The combination of high overall numbers of patients per GP and high numbers of patients aged over 75 years old suggests that doctors working in primary care in these areas face some of the toughest working environments in the country.
At a time when the number of patients registered with practices in England has risen by more than 700,000 over the past year and fully-qualified GP numbers fell by more than 400 in the year to March 2019, GPonline looks at how the general practice workforce matches up with the patient population across the country.
The gaps between CCGs with the most GPs per patient and the least are huge - in NHS Bradford City there are 2,886 patients per FTE GP, compared with 1,577 in NHS Rushcliffe, in Nottinghamshire. When it comes to patients aged 75 and over per GP, the range is even more pronounced - from 305 in NHS Fylde and Wyre, in Lancashire, to just 47 in NHS Tower Hamlets, in London.
Of the 48 CCGs in England in the top quartile for overall numbers of patients per fully-qualified full-time equivalent (FTE) GP, 15 are also in the top quartile for numbers of patients aged 75 and over per FTE GP, our analysis of data published by NHS Digital shows.
One, NHS Thanet CCG in Kent, is in the top five areas nationally both for overall patients per GP and for patients aged 75 and over per GP.
BMA GP committee chair Dr Richard Vautrey said the major variation nationally in patients per GP is 'a real concern', and warns that the gaps risk creating a 'vicious cycle' for GP recruitment. The GPC chair said numbers of older patients per GP were a 'very good indicator of workload', particularly alongside data on overall patients per GP.
He said: 'The evidence behind the Carr-Hill formula showed age and sex are the main determinants of workload. The older your population, the more health burden there will be to respond to. It is where we need to see an expansion of staff - if you are in a hard-to-recruit area, it is hard to respond to patients' needs, there is more of a burden on those working there, and that leads to burnout and potentially a vicious cycle.'
Despite a clear link between the GP:patient ratio in different parts of the country and workload, GPonline analysis also reveals that in many areas where primary care doctors are in short supply, the health service has reacted by recruiting larger numbers of nursing and other staff who deliver care.
In general, areas with the least GPs per patient aged over 75 tend to hire more nursing and other staff to play a role in direct patient care. Of the 15 CCGs in the table above - which have both overall patient numbers and patients aged 75 and over per GP in the top quartile nationally - 11 have numbers of nurses per patient above the median for all CCGs, and 13 have numbers of other healthcare staff above the median level.
Meanwhile, analysis by GPonline shows that patient satisfaction with GP services across these 15 underdoctored CCG areas is within just four percentage points of the national average. Nationally, 83% of patients say their GP services were very or fairly good - compared with 79% of patients in these areas.
However, the figures suggest that this approach is not always perfect for older populations who may be more likely to need, and to expect, face-to-face consultations with a known GP.
NHS Thanet CCG, in Kent, has the country's second highest number of patients aged over 75 years old per FTE GP, as well as the fifth highest overall number of patients per FTE GP. It too has high numbers of nurses and other healthcare staff per patient compared with the national average - but patient satisfaction is at a rock-bottom 74.8%, nearly 10 percentage points below the national figure. Thanet is also among the 10% most deprived areas in England - another factor linked to higher GP workload.
Kent CCGs make up a third of the 15 CCGs in the table above with high numbers of patients overall and over-75s per GP. Kent LMC medical secretary Dr Caroline Rickard said high numbers of older patients in the area placed 'additional demand on the entire NHS system'.
In an area with a shortage of GPs, high demand for appointments and home visiting placed real pressure on general practice, she said - and she said the health service in Kent did 'feel underdoctored' to those working on the frontline.
'The pressure is on you as an individual clinician, trying to manage demand and to deliver the service you expect to deliver, and on GPs as partners who are looking to recruit and have continuity within the partnership and to continue to deliver the service they want. So it is a two-fold pressure.'
Dr Rickard added that there were vacancies in hospital consultant posts in the area too - and that pressure in primary care placed the whole system under strain.
However, she said that Kent was 'trying to come up with an offer that will attract GPs to the area', and that the area was 'very good with new ways of working'.
She said that although the area was short of GPs, it was strong on allied health professionals supporting primary care. Although she said it was too early to be sure, Dr Rickard was hopeful that primary care networks - which are intended to further bolster staff supporting general practice - could help.
She added that the tough working environment could offer great opportunities for GPs: 'I qualified seven years ago as a GP and relocated here, because my husband is from Kent. I have had nothing but opportunity in Kent and Medway - if you are motivated and want to take on extra roles or have a portfolio career, or take on a practice partnership it is a brilliant place to work.'