Over the past decade, the number of NHS general practices in England has decreased by 20% with 15% fewer qualified fulltime equivalent (FTE) general practitioners (GPs) per 1,000 patients, finds a new analysis involving a UCL researcher.
However, the average practice patient list size has increased by 40% during the same time frame.
The study, published in BMJ Open and led by UCL and the London School of Hygiene & Tropical Medicine (LSHTM), combined data from NHS England, the Office for Health Improvement and Disparities, and the Care Quality Commission between 2013 and 2023.
The findings show that over the course of 10 years (2013-2023), the number of people registered with an NHS general practice in England grew by 11% from 56,042,361 to 62,418,295, with a temporary slowdown during the COVID-19 pandemic.
Over the same period, the number of NHS general practices fell by 20% from 8,044 to 6,419, while the average practice patient list increased by 40% from 6,967 to 9,724.
In addition, the proportion of practices with over 20,000 registered patients rose from 1% to 6%.
The researchers also noted significant structural changes in English NHS general practice between 2013 and 2023, with a move towards practices having more administrative and multidisciplinary staff between 2015 and 2022.
This resulted in the total FTE general practice and primary care network workforce per 1,000 patients increasing by 20%.
The total number of qualified GPs working in NHS general practice in England also rose from 34,474 to 36,492.
However, after taking working hours into account, the number of FTE qualified GPs fell from 27,948 to 27,321. And, after factoring in population growth, this means that the average number of GPs fell from 0.53 to 0.45 for every 1,000 patients, representing a fall of 15%. Nursing numbers remained stable.
By September 2022, qualified GPs and other multidisciplinary 'direct patient care' roles (such as pharmacists, physician associates, paramedics and social prescribers), each represented 19% of the FTE workforce. Administrative roles represented 51%.
Co-author of the study, Professor Irene Petersen (UCL Epidemiology & Health Care), said: "Our study highlights the importance of integrating data from multiple sources to gain a comprehensive understanding of the situation in NHS general practice across England."
The analysis found that between 2018 and 2023, there was no clear upwards or downwards trend in the total number of appointments per 1,000 patients with, on average, half provided by GPs.
The researchers warn that falling FTE GP numbers could lead to a tipping point where most general practice appointments are no longer delivered by GPs. They say that the impact of a shift towards larger practices and a diversified workforce on care quality and cost-effectiveness remains uncertain.
Dr Luisa Pettigrew, lead author of the study from LSHTM, said: "Although GP trainee numbers are rising, the new government must also prioritise GP retention. While the headcount of GPs in NHS general practice has marginally increased, when you factor in reported working hours and the growing population, the total number of full-time equivalent GPs per 1,000 patients working in NHS general practice has fallen.
"Trends point to a changing role for the GP partner, from a self-managing owner of a small business to holding responsibility for the governance of a much larger organisation and multidisciplinary team.
"General practice in England appears to be in a period of transition, from the smaller partnership-based model of general practice to that of larger organisations with more administrative and multidisciplinary staff but fewer GPs. However, patients are struggling to get appointments; concerns have been raised regarding the safety of introducing new roles without adequate supervision; and we are now facing the lowest ever levels of public satisfaction with general practice recorded."
The authors also found that roles across general practice were predominantly filled by women and that around one in four GPs completed undergraduate training overseas, mostly in low- or middle-income countries.
The study was funded by the National Institute for Health and Care Research (NIHR).
Study limitations
It was not possible to distinguish between practices that physically closed versus those which merged or were taken over by another practice to become a 'branch surgery'.
Reported workforce trends excluded trainees and ad hoc, short-term locums working in NHS general practice.
FTE hours are unlikely to consistently include GP overtime, which is common in general practice.
Appointment data, available from 2018 onwards, does not capture activities such as reviewing routine correspondence, prescriptions or results, or other general practice work such as staff supervision, management and quality improvement work. Online consultations may also not have been consistently captured in the appointment data.
