London School of Hygiene & Tropical Medicine

Over the past decade, the number of NHS general practices in England has decreased by 20% with 15% fewer qualified full time equivalent (FTE) general practitioners (GPs) per 1000 patients, while the average practice patient list size has increased by 40%, according to an analysis published in BMJ Open.

The study, which combined data from NHS England, the Office for Health Improvement and Disparities, and the Care Quality Commission, was funded by the National Institute for Health and Care Research. It revealed significant structural changes in English NHS general practice between 2013 and 2023 and was led by researchers at the London School of Hygiene & Tropical Medicine (LSHTM) and University College London (UCL).

The findings showed that from 2013 to 2023, the number of people registered with an NHS general practice in England grew by 11%, with a temporary slowdown during the COVID-19 pandemic.

Over the same time period, the number of NHS general practices fell by 20%, while the average practice patient list increased by 40%. The proportion of practices with over 20,000 registered patients rose from 1% to 6%.

While the total number of qualified GPs working in NHS general practice in England rose from 34,474 to 36,492, after taking working hours into account, the full time equivalent (FTE number of qualified GPs fell from 27,948 to 27,321. Factoring in population growth, the average number of GPs fell from 0.53 to 0.45 for every 1000 patients, representing a fall of 15%. Nursing numbers remained stable.

The analysis showed a move towards practices having more administrative and multidisciplinary staff between 2015 and 2022, with the total FTE general practice and primary care network workforce per 1000 patients increasing by 20%.

The authors also found roles across general practice were predominantly filled by women and that around 1 in 4 GPs completed undergraduate training overseas, mostly in low- or middle-income countries.

The researchers warned that falling FTE GP numbers could lead to a tipping point where most general practice appointments are no longer delivered by GPs. They say that the impact of a shift towards larger practices and a diversified workforce on care quality and cost-effectiveness remains uncertain.

Dr Luisa Pettigrew, lead author of the study, a GP and NIHR Doctoral Research Fellow at LSHTM, said:

“Although GP trainee numbers are rising, the new government must also prioritise GP retention. While the headcount of GPs in NHS general practice has marginally increased, when you factor in reported working hours and the growing population the total number of full-time equivalent GPs per 1000 patients working in NHS general practice has fallen.

“Trends point to a changing role for the GP partner, from a self-managing owner of a small business to holding responsibility for the governance of a much larger organisation and multidisciplinary team.

“General practice in England appears to be in a period of transition, from the smaller partnership-based model of general practice to that of larger organisations with more administrative and multidisciplinary staff but fewer GPs. However, patients are struggling to get appointments; concerns have been raised regarding the safety of introducing new roles without adequate supervision; and we are now facing the lowest ever levels of public satisfaction with general practice recorded.”

Irene Petersen, Professor of Epidemiology and Health Informatics at UCL, said:

“Our study highlights the importance of integrating data from multiple sources to gain a comprehensive understanding of the situation in NHS general practice across England.”

Appointment data, available from 2018 onwards, does not capture activities such as reviewing routine correspondence, prescriptions or results, or other general practice work such as staff supervision, management and quality improvement work. Online consultations may also not have been consistently captured in the appointment data.

Publication

Pettigrew LM, Petersen I, Mays N, et al. The changing shape of English general practice: a retrospective longitudinal study using national datasets describing trends in organisational structure, workforce and recorded appointments. BMJ Open. doi: 10.1136/bmjopen-2023-081535