 17 and 26/week/1,000 patients.

Both GPs and other practitioners represented the same proportion (19%) of the NHS general practice workforce by September 2022 once working hours were accounted for. But GPs continued to provide half of all appointments despite the fall in their numbers, while other practitioners provided around a fifth.

“Falling GP numbers delivering the same number of appointments/1,000 [patients] seems unsustainable; therefore, there is likely to be a tipping point in the near future where the majority of appointments in English general practice are no longer delivered by GPs,” suggest the researchers.

The researchers note some limitations to their analysis—among them, the discrepancy in population data provided by NHS England and the Office for National Statistics, and the ‘experimental’ nature of NHS England’s appointments data.

Other general practice work, such as managing correspondence, prescriptions, reviewing test results, staff supervision, management and quality improvement activity isn’t captured by appointments data either. And online consultations delivered through separate messaging software may not be included while workforce data are unlikely to cover overtime, which is common in general practice, they point out.

And they weren’t able to distinguish between practices that closed for good, and those which were taken over by another practice to become a ‘branch’ surgery.

“The move towards larger-scale organizations has been encouraged by government policy and professional bodies to improve quality and generate economies of scale through shared back-office functions, joint service delivery, and standardized processes. However, the evidence regarding whether larger organizations deliver better-quality primary care or are more cost-effective is mixed,” comment the researchers.

Similarly, the diversification of the general practice workforce has also been driven by national policy and proposed as a solution to GP shortages, but concerns have been raised about the impact on continuity of care, cost effectiveness, equity in role distribution, and safety without sufficient GP oversight, they add.