GPs at 'breaking point' in England's most deprived areas

GP practices are under growing strain, with Sky News analysis revealing a "vicious cycle" of workload pressures and recruitment shortfalls in England's most deprived neighbourhoods.

One in every five GP practices in England and Wales has closed since 2013, according to Sky News analysis of NHS data. Doctors are now warning that staff shortages are putting primary care provision at serious risk.

Those practices that remain open are increasingly stretched thin amid rising numbers of patients and falling numbers of GPs.

“GPs are at breaking point,” says Dr Anita Raja, a GP in the West Midlands.

“We’re immensely understaffed. Partners are leaving their partnerships, practices are closing down. If it goes on the way it is, we will have no primary care anymore.”

Image: Dr Anita Raja, a general practitioner in the West Midlands, says GPs are at 'breaking point'

The number of patients per fully qualified GP has grown in two thirds of practices (66%) since 2015. Almost one in four (24%) have seen their patient-to-GP ratio increase by more than 50%.

As a result, GPs face a growing workload, with the number of attended appointments per GP rising by 21% between March 2019 and March 2023.

The British Medical Association recommends that GPs should see no more than 25 patients per day, and describes 35 appointments as the upper limit of “safe” care.

Over the whole of March, the local GP practices for more than three in five people living in England’s most deprived neighbourhoods (62%) saw over 25 patients per day on average, while the nearest practice of over a quarter (28%) saw more than 35 – almost twice the rate across England as a whole (16%).

The average GP is now responsible for 2,337 patients – up from 2,014 in 2015.

“When I was a young GP, it was considered normal to have a list size of about 1,700 to 1,800 patients,” says Professor Kamila Hawthorne, chair of the Royal College of GPs.

“We’re not seeing it slowing down and we’re not seeing it stopping and that is extremely worrying.”

Sky News analysis has found that the average local GP serving people living in the most deprived 10% of neighbourhoods is even more stretched, with 3,453 patients on their list.

“Those patients that they’re looking after in deprived areas also tend to be sicker,” says Prof Hawthorne.

“And this means that in an already overburdened picture, you’re getting a kind of double whammy in deprived areas.”

Using NHS data to adjust for these higher health needs, Sky News has found that the local GP for someone living in one of England’s most deprived areas has, on average, a 61% higher patient workload than the average local GP for residents of the country’s wealthiest areas.

This gap has increased slightly since 2015, when it stood at 59%. That’s despite the government’s efforts to incentivise trainees to take up posts in under-served areas.

Launched in 2016, the Targeted Enhanced Recruitment Scheme offers trainees a one-off payment of £20,000 if they agree to spend three years working in an area struggling with recruitment shortfalls.

The fifth of practices with the highest patient-to-GP ratios in 2015 have seen significant improvements, with their ratios falling by 21% on average.

However, increases in other practices have meant that the overall impact has been small. The gap in average patients per GP between the busiest and least-busy GP practices has fallen from 4,523 to 4,345, a decline of just 4%.

Ethnic disparities, meanwhile, have grown. The local GP for an average person of South Asian background has 22% greater patient workload than that of the average white person, up from a 17% difference in 2015.

That’s true even if we account for other key factors, like rurality and deprivation. Among people living in the most deprived parts of Britain’s major cities, for instance, those of South Asian background on average have a GP with a 25% higher patient workload than those of a white background.

Practices with more patients per doctor tend to perform worse in the NHS’s annual quality survey. Those that came in the bottom 10% of the survey last year have an average of 3,245 patients per GP, compared to just 2,278 in the best-performing practices.

A record 3,497 English GPs quit general practice in the year to March, with overall GP numbers falling by 379.

England’s missing GPs

During the 2019 general election campaign, the Conservative party promised they would recruit an extra 6,000 GPs by the end of 2024.

Since the election, the number of fully qualified GPs in England has risen by 486. Yet increasing rates of part-time work mean the number of full-time equivalent GPs has actually fallen by 514.

That has left GP practices increasingly reliant on trainees. As of April, trainees now account for 25% of all doctors in GP practices, up from 15% in 2017.

Health Secretary Steve Barclay has pointed to the rise in trainee numbers as evidence that the government is making progress on GP shortages. Speaking to MPs in May, Mr Barclay noted there were now “2,000 more doctors in general practice” than in 2010, a figure which includes trainees.

The problem for the health service is that few of those trainees are staying on to become fully qualified GPs.

“The recruitment is great, but retention is a huge issue,” says Dr Raja.

“The government hasn’t realised that what people are going to do now is get into GP recruitment schemes, get the Royal College exams from the UK and leave – because they are paying them much more abroad and they’re going to welcome them with better working hours and less patients per doctor.”

Between 2018 and 2019, the number of GP trainees working in English practices increased by 700.

While most of those beginning their training in 2019 would have finished last year, there has been no equivalent surge in the number of newly qualified GPs. In fact, the number joining the register aged under 35 fell slightly last year, from 798 to 758.

“There’s a belief that you just need to train more, and you’ll get more at the end,” says Billy Palmer of the Nuffield Trust, a health think tank.

“Well, that’s not what’s happened in general practice. All the push at the moment is just to train more, but we don’t see any more joining.

“Are they going to the private sector? Are they going abroad? It might just be competition for GPs at the end of the pipeline, and the NHS losing out.”

Part of the problem may be rules around immigration, says the Nuffield Trust’s Lucina Rolewicz.

“GP training typically takes three years, and after that it’s typically too early to apply for leave to remain. And it’s quite hard for them to then find a practice that would act as a sponsor for their visa for those two years.”

In March, a members’ survey by the Royal College of GPs found that 30% of foreign trainees were considering not staying on as an NHS GP because of the difficulties surrounding the visa process.

‘It’s a vicious cycle’

“There’s also a question of once you’ve got that cohort joining, how do you get them to stay?” adds Mr Palmer.

In the year to March, 500 GPs aged under 35 quit general practice – more than one in every eight (12.9%), the highest rate on record.

A survey by the Royal College of GPs last year found that 43% of GPs leaving the profession cited burnout or work-related stress as a factor in their decision.

“It’s a vicious cycle,” says Mr Palmer.

“If you’re in a workplace where they’re struggling to recruit fully qualified GPs, of course that puts pressure on other members of staff and makes it less desirable as a place to work.”

In the same survey, one in four active GPs (23%) reported being unable to cope with the stress of the job most days, while two in five (39%) said they were “likely” or “very likely” to quit within the next five years.

“You sometimes question why you’re doing this. I mean, do you want to do this for the rest of your life?” says Dr Raja.

“I’m in my late 30s now. I’ve spent my whole youth studying medicine. You almost feel obliged to keep going. Of course, you’ve got the option to emigrate. And that’s probably what most of us are looking at.

“It’s just so difficult, because I was trained here and I want to give this system my 100%. But the way things are, we do think about these things. It’s a broken system.”