Number of GP practices is shrinking, but patient lists are growing in England

Over the past decade, the number of NHS GP practices in England has shrunk by 20%, but the size of patient lists has increased by 40% to an average of just under 10,000, according to an analysis of three national primary care datasets published in the open access journal BMJ opened.

And while the overall NHS GP workforce grew by 20% between 2015 and 2022, due to the increase in administrative staff and other practitioners, the number of GPs per 1,000 patients fell by 15% over the same period, when taking into account with the working hours. appears from the analysis.

Major structural and organizational changes have taken place in general practice in England over the past decade, but it is difficult to get an overall picture because information about different aspects of general practice is spread across multiple data sets, the researchers explain.

They therefore combined information from different national data sources to describe changes in the organizational structure, workforce and appointments of different types of staff in English general practice, and to consider the implications of these trends.

They drew on general practice data collected by NHS England, the Office for Health Improvement and Disparities and the Care Quality Commission, over five- to 10-year periods from 2013 to 2023.

They found that the number of people registered with an NHS GP practice in England grew by 11% between 2013 and 2023 from 56,042,361 to 62,418,295. And the average proportion of patients aged 65 and over increased from just over 16% to 18%.

But the total number of practices fell from 8,044 to 6,419, equivalent to 178 fewer practices per year and an overall reduction of 20%, while the average practice list size increased by 40% from 6,967 to 9,724 patients, equivalent to 291 more per year.

The number of large practices with lists of more than 20,000 patients also increased from 1% (81) of practices in 2013 to 6% (355) in 2023.

Between September 2015 and September 2022, the total number of qualified GPs working in NHS general practice in England increased from 34,474 to 36,492. But when working hours are taken into account, the number of people working the equivalent of a full-time job fell from 27,948 to 27,321.

The average number of GPs fell from 0.53 to 0.45 per 1,000 patients, a decline of 15%, with the decline being significantly greater among male GPs: 23% versus 4% among female GPs.

The proportion of practices reporting a trainee GP increased from just over a third (35%) to half (50%) between 2018 and 2022. But there is no guarantee that trainee GPs will work full-time in general practice or remain there once qualified. it, the researchers point out. And the NHS continues to rely on doctors qualified abroad: they make up a quarter of GPs in NHS general practice.

As for other staff, the average number of nurses remained relatively stable between 2015 and 2022: on average, 97% of practices employed a nurse. But the average number of other roles, including pharmacists, social prescribers, junior doctors and paramedics, increased by 67%, with the proportion of practices directly employing these other staff rising from 72% to 89%.

Administrative roles also increased by 14% during this period and made up more than half of the NHS general practice workforce by September 2022.

Based on new national data, the researchers estimate that between 2018 and 2023 there were between 63 and 119 (average 98) general practice appointments per week for every 1,000 patients, carried out by all types of doctors. Appointments peaked between September and November each year, declining between April and August 2020 in the wake of the first COVID-19 lockdown.

The number of GP visits varied from 35 to 57/week/1,000 patients, with no clear trend over time, taking into account population growth. Appointments with nurses ranged between 18 and 28/week/1,000 patients. Appointments with other practitioners varied between 17 and 26/week/1,000 patients.

Both GPs and other practitioners represented the same share (19%) of the NHS GP workforce in September 2022, once working hours were taken into account. But despite the decline in their numbers, GPs continued to provide half of all appointments, while other practitioners provided about a fifth.

“Decreasing GP numbers yield the same number of appointments/1,000 [patients] seems untenable; therefore, there is likely to be a tipping point in the near future where the majority of appointments in English general practice are no longer made by GPs,” the researchers suggest.

The researchers note some limitations to their analysis, including the discrepancy in population data from NHS England and the Office for National Statistics, and the ‘experimental’ nature of NHS England’s appointments data.

Other general practice activities, such as managing correspondence, prescriptions, reviewing test results, staff supervision, management and quality improvement activities, are also not captured in appointment data. And online consultations delivered via separate messaging software may not be recorded, while staff data is unlikely to cover overtime, which is common in general practice, they point out.

And they couldn’t distinguish between practices that had closed for good, and practices that were acquired by another practice to become a “branch” practice.

“The move towards larger scale organizations has been encouraged by government policy and professional bodies to improve quality and generate economies of scale through shared back-office functions, joint service delivery and standardized processes. However, evidence that larger organizations perform better in primary care quality or that is more cost-effective is mixed,” the researchers said.

Similarly, diversification of the general practice workforce has also been driven by national policy and proposed as a solution to the GP shortage, but concerns have been raised about the impact on continuity of care, cost-effectiveness, equality of roles and safety without sufficient care. General practitioner supervision, they add.