There is both a shortage of GPs in the system, and a shortage of jobs for GPs, which could be seen as a ludicrous situation.
Practice managers say there are two reasons for this, and the ARRS touches on both. First, there is a lack of funding; second, practice premises are often inadequate to accommodate GPs.
In 2019, as part of the five-year contract, the BMA GP Committee and NHS England agreed to set annual increases of around 2% a year. At the time, many saw this as helpful for GPs – and there were even suggestions that other parts of the NHS were envious.
Up until 2021/22, GP practices were seeing a real-terms increase in funding. Part of this would have been the money they received for carrying out Covid vaccinations. But 2022/23 saw a real-terms funding decrease.
Since then, we have seen huge inflation and the cost-of-living crisis, yet the funding uplift remained at around 2% a year. This means that there has been a drastic cut in practices’ real-terms funding. The Labour Government’s first Budget has exacerbated matters with the increase to employers’ National Insurance Contributions (NICs), which was intended to raise money for the NHS. GP practices were considered the big losers in this policy; they were not guaranteed public funding from the increase because they were considered ‘private sector’, yet GP practices do not benefit from tax breaks for smaller businesses because they are considered ‘public sector’ for this purpose.
Since then, Wes Streeting has announced the increase in funding of £889m a year – roughly 6%. This funding has been welcomed by the profession, although cautiously. The Cogora white paper analysis suggested the increase in National Insurance will cost practice £260m. Furthermore, the details of how the funding will be provided to practices – and, crucially, what extra work they will be expected to do – won’t become clear until 2025/26 contract negotiations with the BMA’s GP Committee England are concluded.
But practices are currently facing a funding squeeze that has the effect of making ARRS staff look more attractive, even if the available roles are not the most appropriate for patient care.
These staff are not only paid lower salaries but their costs are at least partly reimbursed by the NHS.
Dr Ian Sweetenham, a GP partner in Cambridgeshire, says: ‘We couldn’t find GPs two years ago. Now that I have them coming out of my ears, I have no money to employ them.’
The general practice funding shortfall leaves practices facing unwelcome decisions. Around 6% of practices said they have had to make redundancies, while a further 20% said they had to decide not to replace departing staff.
This is affecting care. A GP partner in Leicestershire says: ‘As a practice we are always short of appointments, patient demand is tremendous. However, purely for financial reasons and the fact that the practice is struggling to function at a profit, when our three – session salaried GP resigned we made the decision not to replace them. Instead, we decided to try to manage as best as we could without these sessions. This was in spite of the fact that when we advertised to recruit a replacement for another departing GP in the last year, we had more than 20 applicants so would have had no difficulty finding a good-quality candidate to fill the sessions had we chosen to.
‘In addition to this, we have also chosen not to replace two reception staff members who left – again, in the hope to save money. I reiterate, not for profit, but hoping to break even.’
In this context, cheaper non-GP staff look more attractive. One GP partner in Buckinghamshire said their practice had to ‘restructure [to] keep our doors open and allow us to continue to provide a service including not replacing all the clinical sessions a retiring GP used to offer. More GP sessions are being replaced by cheaper clinicians’.
GP pay is often highlighted when practice funding is under scrutiny. In 2022, following such scrutiny, the Government amended the GP contract so that partners earning more than £150,000 would be forced to declare their earnings. But simply reducing earnings would not enable them to hire more GPs.
The GP partner from Warwickshire says: ‘I earn good money as apart-time partner, and there’s an argument that my partners and I could earn less and there would be money for another GP.
‘However, it isn’t as simple as that. We’re being offered two days of an advanced care practitioner anyway by the PCN, and it seems silly not to use this. One of our nurses has just completed her ACP training, so we’ll have her for another two-and-a-half days. I’d rather have another GP, but we’re reluctant to have both. We’re unsure what Wes Streeting plans for general practice, and we don’t want to commit to another GP unless we know our funding will continue at the same level.’