GP in-depth review: Preliminary findings

GP in-depth review Preliminary findings March 2013 www.cfwi.org.uk GP IN-DEPTH REVIEW Preliminary findings Table of contents 1. 2. 3. 4. 5. Executive summary ....................................................................................................................................................... 4 1.1 Why this review?...................................................................................................................................................................4 1.2 Key findings ...........................................................................................................................................................................4 1.3 Emerging recommendations .........................................................................................................................................5 Introduction...................................................................................................................................................................... 6 2.1 About this project................................................................................................................................................................6 2.2 The CfWI workforce planning framework..................................................................................................................6 Context ............................................................................................................................................................................... 7 3.1 Policy drivers .........................................................................................................................................................................7 3.2 Previous recommendations on GP training numbers .........................................................................................8 3.3 Trends in GP training..........................................................................................................................................................8 3.4 How GPs are organised .....................................................................................................................................................9 3.5 Public health and GPs ..................................................................................................................................................... 11 3.6 Academic GPs .................................................................................................................................................................... 12 3.7 Interplay of GPs with other primary care professions ....................................................................................... 12 GP workforce supply .................................................................................................................................................... 14 4.1 Trends in the existing GP workforce......................................................................................................................... 14 4.2 Regional variations .......................................................................................................................................................... 15 4.3 Retirement and leavers.................................................................................................................................................. 18 4.4 Gender and participation rate ..................................................................................................................................... 19 4.5 GP participation rates ..................................................................................................................................................... 20 4.6 Scenario-based forecasting ......................................................................................................................................... 20 4.7 Future GP workforce supply scenarios.................................................................................................................... 21 4.8 GPs and the wider medical workforce ..................................................................................................................... 22 Demand for GP services ............................................................................................................................................. 23 5.1 Trends in activity and demand for GP services .................................................................................................... 23 5.2 Has GP workload increased? ........................................................................................................................................ 24 5.3 GP role and case complexity ........................................................................................................................................ 24 5.4 Future GP workforce demand ..................................................................................................................................... 25 5.5 Productivity growth and future demand ................................................................................................................ 26 6. Supply and demand scenarios ................................................................................................................................. 27 7. The future GP and primary care............................................................................................................................... 29 7.1 More of the same? ........................................................................................................................................................... 29 7.2 Dimensions of change ................................................................................................................................................... 29 THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 2 GP IN-DEPTH REVIEW Preliminary findings 7.3 8. Future primary care models......................................................................................................................................... 30 Concluding remarks .................................................................................................................................................... 31 Annex A: Comment by the Royal College of General Practitioners........................................................................ 32 Annex B: Acknowledgements .............................................................................................................................................. 33 Annex C: Supporting data ...................................................................................................................................................... 34 Annex D: Scenario summary ................................................................................................................................................ 36 Annex E: Modelling assumptions ....................................................................................................................................... 41 Annex F: Delphi modelling assumptions ......................................................................................................................... 45 References .................................................................................................................................................................................. 47 THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 3 GP IN-DEPTH REVIEW Preliminary findings 1. Executive summary This report presents our preliminary findings for consultation purposes. We welcome your contributions. Please note that as some data and assumptions will be updated for our final forecasts, the analysis and conclusions in our final report may differ from those presented below. 1.1 Why this review? General practice is the largest medical specialty group, and GPs see more patients every day than any other part of the NHS. Accessible and well resourced general practices are essential if the NHS is to deliver good patient outcomes. Over the last 15 years the English medical school intake and number of doctors working in the NHS have risen considerably. Demand for GP services has also risen, driven by a range of factors:      population growth, higher birth rates and an ageing population increased prevalence of chronic conditions (e.g. diabetes, obesity, dementia) and multi-morbidity better-informed patients with higher expectations increasing non-clinical duties (e.g. GP representation on clinical commissioning groups) policy initiatives for better-quality care, delivered closer to home. In the short term, the focus is on increasing specialty training number to reach the Government s recruitment target for England of 3,250 GP trainee places per year by 2015. The General Practice Task Force is working to achieve this target. The CfWI s in-depth GP workforce review has a longer-term and more strategic remit: to provide the evidence base for sustainable improvements in planning for the GP workforce of the future, looking ahead to 2030. It will also help to prepare the way for a possible CfWI primary care review in 2013-14. We are working closely with our commissioners – the Department of Health (DH) and Health Education England (HEE) – as well as the GP Task Force, the Royal College of General Practitioners (RCGP) and other key stakeholders. 1.2 Key findings There has been both significant growth in the size of the NHS medical workforce, and a shift in its balance from general practice towards secondary care. The number of GPs has grown by at least 29 per cent between 1995 and 2011, to around 35,400 (excluding GP registrars and GP retainers). This increase was in line with the total growth in NHS staff over that period. THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 In contrast, the total number of consultants in other medical specialties has doubled over that period, and the number of other doctors (excluding consultants and GPs) has also risen 50 per cent. By 2011 there were 67.8 GPs per 100,000 population in England, compared with 58.1 in 2000. We project this ratio to improve to around 83-84 GPs per 100,000 population by 2030. However, the national picture masks considerable local and regional variation, with access to GPs still unequal between areas of high and low deprivation. We will analyse these variations and discuss support for under-doctored areas in our final report. We estimate that if the 3,250 GP trainee places target is achieved by 2015 and maintained it will increase baseline supply projections by around 43 per cent or 15,300 GPs by 2030 (headcount basis). On a full-time equivalent (FTE) basis we project an extra 12,800 GPs by 2030: up 41 per cent. By contrast, we expect a 23 per cent increase in the total number of hospital-based doctors (FTE basis) over the same period, pointing to some rebalancing in the medical workforce to primary care. Alongside the boost to GP workforce supply from expanded training programmes, a range of other measures might help improve effective workforce supply, including:      making general practice a more appealing career choice for medical students measures to encourage returners and improve retention making it easier for consultants in other specialties to switch to general practice increasing the supply of practice nurses greater collaboration with specialists. Taking into account likely supply and demand scenarios, it is our preliminary assessment that the boost in GP trainee numbers to 3,250 by 2015, if achieved and maintained, may be sufficient for workforce supply to meet expected future patient demand to 2030. However we note that several demand scenarios are well above our baseline supply projection, while most of our supply scenarios are below it. Accordingly, a range of other measures to improve supply (as outlined above) or curb demand may be needed to accompany the boost in GP training numbers. On the demand side, we see some scope for GPs to improve their ways of working over the longer term. Such gains would help to ensure that any remaining demand-supply gap is closed. We welcome views on our modelling assumptions and preliminary results. Page 4 GP IN-DEPTH REVIEW Preliminary findings By 2030, we expect women to be the majority of the GP workforce. The average age of GPs will be lower, and the number of GPs in their thirties will have doubled. GPs are increasingly seeing patients with long-term care needs, who require longer consultations and subsequently require an increased level of case management. Many GPs we have spoken to say they struggle under a large workload; reports of stress and burnout are common. Though anecdotal, these recurring themes are supported by recent surveys and more substantive evidence. The latest available studies of GP workload (2006-07), and of activity and consultation rates (2008-09) point to longer average consultation times, more consultations per patient (particularly for older people), and more case complexity than a decade or two ago. We note with concern the lack of recent substantive evidence on GP activity and workload – a major gap in the evidence base. Likewise, there is a significant lack of quantitative data on the practice nurse workforce. Recent research also indicates that the role of the GP has expanded over the past decade, with increasing demands and competing tensions. A significant proportion of a GP s role now involves non-clinical duties. We welcome evidence on GP activity, workload and the changing role of GPs. Despite these data limitations, our analysis of the available evidence on the demand for GP services points to a workforce under considerable strain. The existing GP workforce has insufficient capacity to meet current and expected patient needs. The way GP practices are organised is also changing, with fewer single-handed practices (now accounting for just over three per cent of patients), while very large practices now see around one in seven patients. We expect this consolidation to continue, as larger practices have greater flexibility and are better able to absorb cost pressures. In addition there has been a shift towards more salaried GPs and fewer GP partners, which is likely to continue. The prevalence of long-term conditions, combined with rising patient expectations and lifestyle factors such as diet, exercise, tobacco and alcohol use, means the way primary care is delivered may need to change significantly in the future. We expect primary care commissioners to seek better coordinated patient care through more collaborative delivery and effective use of skill mix in multidisciplinary teams. We also expect the growing number of very large GP practices (including federations of practices) will coordinate a broader range of primary care services across multiple sites and extended hours. THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 1.3 Emerging recommendations We reaffirm our previous recommendation (CfWI, 2011a) that there needs to be a substantial increase in GP training phased in over several years. We consider that achieving and maintaining 3,250 GP trainees per annum is necessary to address future demand, and should be the top priority. A substantial share of this workforce increase should go towards improving support for under-doctored areas to help achieve more equal access to GP services across England. Given the rapidly changing nature of healthcare and the inherent uncertainties about future demand, however, we also recommend there be periodic reviews of future GP workforce supply and demand every 3–5 years, supported by a stronger evidence base. We recommend that the Health and Social Care Information Centre (HSCIC) commission another GP workload survey. In addition, there is a need for more frequent – preferably annual – data on GP activity and consultation rates to be published, drawing on the GP Extraction Service (GPES). Better data on practice nurses and the wider primary care workforce are also needed by the time of the next GP workforce review. Action is needed to improve the attractiveness of general practice as a career, including promotion among medical students (and possibly earlier). We see merit in seeking to retain the existing workforce, for example retainer schemes – particularly in areas where GPs are under most pressure – and providing support for returners through return-to-practice schemes. The GP Task Force is reviewing these areas. In light of evidence of the broadening role of GPs, we recommend that the Royal College of General Practitioners consider a review of competency domains. This would include key stakeholders from the health and social care professions, primary care commissioners and patients. We recommend that the Shape of Training Review consider how more flexible and open-ended medical career pathways might be developed, including making it easier for consultants in other specialties to switch to general practice. We endorse moves by NHS commissioners to encourage more innovative and collaborative approaches to primary care delivery. This would make more effective use of other primary and community care professionals, such as practice nurses and pharmacists, possibly working in community-based multidisciplinary teams. We look forward to hearing the views of GPs, other health professionals, professional bodies, employers, patients and the public. Please sign up for one of our roadshows in March/April 2013, or contribute to our LinkedIn online forum http://www.linkedin.com/groups/Friends-CentreWorkforce-Intelligence-CfWI-4274008 Page 5 GP IN-DEPTH REVIEW Preliminary findings 2. Introduction 2.1 About this project The CfWI has been commissioned by the Department of Health (DH) and Health Education England (HEE) to undertake an in-depth review of the GP workforce in England. This is a medium-term, strategic review looking ahead to 2030. The CfWI project team has listened to the views of around 60 GPs and other health professionals (see Annex A). The team is also working closely with members of the General Practice Task Force, chaired by Dr Simon Plint. The Task Force will make recommendations on workforce, education and training, cost and timescale for delivering the national training numbers needed by 2015. There are shared areas of interest between the two projects, including reviewing how workforce data collection could be improved.  making recommendations, if appropriate, on GP service delivery models and the affordability of different options. A greater level of analysis will follow in the final report, due to be submitted by the end of May 2013. 2.2 The CfWI workforce planning framework The CfWI has a unique workforce planning framework. The stages of our research for this project are outlined in figure 1. Involvement of stakeholders throughout ensures our findings are robust. For more details please refer to our recent technical reports (CfWI 2012a, 2012b). Figure 1: The CfWI workforce planning framework The main areas of investigation for the project are:     reviewing current workforce capacity issues in general practice assessing the current GP recruitment target for England, (which is being supported by the Workforce Leadership Group at the DH and managed through the joint working group through to deaneries) and reviewing options for GP training and recruitment targets beyond 2015 understanding the likely impact of shifts in care in the medium and long term developing and refining the CfWI GP system dynamics model THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 6 GP IN-DEPTH REVIEW Preliminary findings 3. Context 3.1 Policy drivers We have identified seven key policy drivers likely to be of relevance to the GP workforce now and in future. The move towards GP-led commissioning Clinical commissioning groups (CCGs) will have responsibility for commissioning and budgeting most healthcare services for their local populations, supported by the NHS Commissioning Board (NHS CB). GP involvement will increase non-clinical duties but also raise their influence in commissioning decisionmaking. GP revalidation The General Medical Council (GMC) introduced licences to practise in November 2009, and all GPs are registered. All doctors will have to go through a process of revalidation, whereby evidence must be provided that doctors are fit to practise. This process began in late 2012, and all doctors will have been revalidated by March 2016. Shift in the shape and scope of GP services The shape and scope of GP services is a key driver. Expanded practices may offer a broader range of services and develop their skill mix, with practice nurses and pharmacists perhaps taking a larger role. Integrated working between primary and secondary care There has been a long-standing desire to better integrate primary and secondary care. The benefits of a more coherent interface include better health outcomes, more cost-effective care and an improved patient experience. A possible route to this includes creating GP federations to enable a greater sharing of expertise and a broader range of services offered. Other ideas include sharing patient records, increasing the scope of general practice and improving financial incentives for integration. Barriers include risk aversion, cultural differences between professions, tariff concerns and governance issues. Revision and implementation of new GP contracts The UK Government s intention to introduce changes to GP contracts from April 2013 will have an impact on the way GPs work and the services they deliver. Some of the proposed changes include:  changes to the Quality and Outcomes Framework (QOF) recommended by the National Institute for Health and Clinical Excellence (NICE) THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013    increasing the upper thresholds for 20 QOF indicators next year and for remaining indicators from 2014 to match upper quartile achievement phasing out organisational indicators and encouraging GPs to take on new work to retain this funding introducing new services provided as part of a basket of services administered through directed enhanced services (DES) such as testing for dementia in at-risk groups. Public health Public Health England (PHE) has recently been established to protect and improve health and wellbeing in England, and to reduce inequalities. It will take up its full powers in April 2013. It will be collaborating with partners to encourage integrated care as the preferred local model, particularly for people who live with long-term conditions. See section 3.5 for more details. Mid Staffordshire NHS Foundation Trust Public Inquiry The Francis report (2013) states that patients are the first priority and recommends they receive effective care from caring, compassionate and committed staff working in a culture of openness and transparency (including performance and outcomes). The report recommends that GPs take a monitoring role when their patients receive acute hospital and other specialist services. They should be an independent, professionally qualified check on the quality of service and outcomes. They need to have internal systems enabling them to be aware of patient history. They have a responsibility to all their patients to keep themselves informed of the standard of service available at various providers in order to make patient choice a reality. Robert Francis states that: A GP s duty to a patient does not end on referral to hospital, but is a continuing relationship. They will need to take this continuing partnership with their patients seriously if they are to be successful commissioners. (Francis, 2013, recommendation 123). Page 7 GP IN-DEPTH REVIEW Preliminary findings 3.2 Previous recommendations on GP training numbers This report is not the first review to recommend an increase in GP training posts. The NHS Next Stage review (DH 2008) recommended: In the light of the increasing demand for primary and community care services, SHAs will be expected to expand GP training programmes in 2009 based on existing resource allocation. Further expansion of training programmes in England by up to 800 places is also being planned so that in future at least half of doctors going into specialty training will be training as GPs. The expansion of general practice underlines our commitment to supporting and improving primary care. This would have increased GP training places in England to around 3,300 per annum. While this review led to some increases in training posts (see Figure 2 and Table B1) they were insufficient to reach this recruitment target. Our previous report on the GP workforce (CfWI 2011a) recommended a phased increase in GP training posts: The CfWI recommends an increase of 450 entry-level training posts phased over the next four years. This should be achieved by a significant reduction in other areas of specialty training, in order to achieve the shift required. Further work is needed to improve the fill rate of existing and future GP training posts. This recommendation would have seen training places reach a stable number of 3,250 by 2014. The 2011 CfWI report also recommended a further review of our recommendations in 2013 . THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 The government s current GP recruitment target – the focus of the general Practice Task Force- was set out by Earl Howe, the Parliamentary Under-Secretary of State, Department of Health last year: The Centre for Workforce Intelligence, which is our independent advisory body on workforce planning, recommends that we should increase the number of entry-level training posts by 450 to around 3,250, phased over the next four years. (Hansard, 2012). 3.3 Trends in GP training Figure 2 shows that the number of GP training vacancies averaged around 2,700 per year between 2009 and 2012 – significantly below the Government target of 3,250 GP doctors in training per year by 2015. This rose to 2,850 vacancies in 2013. The competition ratio has ranged between a low of 1.76 (2010/11) and a high of 1.9 (2012/13). According to data from Health Education England (2013a), general practice had the third lowest competition ratio of fourteen medical specialties, though the ratio for all specialty applicants was only 1.99. This relatively low competition ratio indicates a need for general practice to improve its appeal and attract more doctors in training. The majority of current GPs in training work full time. About 12 per cent train less than full time (LTFT). The average participation rate of LTFT GPs in training is 0.58, which is approximately three days a week. This less than full-time participation means these doctors in training are expected to take at least five years to train, compared to three or four years for the majority of GPs in training, and will therefore reduce the rate of production of trained GPs. Page 8 GP IN-DEPTH REVIEW Preliminary findings Figure 2: GP postgraduate trainee recruitment 2009–12 6,000 1.8 GP trainee numbers 5,000 1.6 1.4 4,000 1.2 3,000 1.0 2,000 0.8 Applicants (right axis) 0.6 Vacancies (right axis) 0.4 1,000 0.2 0 0.0 2009-2010 2010-2011 2011-2012 2012-2013 Recruitment year Competition ratio 2.0 Accepted offers (right axis) Competition ratio (left axis) 2013-2014 Sources: See Table B1 in Annex C 3.4 How GPs are organised General practices are not homogenous. They vary considerably by the size of their practice and patient list, by the type of contract, and by local health economy. As with businesses in other sectors, drives for economies of scale have led to the decline of small GP practices and the emergence of larger ones. As figure 3 shows, single-handed practices have been in steady decline for many years. Singlehanded GP practitioners now account for only around 12.5 per cent of practices and just over three per cent of patients. By contrast, very large practices (those with ten or more partners) have nearly doubled in number since 2005, and now handle around one in seven patients (NHS HSCIC 2012a). We expect this shift to continue. On present trends, very large practices could cover over half of the patient list for England by 2030. 2. The new 2004 contract introduced Quality Outcomes Framework (QOF) measures to help improve standards, as well as providing scope for extending services (The King s Fund, 2011). The Personal Medical Services (PMS) contract was introduced in 1998, and is a locally negotiated contract enabling GPs to innovate in response to local needs. The differences between the GMS and PMS contracts decreased after the 2004 GMS revision (Simon, 2008), as both contract holders have the opportunity to opt out of out-of-hours services, and most PMS contractors take part in QOF. 3. The third main type of contract is the Alternative Medical Services Contract (APMS), which allows commercial or voluntary organisations to provide primary care services. GMS and PMS contractors can also convert to APMS. APMS contracts allow primary care trusts (PCTs) freedom to provide services themselves, often to address capacity issues (Gregory 2009). The awarding of APMS has thus far remained limited (The King s Fund, 2011). 4. The Primary Care Trust Medical Services (PCTMS) contract allows PCTs to provide medical services directly, but this contract will be phased out by April 2013. There are four contract types under which GP practices (which are effectively private businesses contracted to the NHS) deliver services: 1. Before the 2004 revision, most GP practices were contracted under the General Medical Services (GMS) contract, through which GPs received payment for each piece of work done according to the number of registered patients. THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 9 GP IN-DEPTH REVIEW Preliminary findings Figure 3: Proportion of GP practices by number of GPs 2004 –11 45% 40% 35% 30% Single-handed GPs 25% Practices with 2-4 GPs 20% Practices with 5-9 GPs 15% Practices with 10+ GPs 10% 5% 0% 2004 2005 2006 2007 2008 2009 2010 2011 Source: NHS HSCIC (2012a) Figure 4: 2001–11 GP employment status – headcount 30,000 Number of GPs 25,000 20,000 GP partners 15,000 Salaried / other GPs GP registrars 10,000 GP retainers 5,000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Source: NHS HSCIC (2012a) There has been significant change in the employment status of GPs, as figure 4 shows. From a very small share of the GP workforce a decade ago, salaried GPs now account for one- THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 1 quarter of all GPs, excluding GP registrars and retainers (NHS Page 10 GP IN-DEPTH REVIEW Preliminary findings HSCIC 2012a). Our Delphi panel considered this proportion could increase to one-third of the workforce by 2030. Figure 5 : The GP practice team models of service delivery and the future employment status GPs is discussed later in the report. Figure 5 provides data on the wider GP practice workforce. General practitioners themselves accounted for 22 per cent of practice staff in 2011, with administrative and clerical staff making up the largest share of the practice team (52 per cent), and 13 per cent practice nurses. Direct patient carers (which include health care assistants) accounted for eight per cent in 2011, but have shown strong growth in recent years. 3.5 Public health and GPs Across England, investment in public health should provide a return , as the population becomes healthier and uses GPs (and other health services) less. GPs have a key role in promoting public health, due to their community links. GPs can also help with planning for public health through data collection and targeted interventions. GPs (excluding retainers and registrars) Practice nurses Direct patient carers Admin and clerical Other Source: NHS HSCIC (2012a) According to the King s Fund (2011), salaried GPs give flexibility, as they often have short-term contracts and do not have the financial commitment of GP partners. GPs from overseas are more likely to have salaried status (Ding et al 2008). The importance and role of salaried GPs in alternative GP representatives will sit on health and wellbeing boards, to inform local public health initiatives. Board members will also include an elected representative, public authority representatives for adult social services, children s services and public health, a local Healthwatch representative and CCG representatives (DH 2012d). GPs will play an integral role on these boards, and the presence of local authorities will enable an integrated local public health strategy. In addition, Public Health England (PHE) has recently been established to protect and improve health and wellbeing in England, and to reduce inequalities. It will take up its full powers in April 2013. PHE is involved in a national collaboration with the NHS CB, LGA, Department of Health and Monitor to encourage integrated care as the preferred local model, particularly for people who live with long-term conditions . 1 The GP Retainer Scheme is designed to ensure that doctors who can only undertake a small amount of clinical work may keep in touch with general practice, retain their skills, and progress their careers with a view to returning to NHS general practice in the future (West Midlands Deanery, 2013). THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 11 GP IN-DEPTH REVIEW Preliminary findings 3.6 Academic GPs An alternative to the three-year GP training programme for GPs is to undertake a National Institute of Health Research (NIHR) academic clinical fellowship (ACF). There will be 25 fellowships available for GPs in England in 2013 (GPNRO 2013). These posts allow those who have completed the Foundation Programme and have academic potential a chance to combine standard GP training with additional academic training. There are also further programmes for fully qualified GPs to undertake academic training. In-practice fellowships help provide 50 per cent protected research time. The NIHR clinician scientist route allows those capable of leading research in their discipline (with a PhD) to undertake supported postdoctoral training (NIHR 2013). Academic GPs are a small but important part of the workforce. Our final report will include a deeper investigation of their role. 3.7 Pharmacists As medicines experts, pharmacists are well placed to address complexities emerging from multiple morbidity and long-term conditions. Primary care pharmacists work closely with GPs and can offer advice on good prescribing, which can lead to more effective first-time prescriptions and help to address capacity issues in the NHS. Participants at the recent CfWI pharmacy in-depth review scenario generation workshop (held in January 2013) considered there was a good case for an expanding role for pharmacists. This could involve routine testing, helping to manage long-term conditions, and advising patients on the use of technology. Technology initiatives such as e-prescribing, which replaces paper-based prescribing and supports auditing (CfWI 2011b), offer potential cost savings. As with practice nurses, greater use of pharmacists in primary care teams will need careful implementation. Interplay of GPs with other primary care professions GPs are part of a wider primary care workforce. Skill mix is an important productivity consideration. The CfWI is planning a full primary care review in 2013– 14, which will involve modelling the whole workforce. Our final report for this review will involve a more thorough look at the interplay between professions, using case studies, and also an exploration of the relationship between hospital-based medicine and general practice. Practice nurses Despite evidence of growing GP workloads, the number of practice nurses employed by GP practices has declined by more than 2,000 since its 2006 peak (figure 6). A number of factors may explain this, including GP partners attempting to reduce staff costs by replacing nurses with secretaries or healthcare assistants, or by doing more work themselves. Another factor may be a supply issue of not enough practice nurses being trained, reflecting both problems with the training pathways and the fact that other nursing careers are more attractive (see CfWI, 2012d). Either way, the rise in the GP: practice nurse ratio, as shown in figure 6, will have added to GP workloads. Our recent report on practice nurses found there were significant data issues to be resolved, as GPs do not routinely collect and report centrally on their workforce, and only a small proportion of training is commissioned centrally by SHAs, and this is often delivered and accessed on an ad hoc basis. Better data on practice nurses (and the wider primary care workforce) are needed by the time of the next GP workforce review. THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 12 GP IN-DEPTH REVIEW Preliminary findings Figure 6: Practice nurse headcount/FTE and GP:practice nurse ratio 25,000 7 Number of practice nurses 20,000 6 5 15,000 4 10,000 3 Ratio GP: practice nurse 8 2 5,000 Practice nurses headcount (left axis) Practice nurses FTE (left axis) 1 Ratio GP: practice nurse (right axis) 0 0 1995 1997 1999 2001 2003 2005 2007 2009 2011 Source: NHS HSCIC (2006a, 2006b and 2012a) THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 13 GP IN-DEPTH REVIEW Preliminary findings 4. GP workforce supply 4.1 Trends in the existing GP workforce There has been both significant growth in the size of the NHS medical workforce, and a shift in its balance from general practice towards secondary care. As figure 7 shows, the number of GPs grew by at least 29 per cent between 1995 and 2011, up from 27,465 to 35,415, excluding GP registrars and GP retainers (NHS HSCIC 2 2006b, 2012a). This increase was in line with the total growth in NHS staff over that period. On a FTE basis, the increase in GPs was 20 per cent between 1995 and 2011. In contrast, the number of consultants in other medical specialties doubled over that period, and the number of other doctors (excluding consultants and GPs) rose by 50 per cent. The number of GPs per 100, 000 population has also been steadily increasing. On a per capita basis, there were 67.8 GPs per 100,000 population in 2011, compared with 56.8 in 1995. However, the national picture hides marked local and regional variation, with access to GPs still unequal between areas of high and low deprivation (see section 4.2 below). The size of the GP workforce in England, measured on both a FTE and per capita basis, peaked in 2009 and saw modest declines in the subsequent two years. However, this picture may change with the publication of the 2012 medical census. Immigration to the UK has been a major demographic trend of the past 60 years and is reflected in the composition of the healthcare workforce. As Table B2 shows in Annex C, the GP workforce is becoming ever more diverse. By 2011, 77.6 per cent of GPs had undertaken their initial medical training in the UK, down from 81.5 per cent in 2001. The incomers are largely from outside the European Economic Area (EEA) –17.8 per cent of the workforce, compared with 4.6 per cent from the EEA (NHS HSCIC, 2012a). Although it would appear that general practice is significantly dependent on overseasqualified staff, the proportion is below that of the total doctor workforce in England, of which only 64.3 per cent qualified in the UK (NHS HSCIC, 2012b). 2 The29 per cent increase is likely to be an understatement, as the HSCIC introduced a more stringent headcount methodology in 2010. Figures from the 2012 medical census are due to be published on 21 March 2013. THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 14 GP IN-DEPTH REVIEW Preliminary findings Figure 7 : Number of GPs and GPs per 100,000 population 1995 to 2011 120 GPs per 100,000 population (right axis) 40,000 GPs, headcount basis* (left axis) 100 GPs, FTE basis* (left axis) 30,000 Number of GPs 80 25,000 20,000 60 15,000 40 10,000 20 5,000 0 GPs per 100 000 population 35,000 0 1995 1997 1999 2001 2003 2005 2007 2009 2011 Source: NHS HSCIC (2012a) and ONS (2012a and 2012b) *Excluding GP registrars and retainers 4.2 Regional variations Regional variations in GP levels merit analysis. Prosperous rural areas typically find it easier to recruit than poorer urban areas. Poor local amenities, smaller practices and a higher workload generated by a disadvantaged population act as disincentives for GPs to work in such areas (Sibbald, 2005). experienced an increase in the rate of vacancies from 2008 to 2010. Distribution of GPs is closely linked to regional training capacity and programmes, as the large majority of GPs remain in the area where they complete their training. Although the numbers used in Table B3 in Annex C are from voluntary questionnaires, seven of the ten SHA regions THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 15 GP IN-DEPTH REVIEW Preliminary findings Figure 8: Primary care trust (PCT) quartile analysis of GPs per 100,000 population Source: DH (2009) Areas in England where deprivation is high broadly correspond to the areas with fewer GPs per head. Figure 8 shows the PCT analysis of GPs per 100,000 population. 3 Areas in England where deprivation is high are broadly the areas with fewer GPs per head. This shows that the current GP training system may have led to inequality in the levels of GPs across the country over the past two decades, even as the overall number of GPs has increased. Of the bottom quartile of PCTs (by GPs per 100,000 population), 23 of these 38 PCTs are in the most deprived quartile of PCTs, with only one found in the least deprived quartile. In terms of the quartile with the most GPs per 4 100,000 population, 19 of the 38 PCTS are in the least deprived quartile, with just two from the most deprived quartile having a good GP supply (DH 2009). Given the large variation in access to GP services across England, we recommend that a substantial share of the projected increase in the GP workforce go towards improving support for under-doctored areas. We will analyse these local and regional variations and discuss under-doctored areas in more detail our final report. 3 For this measure, the ten most deprived primary care trusts were: Heart of Birmingham Teaching PCT, Liverpool PCT, City and Hackney Teaching PCT, Tower Hamlets PCT, Manchester PCT, Knowsley PCT, Newham PCT, Islington PCT, Middlesbrough County PCT and Birmingham East and North PCT. THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 4 For this measure, the ten least deprived primary care trusts were: Surrey PCT, Buckinghamshire PCT, Richmond and Twickenham PCT, South Gloucestershire PCT, Wiltshire PCT, Hampshire PCT, Leicestershire County and Rutland PCT, Berkshire West PCT, Oxfordshire PCT and West Hertfordshire PCT. Page 16 GP IN-DEPTH REVIEW Preliminary findings Age profile and retirement trends Figure 9: GP headcount by age band and gender 4,000 3,500 Men Headcount 3,000 Women 2,500 2,000 1,500 1,000 500 0 Age band Source: NHS HSCIC (2011) In 2010, 54 per cent of students entering English medical schools were women (GMC 2011). The large increase in the proportion of medical school intake who are women has led to a more equal gender balance both in GP training and the GP workforce. In 2012, 65 per cent (2,176) of entrants to GP speciality training were women. than men, and more men in the higher age bands, from 50 onwards, and fewer women. The same pattern applies for the FTE age profile. By the end of the forecast period we expect women to be the majority of the GP workforce. We will elaborate on the changing gender mix of the GP workforce, and its implications, in the final report. This changing gender mix is reflected in age and gender profile in figure 9. There are more women GPs under the age of 40 Figure 10: Age of GPs - 2000 to 2030 20,000 18,000 2000 2010 2020 2030 16,000 Number of GPs 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 Source: NHS HSCIC (2011) and the CfWI system dynamics medical workforce model for England THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 17 GP IN-DEPTH REVIEW Preliminary findings The age of the GP workforce has implications for the participation rate, with figures 13a and 13b showing that GPs over 60 have lower participation rates than their younger colleagues. Although the number of GPs aged 50 or older is set to increase between 2013 and 2030, the much larger increase in those under 50 should see the average age of the GP workforce drop. The biggest increase will be in GPs in their thirties, whose numbers are set to double by 2030. This reflects the impact of more training places. 4.3 Retirement and leavers Figure 11:Past trends and forecasts of GP retirements per year, by gender 1,600 1,400 Headcount 1,200 1,000 Historical estimate - men 800 Historical estimate - women 600 Forecast - men 400 Forecast - women 200 2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 0 Source: NHS HSCIC (2009–2012) and CfWI system dynamics medical workforce model for England Figure 11 shows the historical and projected retirements per year for GPs. The historical data (2008 to 2010) is calculated from comparing the number of GPs aged 49 or over, year on year, by age, and gives a representation of the number of retirements. The median (most common) retirement age over this period was 59, with 49, 54, and 64 also common ages for retirement, while the mean (average) retirement age was 58 for women and 60 for men. Data for the year 2011 is missing because the 2012 census data is not yet available for comparison. The data from 2012 onwards is a forecast from the CfWI s system dynamics medical model. It uses the historical probability (2008 to 2010) of retiring at a given age to forecast how many GPs will retire from the future workforce. This is the assumption that is used in our baseline forecast for GP supply (shown later in figure 14). The chart shows there are currently more men retiring from GP contracts than women, reflecting the greater proportion of men in the workforce. The shift to a more gender-balanced workforce is shown in the forecast by THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 the trend towards an equal number of retirements in longer term. According to the BMA s National Survey of GP Opinion 2011 (BMA, 2011), 13 per cent of respondents reported an intention to retire in the next two years, across the UK. Respondents who indicated they intend to retire in the next two years were most likely to be aged between 58 and 60 (35 per cent). 26 per cent of respondents intending to retire in the next two years were below the age of 58. Women respondents who intended to retire in the next two years were more likely than men to be younger than 55, which accords with the intended retirement age of respondents in 2007. Men intending to retire in the next two years were more likely to be over 65. A benefit of the BMA survey is that it asks those intending to retire what plans they have made, which should filter out respondents whose intentions are vague. Of those respondents intending to retire in the next two years, 86 per cent reported having sought or obtained financial advice, and 37 per cent reported having given notice to their practice. Page 18 GP IN-DEPTH REVIEW Preliminary findings 4.4 Gender and participation rate Figure 12: GP workforce by gender, 2001–11 Men Women Full-time equivalents 20,000 15,000 10,000 5,000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Source: NHS HSCIC (2012a) As shown in figure 12, the GP workforce gender split in 2011 was 56 per cent men and 44 per cent women. The average annual percentage growth between 2001 and 2011 was much higher for women GPs (+4.9 per cent) than men (+0.3 per cent). THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 As we will discuss, the gender split has implications for workforce planning, as women s average lifetime participation rate is lower than that of men (NHS HSCIC, 2012a). Page 19 GP IN-DEPTH REVIEW Preliminary findings 4.5 GP participation rates Trends in GP participation rates are dependent on both age and gender, as shown in figure 13a and 13b. From 2008 to 2011, men had an overall higher participation rate than women, who are more likely to work less than full time due to family commitments. As outlined in figure 9, women will soon comprise the majority of GPs in England, and an increasing number have become equity partners in group practices. An increasing number of young GPs, however, are entering practice as salaried doctors – and most of these are women working less than full time (Women and Medicine, Royal College of Physicians, 2009). At present, salaried posts comprise a small proportion of all GP posts, but this sector looks likely to expand in the future. Salaried, part-time practice could become the long-term mode of working for a large number of GPs. The participation rate of women has been reducing over the years (with only one age group increasing their participation) as it has become more feasible to balance work and family commitments through less than full-time working. The participation rate for men has remained fairly steady. For women, there is more variation in the participation rate of the different age groups. Younger women GPs have a higher participation rate, which declines with age. However, if women are still working beyond the age of 56, their participation rate is high compared to younger women. Since 2008 there has been a steady decline in participation rates for older women GPs. For men, participation rate between 2008 and 2011 remained steady, being above 0.90 for all age groups. Figure 13a and 13b: Participation rate of men and women GP providers, by age band, 2008 to 2011 1.00 1.00 0.95 Men 26-30 0.90 Men 31-35 Men 36-40 0.85 Men 41-45 0.80 Men 46-50 Men 51-55 0.75 Participation rate Participation rate 0.95 Women 26-30 Women 31-35 0.90 Women 36-40 0.85 Women 41-45 0.80 Women 46-50 0.75 Women 51-55 Men 56-60 Women 56-60 0.70 Men 61-65 0.70 0.65 Men 66-70 0.65 2008 2009 2010 Women 61-65 Women 66-70 2008 2011 2009 2010 2011 Source: NHS HSCIC (2011) 4.6 Scenario-based forecasting Rather than attempt to predict the future, the CfWI (2012a, 2012b) has developed a scenario-based approach for in-depth workforce reviews that recognises the complexity of factors influencing demand and supply and the intrinsic uncertainty of the future. The key benefits of this approach are to:    support longer-term workforce planning, up to 2030 support more robust decision-making, taking account of the uncertainties of the future help decision-makers be more alert to emerging risks as the future unfolds. Specifically, we have:  identified key drivers of demand and supply for the GP workforce under review, focusing on high-impact, THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013     high-uncertainty drivers that may have an impact in the next 20 years worked with stakeholders to generate future scenarios: plausible futures based on the factors that will impact most on the future healthcare workforce yet which are the most uncertain compiled data to populate the workforce model, and sought a consensus view using a Delphi exercise to quantify key uncertain parameters for modelling, such as future retirement patterns, as these could vary across the scenarios (plausible futures) modelled (using Vensim DSS software) current and forecast demand and supply for the workforce in six plausible future scenarios designed an interface to enable us to model (simulate) the impact of policy changes. Page 20 GP IN-DEPTH REVIEW Preliminary findings 4.7 Future GP workforce supply scenarios Figure 14 shows the CfWI s forecasts of supply (red lines) for GPs for the six plausible future scenarios, compared with baseline supply (black line). The baseline projection means workforce supply if the training pathway, staff attrition and retirement stay the same. It also assumes the 2015 recruitment target for GP speciality trainee places of 3,250 is both achieved on schedule and then maintained through to 2030. Figures are shown on a full-time equivalent (FTE) basis. The supply baseline enables comparison with our range of plausible future scenarios, in which supply is either better or worse than the baseline. Creating a baseline requires workforce data from a range of sources, coupled with a number of modelling assumptions (see Annex D for more details). The variation between the six scenarios represents the judgment of the Delphi panel about the range of ways the future might plausibly unfold. The individual scenarios are not of particular interest; what matters more is the range of uncertainty. Figure 14 shows considerable uncertainty about future GP workforce supply (as shown by the divergent red lines). Five of the six supply forecasts (red lines) are below the baseline, indicating that the Delphi panel anticipates lower participation rates and/or earlier retirement than our baseline modelling assumptions. Scenario 1 – a rosy future in which there is patient-driven workforce development and a perceived increase in the status and attractiveness of the GP profession – shows supply above the baseline. In this scenario, the Delphi panel considered GPs would retire later and/or work more hours by 2030 than they do today. The two scenarios with the lowest supply forecasts (further away from the baseline supply) indicate a future where there is a meltdown in care and a technology-reliant healthcare system, and thus the role of the GP becomes marginalised in those two scenarios. The scenario above the baseline is scenario 1, where a system emerges of content patients and doctors, extension and significant investment in GP training, with Foundation Year 2 including a compulsory primary care rotation. The CfWI medical and dental student intakes review (DH 2012b) gives an indication of the impact policy changes such as extending GP training to four years in the near future. It shows that a one-off extension leads to a sudden drop in GP supply, which then takes several years to reach the level that would be maintained without the policy change. This suggests that if a policy to extend GP training were to be implemented, consideration should be given to phasing it in. Figure 14: Projected supply for the GP baseline and six scenarios 55,000 50,000 Full-time equivalent Supply - baseline GPs Supply - scenario 1 - 6 45,000 40,000 35,000 30,000 2010 2015 2020 2025 2030 Source: CfWI system dynamics medical workforce model for England THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 21 GP IN-DEPTH REVIEW Preliminary findings 4.8 GPs and the wider medical workforce Since at least the mid-1990s the growth of the GP workforce has broadly matched overall growth in the NHS workforce, but failed to keep pace with growth in other, typically hospitalbased, medical specialties. As a result, the GP share of the total medical workforce in England has fallen significantly. Achieving and maintaining the 2015 training recruitment target will increase the GP workforce significantly by 2030, leading to some rebalancing in the medical workforce from secondary to primary care. Our baseline supply projections indicate there will be an additional 15,300 GPs (headcount) or 12,800 GPs (FTE basis) by 2030: increases of 43 per cent and 41 per cent respectively compared with their 2011 levels. many doctors will obtain their Certificate of Completion of Training (CCT) in non-GP specialties in the period to 2030, the large increase in consultants will be partly offset by a fall in specialty and associate specialist (SAS) doctors. As figure 15 shows, our baseline supply projections are for the number of hospital-based doctors (CCT holders and SAS grades) to increase by 23 per cent between 2011 and 2030, on a FTE basis. One implication is that the mix of hospital-based doctors will change, with a larger proportion of service delivered in the future by CCT holders and a smaller proportion by SAS doctors and doctors in training. Provided such an increase is affordable, this should facilitate the move to seven-day consultant-supervised treatment (AoMRC, 2012). By contrast, our model forecasts a smaller increase in hospitalbased doctors over the same period. This is because although Figure 15: Supply baseline projections for GPs and hospital-based doctors, England 70,000 Number of GPs 60,000 50,000 40,000 Hospital-based doctors, headcount Hospital-based doctors, FTE 30,000 GPs, headcount GPs, FTE 20,000 2010 2015 2020 2025 2030 Source: CfWI system dynamics medical workforce model for England. See Annex D for modelling assumptions. THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 22 GP IN-DEPTH REVIEW Preliminary findings 5. Demand for GP services 5.1 According to the 2006/07 UK GP Workload Survey (the most recent version available) (NHS HSCIC, 2007), the average length of surgery consultations with GP partners (as opposed to all GPs) increased from 8.4 minutes in 1992/93 to 11.7 minutes in 2006/07. Trends in activity and demand for GP services Evidence of a higher GP workload in recent years is provided in figure 16. The main strain on GP services has come from a large increase in consultations for patients aged over 60. For instance, in the 85–89 age category there was a 94.5 per cent increase in the consultation rate per person from 1995/96 to 2008/09. The rise in the number of consultations may be explained by increasing long-term conditions and comorbidities. The previously mentioned ageing population and increased life expectancy also add to the GP workload. The GP workforce will need to find ways to adapt if this trend of increasing workload pressure and case complexity continues. Alternative solutions, such as sharing the workload with other professions and encouraging more patient self-care through technology, were explored in the six scenarios generated by a group of stakeholders at our workshop in November 2012. Following a Delphi exercise to quantify the scenarios, we have been able to model future demand. Figure 16: Trends in GP consultation rates by age and year 1995/96–2008/09 14 Consultation rates per person year 1995/96 2000/01 2008/09 12 10 8 6 4 2 90+ 85-89 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 Under 5 0 Age range of patient Source: NHS HSCIC (2009) THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 23 GP IN-DEPTH REVIEW Preliminary findings 5.2 Has GP workload increased? The latest substantive evidence on GP activity and workload is from a HSCIC report on consultation rates from 1995 to 2009 (NHS HSCIC, 2009) and the 2006/07 UK GP Workload Survey (NHS HSCIC, 2007). Both point to significant increases in GP workload. Surveys since then by the RCGP (2012d) and the BMA (2011) have provided supporting evidence for increases in workload. The most recent survey on GP workload was undertaken by six local medical committees in South West England. The survey found that: over 90 per cent of GPs reported that their working day had become longer in the last three years, 96 per cent reported that the intensity of work had increased over the last 3 years and 94 per cent reported their work had become more complex. (Pulse 2013).     the increase in the volume and complexity of health and social care needs, as more people live for longer with long-term and often multiple conditions the shift of care out of the hospital and into the community, both as a means of bringing care closer to patients and their families financial constraints as a result of the economic situation, resulting in a need to transform services to reduce costs while maintaining or increasing quality the challenge to engage patients more in their own care and to promote healthy lifestyles and behaviours. In light of evidence of the broadening role of GPs, we recommend that the Royal College of General Practitioners consider a review of competency domains. This would include key stakeholders from the health and social care professions, primary care commissioners and patients. However, these surveys have had low response rates or have been self-selected, so their results cannot be relied on. We were unable to identify any more recent substantive research or evidence on GP capacity or workload since then. This is a major gap in the evidence base and accordingly we recommend that the HSCIC commission another GP workload survey to provide a much-needed overview of the workload and skill mix of general practices in the UK. In addition, we recommend that more frequent – preferably annual – data on GP activity and consultation rates be published, drawing on the GP Extraction Service (GPES). Despite these data limitations, our analysis of the available evidence on the demand for GP services points to a workforce under considerable strain. It is our preliminary assessment that the existing GP workforce has insufficient capacity to meet current and expected patient needs. 5.3 GP role and case complexity In recent years the role of GPs has increased significantly in breadth. Increasingly, GPs need to consider multiple agendas, 5 balancing local and bigger-picture thinking (Patterson, 2012) . Future GPs may assume more roles: social worker, public health advisor, commissioner and doctor. There is also the widespread perception that the job of a GP has become more complex due to: 5 Further research by Professor Fiona Patterson, Dr Mei-Ling Denney and Professor Abdol Tavable from the Work Psychology Group is to be published in 2013. THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 24 GP IN-DEPTH REVIEW Preliminary findings 5.4 Future GP workforce demand As explained above, rather than attempt to predict the future, the CfWI has developed a scenario-based approach for indepth workforce reviews that recognises the complexity of factors influencing demand and supply and the intrinsic uncertainty of the future. Figure 17: Projected demand for the baseline and the six scenarios 55,000 Full-time equivalent 50,000 Demand - baseline GPs Demand - scenario 1 - 6 45,000 40,000 35,000 30,000 2010 2015 2020 2025 2030 Source: CfWI system dynamics medical workforce model for England Figure 17 shows the CfWI s projections of demand (blue lines) for GPs for the six plausible future scenarios, compared with the baseline demand (black dash line) to 2030. various trends have different degrees of certainty, and there is inherent uncertainty regarding issues such as the pace of economic recovery and major policy initiatives. Baseline demand is projected to increase by just over one per cent per annum, based on two drivers: population growth and the changing age and gender composition of the population, particularly the increase in older people (see Annex D for details). However, as the baseline does not include changes in patient expectations, the rise of multiple morbidities and case complexity, or the potential impact of greater prevalence of non-age-related long-term conditions, such as obesity or diabetes, it most likely underestimates future patient demand for GP services. The six demand scenarios indicate considerable uncertainty about future demand (as indicated by the divergent blue lines). Across all six scenarios there is a sustained rise in demand for GPs, and demand considerably outstrips baseline demand. Participants in the Delphi panel exercise were asked to quantify how many GPs would be needed to meet all healthcare demand by 2030 ( for those registered with a GP, what do you think would be the average change in NEED for healthcare by 2030? ) and took into account a wide range of factors, not just demographic trends. The baseline scenario enables comparison with our range of plausible future scenarios, in which demand is either better or worse than the baseline. Creating a baseline is difficult, as the THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 25 GP IN-DEPTH REVIEW Preliminary findings 5.5 Productivity growth and future demand A key caveat to all the projections of future demand outlined in this report is that both our model and the Delphi panel exercise assumed zero productivity growth. While this may be a reasonable short-term assumption, it is unrealistic to assume there is no scope for GPs to improve their ways of working over the longer term. However, general practice is inherently labour intensive, so it would not be sensible to assume large productivity gains can easily be achieved. Accordingly, we have estimated the potential impact of quite modest productivity gains on future demand. Figure 18 shows the impact on GP demand of 0.4 per cent and 0.8 per cent annual productivity growth between 2011 and 2030. The 0.4 per cent figure is the Office for National Statistics (2012c) estimate of average annual growth in health sector productivity between 1995 and 2010, while the 0.8 per cent figure is a recent mid-range estimate from the Office for Budget Responsibility (2012). Both are well below average national productivity growth rates. Rather than include all six scenarios, figure 18 shows the impact of the two productivity assumptions on the baseline demand and on an average of the six demand scenarios. We also include baseline GP supply (red line) for comparison. All figures are on a full-time equivalent (FTE) basis. As Figure 18 shows, the average future demand scenario (dark blue line), assuming zero productivity, is above our baseline supply projection. Annual productivity growth of 0.4 per cent (green lines) would bring average future demand below baseline supply, allowing for a slightly lower-than-expected increase in the GP workforce by 2030. This suggests that a modest improvement in efficiency, coupled with maintaining 3,250 training places, may be sufficient to close the supplydemand gap. The 0.8 per cent annual productivity growth assumption (light blue lines) brings the productivity-adjusted average of the six demand scenarios closer to our baseline demand projection, and even further below baseline supply. Although these calculations are illustrative, they demonstrate the vital importance of measures to improve working processes, making it possible to release clinical time to achieve better patient outcomes and a more efficient practice. A wide range of potential measures could be deployed; many have been identified by the GP productive practice (NHS Institute for Innovation and Improvement, 2012). While their individual impact may be small, cumulatively they could yield the sort of modest productivity gains discussed here. We propose including a modest productivity growth assumption in the modelling for our final report. We would welcome views on what this figure should be. Figure 18: Productivity-adjusted projection for GP demand 50,000 Average demand scenario, zero productivity Average demand scenario, 0.4% productivity Full-time equivalent 45,000 Average demand scenario, 0.8% productivity Baseline GP supply Baseline demand, zero productivity 40,000 35,000 30,000 2010 2015 2020 2025 2030 Source: CfWI estimate, based on ONS (2012c) and OBR (2012) THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 26 GP IN-DEPTH REVIEW Preliminary findings 6. Supply and demand scenarios Following a Delphi exercise to quantify the key demand and supply variables under each scenario (see Annex D and F), our scenario forecasts for both demand and supply are shown together in figure 19. This points to both upside risk on demand for GP services and downside risk on workforce supply. Accordingly, a range of other measures to improve supply or curb demand may also be needed. It s a mixed picture, with considerable overlap between supply and demand scenarios. Baseline supply is above both baseline demand and half of the demand scenarios; four of the six supply scenarios are also above baseline demand. This suggests there is a reasonable prospect that the boost in GP trainee numbers proposed may be sufficient for workforce supply to meet expected future patient demand. Alongside expanded GP training, a range of other measures might help improve effective workforce supply, including:      On the other hand, we note that three of the future demand scenarios are above all the supply scenarios, while five supply scenarios are below our baseline supply projection. making general practice a more appealing career choice for medical students measures to encourage returners and improve retention making it easier for consultants in other specialties to switch to general practice increasing the supply of practice nurses greater collaboration with specialists. Figure 19: Combining GP supply and demand for the six scenarios 55,000 Demand - baseline GPs 50,000 Supply - baseline GPs Full-time equivalent Demand - scenario 1 - 6 45,000 Supply - scenario 1 - 6 40,000 35,000 30,000 2010 2015 2020 2025 2030 Source: CfWI system dynamics medical workforce model for England A final caveat on these modelling results. Our supply and demand forecasts rely on data and assumptions, some of which will be updated after the publication of the preliminary findings report. We are working with the RCGP and deans to refine the delay and attrition during training data and THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 assumptions, and we also hope for updates from the HSCIC, GPNRO and GMC. Therefore the final forecasts may not match those in this preliminary findings report. As a result, the analysis and conclusions in our final report could differ from those presented here. Page 27 GP IN-DEPTH REVIEW Preliminary findings Figure 20 : Projected number of GPs and GPs per 100,000 population 2011 to 2030 140 GPs per 100,000 population (right axis) 50,000 GPs, headcount basis* (left axis) 40,000 Number of GPs 100 30,000 80 60 20,000 40 GPs per 100 000 population 120 GPs, FTE basis* (left axis) 10,000 20 0 0 2011 2013 2015 2017 2019 2021 2023 2025 2027 2029 Source: CfWI baseline supply projection; ONS (2011) *Excluding GP registrars and retainers It is worth outlining what these projections mean for future workforce numbers. Figure 20 shows projected GP numbers from 2011 to 2030, together with the estimated ratio of GPs per 100,000 population using our baseline supply projections. It shows a steady rise in the number of GPs, with GP coverage improving to around 83-84 per 100,000 population by 2030, from the 2011 figure of 63 per 100,000. This figure is dependent on reaching the 3,250 target for GP trainee places THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 and maintaining this level of recruitment over the forecast period. Reflecting our participation rate assumptions, a net increase of around 15,300 GPs between 2011 and 2030 translates to an extra 12,800 GPs on a full-time equivalent (FTE) basis. That is a large boost to the workforce by any measure. Page 28 GP IN-DEPTH REVIEW Preliminary findings 7. The future GP and primary care 7.1 More of the same? The prevalence of long-term conditions, combined with rising patient expectations and lifestyle factors such as diet, exercise, tobacco and alcohol use, means the way primary care is delivered is likely to change significantly in the future. As health and social care needs grow in both volume and complexity, and health budgets remain constrained, pressure on the current fragmented system will continue to build. There is much talk of a patient-centred approach, multidisciplinary teams and greater collaboration between primary, secondary and social care. As the Royal College of General Practitioners attests in The 2022 GP (2013): We are moving instead towards a twenty-first century model of integrated care where patients and professionals work closely together in flexible teams, formed around the needs of the patient and not driven by professional convenience or historic location. This is similar language to the NHS Commissioning Board s emerging narrative on person-centred coordinated care (NHS CB, 2013), and many other recent statements from official bodies, colleges, professional associations, think tanks and patient organisations. We expect primary care commissioners will seek better coordinated patient care through more joined-up and collaborative delivery and more effective use of skill mix in multidisciplinary teams. As we outlined earlier in this report, the CfWI acknowledges the need for a substantial increase in GP workforce capacity to meet current and expected demand, by increasing GP specialty training levels to at least the 2015 recruitment target. But although this is the right short-term response, we are doubtful that more GPs is necessarily the best way of improving access, consistency and quality of primary care services over the long term. As NHS North West London (2012) found when it surveyed primary care professionals, there is a wide belief that more of the same and just working harder cannot be the answer . 7.2 Dimensions of change The British model of contracting GP services is now over a century old. General practice has come a long way since then, through expansion of the GP workforce, advances in medical treatment and social and demographic changes. However, the basic model remains of a skilled generalist doctor delivering good quality primary care services, prescribing and referring to secondary care. THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 We expect the future model of general practice to share many features with today s. However, key dimensions of change include:    changes in the role of GPs changes in how general practices are organised changes to GPs role in the wider primary care or community-based healthcare system. We discussed in section 5.3 how the role of the GP has expanded over the past decade, with GPs having to consider multiple agendas and take on more complex cases, while facing increasing demands and competing tensions in the role. We expect this to continue over the next two decades, with GPs spending more time seeing complex patients, able to routinely structure care around multi-morbidity as well as individual conditions (RCGP, 2013). We also expect greater specialisation and diversity of roles among GPs, with some wishing to lead service planning, commissioning or quality improvement while others prefer to extend their clinical, public health, academic or education and training roles. Greater flexibility in medical training could also see a move from GPs with special interests to dual specialties. As we noted in section 3.3, the way in which GP practices are organised is changing. The proportion of GPs working on a salaried or locum basis is rising; the proportion who are GP partners – while still a clear majority – is gradually declining. Practices are getting bigger: single-handed practices are in steady decline and very large practices (those with ten or more partners) are appearing. We expect this consolidation to continue. By 2030 over half the patients living in urban areas could be covered by a very large practice, federation of GPs or primary care network. Social enterprises and private companies may also play a larger role in delivering primary care in the future. However they are organised, the emergence of larger practices and networks should improve patient access via multiple sites, extended hours, and a broader range of health services. This trend also has the potential to bring isolated practices within more formal accountability structures, encourage greater collaboration between practices, and help offset cost pressures through economies of scale, better IT and administrative functions. Larger practices, federations and networks will also facilitate greater GP role diversity and extended responsibilities. We expect the growing number of very large GP practices (including federations of practices) will coordinate a broader range of primary care services across multiple sites and extended hours. Page 29 GP IN-DEPTH REVIEW Preliminary findings 7.3 Future primary care models Finally, how might GPs role in the wider primary care (or community-based) healthcare system change? There are two main alternatives. The Royal College of General Practitioners model is to develop and implement more generalist-led integrated services in the community (RCGP, 2013). Under this model, GPs would continue to play the generalist role but also spend more time overseeing the delivery of patient care by multidisciplinary teams. This can be seen as a natural evolution of existing trends. A more radical departure would involve managing primary demand and cost pressures through a broader, less GPreliant skill mix. GPs would still deliver much of the service, but would spend more time dealing with patients with complex needs and long-term conditions, coordinating care pathways and supporting greater patient self-management. Practice nurses and nurse practitioners would play a greater service role, freeing up GPs time. District and community nurses, health visitors, pharmacists, optometrists and physiotherapists may also make a broader contribution to primary care delivery than they currently do. This model may also use a nurse-led triage system or other gateway to manage patient demand. Under either model there would be more GPs with a special interest, and more community-based specialists. Both models have the capacity to deliver the high-quality, cost-effective and better coordinated primary care that patients expect. In practice we are likely to see both models emerge across the country, alongside smaller more traditional GP practices. No single model, however flexible, can hope to suit the diversity of local health economies across England. But the two models have quite different training and workforce implications. The GP-led integrated model should be more efficient than existing approaches, but over time would still require considerable expansion of the GP workforce. The alternative model would require more practice nurses and other primary care workers, and better collaboration across district and community nursing. Table 1: Three GP/primary care models Key features of each model Traditional GP practice Large GP-led integrated model Multidisciplinary primary care GP partners <10 > 10 > 10 Leadership team (e.g. directors) No Yes Yes GP-led care Yes Yes In some cases Number of sites 1 or 2 Range of services Limited Several Multi-channel working Limited More potential to use More potential to use Skill mix Limited More potential to use More potential to use Efficiency Low/med Med/high Med/high Several/many Several/many Several Source: CfWI The new GP commissioning structure presents GPs with an opportunity to develop a more innovative and coordinated approach that delivers high-quality patient care and value for money. Any new model of shared care will need to be developed with other health and social care providers, with clear roles and responsibilities for general practice to ensure that care for patients is well coordinated. We will explore these options in more detail in our final report. In the meantime we welcome your views. We also plan to review the whole primary care workforce in more depth in a separate project proposed for 2013-14. THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 30 GP IN-DEPTH REVIEW Preliminary findings 8. Concluding remarks This report outlines our preliminary findings, modelling results and emerging recommendations on the GP workforce in England, as the basis for wide consultation before we prepare our final report in the summer. This report is – deliberately – neither exhaustive nor conclusive. A number of areas are either omitted or only touched on, but will be addressed in more depth in our final report. These include international and UK examples of good practice, the role of the academic GP workforce, out-of-hours GP services, the likely impact of possible shifts in care in the medium and long term, and the workforce implications of more integrated primary care commissioning and of multidisciplinary teams. The emerging recommendations presented in this report are tentative and may change in light of additional evidence. Likewise, we will be refining our modelling assumptions, which could alter some of the projections in our final report. During the remainder of the project we will:      review and update key data inputs conduct sensitivity analysis review and where necessary revise assumptions to which the model is highly sensitive develop and model a range of policy options on training and care delivery models test preliminary model outputs with key stakeholders, including the project reference group. As outlined in the introduction, this workforce review has five main areas of investigation, but our most important aim is to help inform workforce planning to reduce the risk of future GP over- or undersupply in England. Our exam question is: Considering the likely changes to service delivery and models of care over the next 20 years, how do we ensure sufficient supply for the future GP workforce? THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 In the short term, the focus is on increasing specialty training number to reach the Government s recruitment target for England of 3,250 GP trainee places per year by 2015. The General Practice Task Force is working to achieve this target. This in-depth workforce review has a longer-term and more strategic remit: to provide the evidence base for sustainable improvements in planning for the GP workforce of the future looking ahead to 2030. It will also help to prepare the way for a possible CfWI primary care review in 2013-14. If demand for GP services increases at a faster pace than expected, additional measures may need to be considered. Over the longer term, though, we doubt that further substantial increases in the GP workforce supply – beyond those outlined in this report – will be either a fully effective or an affordable solution to rising primary care demand. Other options would need to be explored to curb demand and strengthen supply. These include alternative primary care delivery service models with a different skill mix, more effective demand management, better out-of-hours services, and measures to improve operational efficiency and productivity. There is a strong case for NHS commissioners to encourage a broader, collaborative approach to delivering primary care that makes more effective use of other healthcare professionals, including practice nurses and pharmacists – communitybased multidisciplinary teams offering patients a wider range of services. Options will be explored in our final report. We look forward to hearing the views of GPs, other health professionals, employers, patients and the public. Please sign up for one of our roadshows in March/April 2013, or contribute to our LinkedIn online forum: http://www.linkedin.com/groups/Friends-Centre-WorkforceIntelligence-CfWI-4274008 Page 31 GP IN-DEPTH REVIEW Preliminary findings Annex A: Comment by the Royal College of General Practitioners The Royal College of General Practitioners (RCGP) welcomes this important report, which supports many of our own findings and concerns. The CfWI confirm that investment in, and development of, the GP workforce has failed to match that of hospital based consultants: yet the case for generalist care at point of first contact has been shown to be cost-effective in terms of preventive, acute and chronic care, with high rates of uptake and patient satisfaction. We have argued for years that NHS planning must include the primary care workforce and its infrastructure, allowing for the challenges it has to meet of geographical and social diversity, and fully support the CfWI s recommendation that the growing opportunities to give care closer to home must be matched by a firm shift of resources to training more GPs. The RCGP has already made the case for longer training for GPs to enhance their confidence in managing their extending roles as clinicians, team leaders and commissioners. We agree that the NHS needs more GPs spending longer with their patients to deliver better care. Other recommendations, such as the need to encourage more doctors to choose general practice as a career and to retain trained GPs in the NHS, will need concerted commitment across medical schools, NHS workforce planners and deaneries. The RCGP knows that budgets for returner and retainer schemes have been cut, and has seen the burnout and demoralisation noted both by CfWI and the BMA - a much more positive climate is needed to turn this around. We know that some medical schools are much more likely to graduate doctors who choose GP careers, and suggest this needs further incentivisation to reward such success: the current review of the multi-profession education and training (MPET) levy - which includes the undergraduate medical and dental component service increment for teaching (SIFT) needs to result in enhanced funding for primary care placements which directly impact on career choice. THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 We are frankly relieved to see the CfWI highlight the profound lack of coherent data collection on who is working in primary care, and what they do, and hope that this will lead to an appropriate governmental response. We also noted the suggestion that the RCGP could do a competency review, but the CfWI itself notes the lack of recent substantive evidence on GP activity and workload, a major gap in the evidence base which must be urgently addressed . Funding will be needed to collect more detailed evidence on how the valued skill mix of different primary and community based staff can achieve best outcomes for patients, and where service modifications might maximise efficient and effective care. While we think the critique offered by the report is accurate, there are some areas that concern us:    Following the recent decision by the Higher Education and National Strategic Exchange (HENSE) to reduce medical student intakes, how will the system ensure future increases in specialty training numbers in undersupplied specialties including GP? Will the CfWI in its final report model the workforce risks and benefits of extending the length of GP training? We do not feel that the discussion on salaried vs. partnership models of delivery is relevant in the context of this report. In conclusion, we welcome the bulk of this report, would seek to work with the CfWI and others to achieve the GP workforce needed for a productive NHS in the 21st century, and hope it results in change. Professor Clare Gerada, Chair of RCGP Council Professor Amanda Howe, Honorary Secretary, RCGP Page 32 GP IN-DEPTH REVIEW Preliminary findings Annex B: Acknowledgements The CfWI sought input from a wide range of health professionals as part of the scoping and consultation for this review. The following individuals spoke to us individually, participated in one of the horizon scanning focus groups (October and November 2012), the scenario generation workshop (November 2012), or participated in the Delphi exercise. We would like to thank them for their contributions. Kate Anderson Jenny Aston Dr Maureen Baker Dr James Barnett Dr Tom Black Nadine Boczkowski Liz Brimacombe Dr Benjamin Brown David Burbidge Wilfred Carneiro Dr Nav Chana Dr Rani Dhillon Dr Dina Dhorajiwala Dr Tom Dolphin Yvonne Elliott Chris Evennett Dr Agnelo Fernades Dr Mark Findley Dr Derek Gallen Dr Clare Gerada Jemma Gilbert Professor Simon Gregory Professor Amanda Howe Professor Bill Irish Deborah Jaines Dr Terry John Dr Krishna Kasaranevi Dr Tina Kenny Dr Gillian Kyei Dr Barry Lewis Dr George Lueddeke Dr Arvind Madan Sally Malin Martin McColgan Rachel McGeorge Dr Stephen Millar Dr Sinan Mir Anne Moger Professor James Neilson Dr Vicky Osgood Rhydian Owen Dr Simon Plint Dr Roger Price Dr Mark Purvis Joe Read Claire Ripper Gail Rose Dr Paul Singer Dr Peter Smith Professor David Sowden Dr Andrew Spooner Dr James Thomas Ian Thornber Lorna Tinsley Dr Benjamin Titford Dr Nigel Watson Dr Ian Wilson Dr Martin Wright We would also like to thank our commissioners, Dr Jane Povey (DH) and Patrick Mitchell (HEE). THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 33 GP IN-DEPTH REVIEW Preliminary findings Annex C: Supporting data Table B1: GP training vacancies, 2009/10 to 2013/14 Intake year Applications Vacancies Accepted offers Competition ratio 2009/2010 5,066 2,719 2,626 1.86 2010/2011 4,802 2,732 2,800 1.76 2011/2012 4,752 2,672 2,658 1.78 2012/2013 5,094 2,687 2,669 1.90 2013/2014 n.a. 2,850 n.a n.a Source: GP National Recruitment Office (2012), Health Education England (2013a) Table B2: Location of English GPs initial medical training 2001–11 Country of qualification 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 UK 23,474 23,751 24,707 25,590 26,363 26,082 26,197 26,648 27,817 27,219 27,428 UK share 81.5% 81.3% 81.4% 81.2% 80.5% 78.8% 78.5% 78.4% 77.7% 77.6% 77.6% EEA 1,075 1,206 1,334 1,514 1,647 1,696 1,657 1,619 1,723 1,631 1,626 EEA share 3.7% 4.1% 4.4% 4.8% 5.0% 5.1% 5.0% 4.8% 4.8% 4.6% 4.6% Rest of world 4,253 4,245 4,317 4,419 4,728 5,313 5,510 5,743 6,263 6,233 6,305 Rest of world share 14.8% 14.5% 14.2% 14.0% 14.4% 16.1% 16.5% 16.9% 17.5% 17.8% 17.8% Source: NHS HSCIC 2012a THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 34 GP IN-DEPTH REVIEW Preliminary findings Table B3: Total GP vacancies 2008–10* Region 2008 2009 2010 Percentage point change 2008-10 England 1.3% 1.6% 2.1% +0.8 ppt North East 2.4% 0.7% 3.6% +1.2 ppt North West 1.3% 2.3% 2.1% +0.8 ppt Yorkshire and the Humber 1.5% 1.0% 2.4% +0.9 ppt East Midlands 0.0% 3.2% 3.1% +3.1 ppt West Midlands 1.6% 1.4% 2.9% +1.3 ppt East of England 0.7% 1.7% 1.8% +1.1 ppt London 2.5% 2.4% 2.1% -0.4 ppt South East Coast 1.1% 0.2% 0.5% -0.6 ppt South Central 0.3% 1.5% 1.0% +0.7 ppt South West 1.3% 1.1% 1.7% +0.4 ppt Source: NHS HSCIC 2010 Note: 2010 data is the latest available THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 35 GP IN-DEPTH REVIEW Preliminary findings Annex D: Scenario summary Scenario thinking is essential for workforce planning, as a wide range of factors will influence demand and supply in an intrinsically uncertain future. We worked with knowledgeable stakeholders to identify high-impact, high-uncertainty driving forces that may shape the future, and which workforce planners must therefore be alert to. The objective of the scenario generation workshop is to construct stories that – taken together – describe a range of ways in which the future could plausibly unfold over an agreed timeframe. The objective is not to predict the future, nor to select and define desired futures or solutions. The scenarios should not focus on the internal workings of the profession, but rather:    driving forces outside the profession s direct control how driving forces could impact on each other in causal chains sources of uncertainty. The six scenarios outlined below reflect the outcomes of a scenario generation workshop held on Thursday 29 November 2012, and subsequent discussions with key attendees. Scenario 1: Happy GPs, excellent patient care Scenario 2: GPs good, commissioners bad • Patient-driven workforce development. • Perceived increase in the status and attractiveness of the GP profession. • Patient-driven workforce development. • Perceived decrease in the status and attractiveness of the GP profession. • Increased patient and public involvement in planning and decision making. • Extension and significant investment in GP training. Foundation Year 2 to include a compulsory primary care rotation. • Services increasingly delivered in the community, with better coordination between primary and secondary care. • More flexible working practices leading to GPs becoming accredited with a special interest area. • Fluctuations in public perceptions of GPs. • Primary care not serving needs of the patients. • Widespread public consultation launched to agree case for change in primary care. Consensus emerged. • Recognition that care is best delivered by a content and motivated workforce led to greater remuneration and flexibility of status. • Increased investment in education and training helped make general practice more attractive, recruitment increased. Retirement bulge avoided and retention increased. • Introduction of increased number of roles for the programme GP with a Special Interest (GPwSI) helped improve interface between primary and secondary care. • After the largely successful implementation of CCGs and LETBs, a new GP contract was put in place in 2015. This allowed changes in remuneration and more flexible working opportunities. • Evidence began to surface that the healthcare needs of the population were not being met, possibly due to working in a financially constrained system and poor commissioning decisions. • The press picked up on this story and public support for GP commissioning dropped. • Politicians blamed GPs for making poor commissioning decisions and reflected a public backlash. Key assumptions Key trends Key events Now to 2020 THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 36 GP IN-DEPTH REVIEW Preliminary findings 2020 to 2030 Scenario 1: Happy GPs, excellent patient care Scenario 2: GPs good, commissioners bad • Increased media and public concern over size of budget. New arrangement held firm due to continued strong public and public involvement in decision making. • Services (such as MRI scans) increasingly delivered in the community. • A better interface between primary and secondary care due to more varied training. • Increase in multi-professional working helped deliver cost savings. • A change in government meant that the power to commission was removed from GPs, and commissioning bodies (similar to the former primary care trusts (PCTs) were reinstated. • New leadership emerged from the GP workforce, who wanted to focus much more on the delivery of care. • The refocusing of GP attention to clinical issues and of delivering care meant that clinical services were improved, as was the public perception of GPs. They became seen as important navigators of care pathways for patients. • Services increasingly delivered in the community. • A flexible system with a variation in service delivery models, to cater for local needs. • Increased multi-professional working, with increases in the training and development of the practice nurse workforce mirroring that of the GP. • Community and hospital-based doctors received training in both sectors, so a good understanding and better link-up is achieved. • The broadening of the GP role included working alongside social services to provide care closer to home. • GPs reverting to a clinical role, with commissioning responsibilities removed. Increase in clinical time. • GPs navigators of care pathways, and working closer with secondary care. • GPs maintained their independent contractor status, thus allowing the flexibility brought in by the new contract. The flexibility meant that GPs were able to design the clinical services, and a wide variation of models was observed. • Due to GPs losing public trust over commissioning problems, leadership and innovation were not encouraged or developed. Service delivery model themes THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 37 GP IN-DEPTH REVIEW Preliminary findings Scenario 3: Right plan, but wrong tools Scenario 4: Meltdown in care • Professionally driven workforce development • Perceived increase in the status and attractiveness of the GP profession • Professionally driven workforce development • Perceived decrease in the status and attractiveness of the GP profession • Instability from reform leading to tension between GPs and politicians. • Privatisation of primary care. • Coordination of planning through a plurality of providers. • Lack of organisational cooperation leading to fragmentation. • Interest groups and patients views not working towards the long-term benefit of the profession and poor workforce planning. • Reduction in flexibility of the GP role. Now to 2020 • The implementation of LETBs led to increased spending on continued professional development (CPD) and training and education successfully becoming aligned to patient needs. • Contractual issues emerged that reduced GP flexibility, with regionally determined pay and working conditions. • The profession was less attractive, and the status was lowered. • GPs became disillusioned with healthcare services and widening health inequalities, and problems with delivery were observed. • The new LETBs suffered from a lack of cooperation and did not plan or invest funds in training strategically. Repeated attempts to address this saw a piecemeal approach to skills development and training strategies. • The federated model initially proved attractive to CCGs, but CCGs buckled under the weight of imposed contractual changes. • The patient voice became more assertive through the use of Quality Outcome Framework targets. Competencies had been defined by interest groups, and were poorly designed. 2020 to 2030 • In the 2020 election, the opposition party pushed for radical reform of primary care. An increase in privatised healthcare services was observed. • New policies subsequent to this reform led to a plurality of healthcare provision, and consequently a fragmented training system. • The number of different providers led to increasingly complex issues of GP supply, and of the planning of education and training. This lowered the morale of GPs, meaning lower recruitment and a significant gap in primary care. • Demand for GP services continued to increase, while the supply decreased. • Due to poorly designed competencies and training, doctors in training were mismatched to system demand. A scramble for jobs ensued, with increasing numbers failing to find work in general practice. Numbers in medical schools dropped. • Pay and morale fell in medicine as perceived status dropped. Pressure on medical education training budgets meant lower-quality training and higher fees. A decline in leadership compounded the decline in status. • A fractured, siloed approach to training, and continuing contractual issues meant there was a perceived decrease in flexibility. The quality of recruits decreased, and regional recruitment inequalities increased. Provision of care was in meltdown, general practice had become an unattractive career, and patients were disillusioned. Key assumptions Key trends Key events THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 38 GP IN-DEPTH REVIEW Preliminary findings Service delivery model themes • The GP partnership model has been phased out, with the majority of GPs salaried. • The salaried service included performancebased pay and recognition. • Competition between providers meant that there are pockets of good practice, but due to the lack of cooperation, best practice is not shared. • GP working conditions not reflecting the workforce demographics. Few flexible working arrangements have been offered to a workforce that has a high proportion of women. • Poor relations between different organisations leading to disjointed care, and little multiprofessional working. • Some localities having trouble recruiting GPs due to reductions in numbers of doctors in training, and GPs recruited do not always have the skills needed. Scenario 5: Technology through regulation Scenario 6: Rise of the machines • High regulation of technological developments. • Reliable products with public buy-in. • Low regulation of technological developments. • Unreliable products. • Well-planned use of technology, with training and job roles considered. • Involvement of the public and patients in decision making. • Caution from both the public and public institutions in the use of technology. • Patient as a powerful consumer. • Reshaping of the primary care workforce through the creation of a new, low-paid role. • Poor strategic thinking. Now to 2020 • Continued financial constraints meant legislators and civil servants looked towards technology to provide cost savings. • A consensus was reached among stakeholders, whereby technology would be introduced, underpinned by a robust regulatory structure. A non-departmental public body was set up to provide licenses to products, after rigorous testing. • Health technology modules were introduced to training for healthcare professionals, and GPs helped design high-quality products. • A stable health system was maintained, and products helped people self-diagnose and selfmanage their conditions. • Public awareness of technology in healthcare increased, and legislators responded to this by offering commissioners incentives to invest in technology to allow patient self-monitoring. • The role of 'healthcare technician' was heavily expanded, with only basic certification needed. This meant that many GPs and practice nurses found themselves out of work. • Investment in the GP workforce decreased, as patients were able to diagnose and manage their conditions themselves. • Fierce lobbying from the technology industry meant that a 'light-touch' regulatory model was adopted. 2020 to 2030 • By 2025, public and media frustration grew at a system perceived to stifle innovation. • After initial caution, the products were trusted, and empowered patients demanded more. • Until around 2022, development was steady, with public buy-in of the products. • A series of mergers between the technology companies led to three major companies Key assumptions Key trends Key events THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 39 GP IN-DEPTH REVIEW Preliminary findings Scenario 5: Technology through regulation Scenario 6: Rise of the machines • The regulatory agency responded to these issues by increasing public participation in decision making. • A large primary care workforce was still needed, with face-to-face consultations remaining at a premium. providing telehealth applications to GPs. The market became less competitive. • A loss of competitive edge meant less money was spent on research and development. The applications became unreliable, and misdiagnosis became common. • Public trust in technology broke down, and the public reverted to valuing face-to-face consultations. • The cuts made a decade earlier meant that primary care services were ill-equipped to handle these remodelled public attitudes. • Primary care services found themselves tied in to costly long-term contracts with technology companies, and could not service their patients. • Large workforce needed, with face-to-face consultations still demanded. • Similar contracting model present, with CCGs able to commission services independently. • GPs spending time helping develop clinical technologies, meaning an expanded salaried/locum workforce. • Patient voice more powerful and much higher expectations. Less tolerant of waiting and demanding longer opening hours. • Multi-professional working increased, to help deal with the large demand of face-to-face consultations. • CCG managers are keen to respond to the public's demands and create a stronger out-ofhours system, but the underfunded and underskilled workforce is unable to provide the service desired. Service delivery model themes Source: CfWI scenario generation workshop, November 2012 THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 40 GP IN-DEPTH REVIEW Preliminary findings Annex E: Modelling assumptions Supply modelling assumptions Model element/ variable Data confidence rating Source of data/assumption Validation Data/assumption Annual medical school intake from England VH HEFCE medical and dental return November 20062011. A 2 per cent reduction in intake from 2013/14 n/a 5,766 home fees students per year from 2013 Annual medical school intake from outside of country VH HEFCE n/a 485 students per year from 2013 Annual intake into GP training from the English Foundation Programme n/a Calculated by model from flows into training. n/a Annual intake into GP training from outside England L No specific data was available to the CfWI at the time of modelling. CfWI estimate used due to lack of evidence. 100 (assumed). Annual intake into GP training from outside England, age profile M GMC data, 2010. CfWI estimate used due to lack of evidence. UK age profile used as proxy, see below. Annual intake into GP training from career posts L No specific data was available to the CfWI at the time of modelling. CfWI estimate used due to lack of evidence Estimated at 100 men and 100 women per year. GP training posts filled (%) L The model has been set up to meet the Government target of GPs in training. A 2 per cent reduction in intake from 2013/14 THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 The following number of doctors in training: Year Posts filled 2012 2,669 2013 2,850 2014 3,130 2015 3,250 2016 3,250 2017 3250 Page 41 GP IN-DEPTH REVIEW Preliminary findings Model element/ variable Data confidence rating GP training initial stock H Source of data/assumption Validation Data/assumption Health Education England survey of deaneries, Autumn 2012 (unpublished). Data is available for the count of posts, as well as count of NTNs. The smaller of the two is used to in the model to avoid an overestimate. 8729 calculated as total GP NTNs minus those not in use , OOP and other NTNs. 62 per cent are assumed to be women, based on 2011 HSCIC medical census registrar data. GP training initial stock , age profile by gender VH GMC data, 2010 n/a Table available on request. Median age is 26; over 90 per cent are in the age range 25 to 40. Length of GP training and delays M MRCGP exam pass/fail data. n/a Length of training is influenced by delays. Model uses the assumption that 82.8 per cent of men GPs in training will take 3 years, 5.1 per cent 4 years and 12.1 per cent take five years. The assumption for women is that 71.4 per cent take 3 years, 16.5 per cent 4 years and 12.1 per cent five years. Unpublished and unverified data from Wessex deanery. Health Education England survey of deaneries, Autumn 2012 (unpublished). Deanery stocktaking data shows that 12.1 per cent of all doctors in training are training less than full time, with an average participation rate of 0.58. Therefore we assume these doctors in training will take 5 years to complete. It is assumed that any trainees who pass MRCGP exams on the fourth attempt take four years to complete training. It has been assumed that 16.5 per cent of women doctors in training go on maternity leave during training, and therefore take four years on average. GP training attrition rate (leave the system) M MRCGP exam pass/fail data. Postgraduate deans approached were unable to supply data. The model is set up to replicate attrition of 2 per cent in ST1 and ST2, and 5 per cent in ST3. The ST3 figure is based on historic MRCGP exam results, and those who failed four or more times. Half of the doctors in training who fail training are assumed to leave the system GP training attrition rate (leave GP training to seek a career post L MRCGP exam pass/fail data. THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Postgraduate deans approached were unable to supply data. See GP training attrition rate (leave the system) above. The other half of GPs in training who fail are assumed to seek career Page 42 GP IN-DEPTH REVIEW Preliminary findings Model element/ variable Data confidence rating Source of data/assumption Validation or other training) Percentage who complete training and then leave the system Data/assumption posts or other training posts. L Assumption; no specific data was available to the CfWI at the time of modelling. The CfWI estimate used due to lack of evidence. 5 per cent. Annual inflow of GPs from outside of English system n/a No specific data available to the CfWI. The CfWI estimate used due to lack of evidence. Assumed to be zero. Annual re-joiners to GP M No specific data available to the CfWI. The CfWI estimate used due to lack of evidence. 289 men and 289 women per year (assumed). Annual flow of trained hospital doctors to GP conversion training L No specific data available to the CfWI. The CfWI estimate used due to lack of evidence. Assumed to be zero. GP attrition rate M HSCIC GP census 2008 to 2011, headcount for GP providers, other/salaried GPs, and GP retainers by age and gender. CfWI continues past trends due to lack of specific evidence. Historical data (2008 to 2011) is used to build a picture of the likelihood of a GP leaving the workforce, by age and gender. For example, 13 per cent of 60-yearold men leave, and 14 per cent of 65-year-old men leave. 19 per cent of 60-year-old women trained hospital doctors leave and 22 per cent of 65-year-old women leave. We assume that 4 per cent of trained hospital doctors below the age of 49 leave each year. Participation rate by age and gender. Participation rate calculated by gender and in age bands of one year. The attrition rate accounts for retirements (those 49 and older) and early leavers (those 48 and younger). GP participation rate M HSCIC GP census 2011, FTE and headcount data for GP providers, other/salaried and retainers. Average participation by women of 81 per cent, average participation by men of 95 per cent in 2011. The average participation rate changes each year due to the changing ratio of genders and ages. Initial stock of GPs H HSCIC GP census 2011, headcount for trained hospital doctors by age and gender. THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 n/a 19,359 men, 16,444 women. Page 43 GP IN-DEPTH REVIEW Preliminary findings Model element/ variable Data confidence rating Source of data/ assumption Validation Data/assumption Initial stock of GPs, age profile H HSCIC GP census 2011, headcount by age and gender for GP providers, other/salaried GPs, and GP retainers n/a Age profile represents that of the current English GPs. Age profile of GP rejoiners M No specific data available to the CfWI. CfWI estimate used due to lack of evidence. Assume the same age profile as the GP workforce. Source: CfWI system dynamics medical model for England Baseline demand modelling assumptions The following table shows the assumptions used to forecast future baseline demand for GP services due to demographic changes. Baseline demand accounts for both the increased size of the population and also the changing age and gender balance (particularly a higher proportion of older people) to 2030. In order to obtain the baseline forecasts, we calculated increasing demand for medical care due to population growth using ONS projections of the English population, and weightings for medical services requirement by age and gender. The baseline growth of the English population uses the 2010-based principal population projection for England that assumes:    a long-term average completed family size of 1.85 children per woman life expectancy at birth in 2035 of 83.6 years for men and 87.2 years for women, with constant rates of mortality improvement assumed thereafter long-term annual net migration to the UK of +172,500 per year. The relative demand from people in a particular age band and gender is calculated for the whole population, and summed for each future year to give an estimate of the overall future health service demand by year. The baseline weightings for health service use were calculated for both primary and secondary care. Primary care weightings used PCT revenue allocation weightings by age and gender (DH, 2011). Secondary care weightings used outpatient attendances data by age and gender (HSCIC, 2012). Note that assumptions for the six demand scenarios were estimated by a Delphi panel, as shown in Annex F. Demand for primary Demographic medical care multiplier Source of data/assumption Demand baseline Office for National Statistics (2012a) Table A3-4, Principal projection - England population single year of age, 2010-based. 1.21 NHS Health and Social Care Information Centre (2012) Hospital Episode Statistics for England. Main specialty by age group for all outpatient attendances: All, 2010-11. Department of Health (2011) Exposition book 2011-2012, Table 6: 2011-12 primary medical services component, Age-gender weights. Source: CfWI medical demand model for England THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 44 GP IN-DEPTH REVIEW Preliminary findings Annex F: Delphi modelling assumptions A Delphi panel was used to quantify key assumptions for the future workforce in each of the six scenarios. The questions related to either supply or demand and are shown below. The tables below show the average (median) values obtained from the Delphi panel exercise. Delphi questions – supply assumptions      What do you think the average participation rate of GPs would be in 2030? What do you think would be the percentage of women in the GP workforce in 2030? What do you think would be the percentage change in the number of salaried GPs as a proportion of all GP providers? What do you think would be the percentage change in the number of GPs leaving the workforce for reasons other than retirement? What do you think would be the average retirement age for GPs in 2030? Supply of primary medical care in 2030 Participation rate of GPs (women) Participation rate of GPs (men) Percentage of women in the GP workforce Percentage change in the number of salaried GPs as a proportion of all GP providers Percentage change in the number of GPs leaving the workforce for reasons other than retirement Average retirement age for GPs Supply baseline 0.81 0.95 44% 0 n.a. 58 (women) 60 (men) Scenario 1 0.85 0.9 65% 150% (women) 180% (men) 100% (women) 100% (men) 62 (women) 66 (men) Scenario 2 0.8 0.85 60% 150% (women) 160% (men) 104% (women) 104% (men) 62 (women) 66 (men) Scenario 3 0.78 0.83 60% 180% (women) 190% (men) 115% (women) 120% (men) 58 (women) 62 (men) Scenario 4 0.72 0.8 60% 180% (women) 180% (men) 130% (women) 120% (men) 55 (women) 60 (men) Scenario 5 0.75 0.8 60% 155% (women) 165% (men) 105% (women) 105% (men) 58 (women) 62 (men) Scenario 6 0.7 0.77 60% 190% (women) 190% (men) 150% (women) 145% (men) 58 (women) 58 (men) Source: Delphi GP panel exercise THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 45 GP IN-DEPTH REVIEW Preliminary findings Delphi questions – demand assumptions   For those registered with a GP, what do you think would be the average change in need for healthcare by 2030? What do you think would be the change in the amount of service provided by GPs by 2030, due to changes in models of care such as skill mix, impact of technology, political priorities, timing of service delivery and clinical services delivered? The Delphi panel answers have been converted into a multiplier that indicates how much greater the demand will be in the future compared to current demand. The demographic multiplier used for the demand baseline (see Annex E) is not applied to the six demand scenarios as Delphi participants were asked to take account of demographic factors when estimating changes in future healthcare needs. The multipliers below (aside from the demand baseline) indicate the median percentage change expected by the Delphi panel between 2011 and 2030. A multiplier of 1.35, for example, indicates a 35 percent change over that period. Multiplier due to population growth and ageing population* Multiplier due to change in need for healthcare Multiplier due to change in the amount of service provided by GPs 1.21 – – Scenario 1 – 1.35 1.23 Scenario 2 – 1.40 1.10 Scenario 3 – 1.35 1.01 Scenario 4 – 1.40 0.98 Scenario 5 – 1.40 1.10 Scenario 6 – 1.30 1.01 Demand for primary medical care in 2030 Demand baseline Source: Delphi panel exercise, except where indicated * Demographic multiplier – please see Annex E THE CENTRE FOR WORKFORCE INTELLIGENCE | © CfWI 2013 Page 46 GP IN-DEPTH REVIEW Preliminary findings References Academy of Medical Royal Colleges (AoMRC) (2012) Seven Day Consultant Present Care. [online] Available at: http://www.aomrc.org.uk/publications/reports-aguidance/doc_details/9532-seven-day-consultant-presentcare.html [Accessed February 2013]. British Medical Association (BMA) (2011) National survey of GP opinion 2011. London: Health Policy & Economic Research Unit. 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Page 49 GP IN-DEPTH REVIEW Preliminary findings Disclaimer The Centre for Workforce Intelligence (CfWI) is an independent agency working on specific projects for the Department of Health and is an operating unit within Mouchel Management Consulting Limited. This report is prepared solely for the Department of Health by Mouchel Management Consulting Limited, in its role as operator of the CfWI, for the purpose identified in the report. It may not be used or relied on by any other person, or by the Department of Health in relation to any other matters not covered specifically by the scope of this report. Mouchel Management Consulting Ltd has exercised reasonable skill, care and diligence in the compilation of the report and Mouchel Management Consulting Ltd only liability shall be to the Department of Health and only to the extent that it has failed to exercise reasonable skill, care and diligence. 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