GP practices are merging and closing at pace
More than 4.2m patients have seen their practice close or merge since NHS England became operational in April 2013. This totalled 1,106 GP practices in the period to October 2018 - more than 200 a year - while just 55 new practices have been established. At that point, NHS Digital listed just 7,055 practices in England.
Opportunity: More career options in larger teams/operations
Threat: Small practices no longer viable. Culture clashes within merged practices
GP workload is increasing - especially for GP partners
The sharp decline in GPs opting for partnership roles in recent years has increased the pressure on the senior GPs leading practices, who are working longer hours and completing more consultations per session than either salaried or locum GPs. Polling by GPonline.com has shown that more than a third of full-time partners work more than 50 hours a week, compared with 12.8% of full-time sessional GPs.
And GP locum rates are increasing. The average daily fees that locums received from practices rose by 6.5% in London and by 2.3% in the south of England, according to the annual survey of locum rates by our sister website Medeconomics. Indeed, our own polling of 134 GP partners revealed that 52% worked in so-called zombie practices where they earn less per clinical session than the locums they employ.
Opportunity: Aspiring partners have a choice of practices and can name their terms
Threat: Burn-out for existing partners leading under-staffed practices
GPs are falling out of love with partnerships
The number of GP partners has been falling steadily - hardly surprising at a time of uncertainty within the NHS when potential candidates are reluctant to commit. The evolving lifestyle expectations of new generations of doctors are also an important factor. Put simply, the traditional GP partnership model - and the employment contracts offered to newly qualified doctors - need to be urgently updated to fit the modern world.
Opportunity: The recruitment crisis is forcing a positive rethinking of the GP partnership model.
Threat: The profession will not have the will nor the energy to make the necessary reforms, and the downward spiral will continue.
Falling GP income has finally levelled off
The long-term decline in GP earnings that followed the sharp rise caused by the 2004 contract reforms is now levelling off - but how far is GP pay in real terms from where it was a decade ago?
Average income before tax for GPs in partnership or salaried roles in GMS and PMS practices across the UK hit £92,500 in 2016/17 - a 2.7% rise on the previous year according to NHS Digital. The rise took GP income to its highest point in cash terms since 2012/13, with the increase for partners outstripping the increase for salaried GPs. But real-terms pay in 2016/17 remained nearly a quarter below the level it reached a decade earlier, leaving the average GP today the equivalent of nearly £30,000 worse off in terms of income before tax.
Opportunity: After years of decline, surely the only way is up for GP income?
Threat: The shortage of GPs means rising workload will outstrip the value of rising pay
Patient demand is growing and changing
NHS England has been pushing practices to offer GP appointments outside of core hours, so that by the end of 2018 it could claim 100% of areas in England were opening beyond 8am to 6.30pm, Monday to Friday.
At the same time, NHS leaders were trying to catch up with advancing technology by allowing Babylon to trample over the existing model of general practice with its GP at Hand app - offering quick online video consultations to Londoners who registered at its associated practice in south-west London. That practice list grew by 32,000 patients within a year - overwhelmingly young patients - while Babylon looked to provide similar services in CCGs around the country.
Opportunity: Easy access for patients with smartphones. New ways of working for GPs.
Threat: Traditional practices are not funded nor have the scale to compete with digital providers.
Surgery premises are not the asset they once were
The attraction of premises ownership has dimmed for GPs - with many unable or unwilling to buy in, others unable to sell, and many unable to secure funding to keep them up to date.
As part of the GP contract agreement for 2018/19, NHS England and the GPC agreed to carry out a review of GP premises policy to ensure the system was ‘fit for purpose now and in the future’. GPC chair Dr Richard Vautrey described premises as ‘one of the biggest problems facing practices’, warning that young GPs were steering clear of the risks involved - namely lack of funding, financial liability and the threat of being the 'last partner standing'.
Opportunity: The thorny issue of premises ownership needs to be considered in tandem with the ongoing GP Partnership Review
Threat: Considered 'too difficult' and remains an underlying deterrent to recruitment of GP partners
Medical indemnity is changing
For GPs, Brexit is not the only big change planned for April 2019. The profession is anxiously awaiting the detail of the state-backed medical indemnity scheme that was promised by former Health Secretary Jeremy Hunt in 2017. After a year of virtual silence, the DHSC eventually announced in November 2018 that the scheme would be funded from existing general practice budgets, effectively ending the much-needed morale boost before it had even begun.
Opportunity: Save GPs money and encourage senior partners to delay retirement
Threat: Disillusioned GPs continue to quit partnerships or retire early
GP recruitment is improving
While the government fudges recruitment targets - removing the time limit on its pledge to recruit 5,000 more GPs - the hard work done by the profession to encourage new recruits is starting to pay off. And new roles, such as clinical pharmacists and physician assistants, are gaining traction.
The overall full-time equivalent (FTE) GP workforce rose from 33,012 in June to 34,132 in September, according to provisional data published by NHS Digital. The increase was driven entirely by a large cohort of GP registrars entering the workforce, pushing registrar numbers up from 4,710 in June to 5,854 in September. This is almost double the increase in registrars over the same period in 2017, suggesting that growing numbers of GP trainees are beginning to filter through into the workforce.
Opportunity: Surge in GP trainee numbers breathes new life into training practices and the profession generally
Threat: Preference for portfolio careers leaves practices unable to recruit newly qualified GPs and continuing to rely on locums
And more changes expected to the GP contract...
As well as the reviews of GP partnerships and premises, and the reform of medical indemnity, there are also proposals for major changes to the QOF and the Carr-Hill formula, which determines how much funding practices receive. Health secretary Matt Hancock has indicated that he wants NHS England to take a ‘multi-year approach to the GP contract negotiations’ in future, and said investment in primary care should be linked to improvements in primary care services. So it’s no surprise that negotiators are expecting 2019 to deliver the most substantial changes to the GP contract since 2004.
To find out more about the changes planned for general practice in 2019, and how to prepare your practice, visit our specialist practice management website Medeconomics.
Image credit: iStock.com/Kameleon007