There has been no way of ensuring the equitable distribution of general medical practitioners (GPs) in England since 2001. Deprived areas are being worst affected by shortages of GPs. That trend is increasing, and is widening health inequalities. This essay, by John Gooderham, offers a solution to the problem. The financial implications are neutral, and the running costs are low.
This paper does not tackle the issue of a shortages of GPs and how to overcome that. Nor do I deal with the separate but related problem that some patients have of increasing difficulty of getting to see GPs in person, or the reported difficulty of contacting a practice. And I have not considered whether GPs’ contracts should be for General Medical Services, Personal Medical Services, Alternative Provider Medical Services, or Integrated Care Provers, all of which are largely irrelevant to the question of equitable distribution, as are Additional Roles Reimbursement Schemes, welcome though these are.
Those issues are for others to discuss. This paper is solely concerned with ensuring an equitable distribution of Full Time Equivalent (FTE) numbers of general medical practitioners (GPs) throughout England. This essay is about the principle of fair access for patients, which means not letting GPs work where there are already more than enough GPs, and not letting GPs leave areas where there are not enough GPs, without having them replaced.
The most extreme example of more-than-adequately doctored area appears to be Liverpool where the average list of patients per FTE GP is 1,614 (though that is counter-intuitive and seems highly unlikely to be an accurate reflection of the true position) compared with a national average of 2,289.
Others are Oxfordshire with 1,688; Wirral with 1,720; West Suffolk with 1,731; and East Staffordshire with 1,745 patients per FTE GP. These data are at Clinical Commissioning Group (CCG) level. They have been extracted by the House of Commons Library, though the full list has not been published, and are not at Primary Care Network level.
At the other end of the spectrum, those areas that are most severely under-doctored include Fylde and Wyre with an average list of 2,833 patients per FTE GP; Hull with 2,761; Calderdale with 2,606; Thurrock with 2,592; and Portsmouth with 2,559. Again, however these figures need to be treated with caution, as they are CCG-wide averages, rather than for Primary Care Networks (PCNs). The differences between PCNS, even within the same town, is even more marked. For example, Blackpool North’s average list size for FTE GPs excluding locums and trainees is 4,480 while Blackpool South’s is 1,900; in Hackney Downs the average is 1,885 while in Hackney Marshes it is 2,490; in Portsdown the average is 3,012 while in Portsmouth South it is 2,064; and in Reading Central the average is 5,111 while in Reading West it is 2,987.
Having identified the problem, I offer a solution. Unless this solution is adopted, Tudor Hart’s inverse care law of 50 years ago – that the availability of good medical care tends to vary inversely with the need for the population served – will become even more pronounced. Where GPs work should no longer be left entirely to market forces, as has happened for the past 20 years. But nor should GPs be told where they should work. They never have been, and any attempt to do so would be strongly opposed. Financial incentives might be useful, though, to encourage new GPs to work un under-doctored areas.
History
From the inception of the NHS, sustained efforts were made until 2001 to mitigate the obvious inequity for patients produced by the total freedom previously enjoyed by GPs to work anywhere. Some GPs had lists of 4,000 patients in industrial areas. Others made a good living from just 1,000 in wealthy parts of the country. To address these disparities, the NHS Act 1946 set up the Medical Practices Committee for England and Wales (MPC).
The MPC had a duty to ensure that there was an equitable distribution of GPs throughout the country and that every area had an adequate number of GPs. The words “adequate” and “area” were never defined in the Act or its Regulations, but there was tacit agreement that the former term should be used to describe a local average that was less than the national average list of patients for FTE GPs. What constituted an area was decided by the local NHS, with the MPC’s approval.
After a few years of the NHS, the national FTE GP average list settled down to about 2,000 patients, fluctuating between about 2,200 when there was a national shortage and about 1,800 when there was, relatively speaking, no shortage. The FTE GP national average list is now about 2,211 patients, and is increasing inexorably as the number of FTE GPs in England decreases while the population continues to increase.
Starting work in July 1948, the MPC met weekly as an executive non-departmental public body, with 9 members who were mostly GPs at the start, including the chairman. The MPC assessed every area, the geography of which was decided by the local NHS, as being: severely under-doctored; less than adequately doctored; adequately doctored; or more than adequately doctored. Severely under-doctored areas had average lists of over 2500 patients; under-doctored areas had average lists of between 2100 and 2500; adequately doctored areas had average lists of between 1700 and 2100, while more than adequately doctored areas had average lists of below 1700. There were about 1250 areas in England (about the same as there are Primary Care Networks now).
The MPC was given a discretionary power to refuse applications for inclusion on the local medical list of the NHS if the area was adequately doctored or more than adequately doctored. The MPC was not empowered to refuse applications from suitably qualified GPs to practise in under-doctored or severely under-doctored areas.
The MPC was allowed to make special arrangements for areas of rapid population growth – such as the New Towns – designating them as severely under-doctored from the outset, and by declaring new practice vacancies, attracting additional payments for new GPs while the patient list grew. A similar arrangement existed for declaring vacancies when practices closed.
The discretionary power to refuse to let GPs work if the area was over-doctored was intended to encourage GPs whose applications were refused to move to areas that were under-doctored or severely under-doctored, i.e. negative direction. More often, a GP would realise they wouldn’t be allowed to work in that over-doctored area, and would decide to work somewhere that was under-doctored instead. The system was successful in that by February 1986 there were no severely under-doctored areas, and by November 1999 there were only a handful of under-doctored areas.
There were criticisms that the MPC was too lenient or that it was too strict, and that it was secretive and was dominated by its GP members. There was some truth in all these. There was certainly an apparent bias in favour of granting applications in adequately doctored areas, where the MPC bent over backwards to have regard to other factors that would show there was a need for an increase in the FTE number of GPs.
More importantly, the MPC realised belatedly that greater account needed to be taken of an area’s deprivation, and that was achieved by ALFRED – adjusted lists for really equitable distribution – introduced in 1997. The Index of Multiple Deprivation (IMD) was used to create large numbers of extra patients in deprived areas, so that such areas would have their average lists increased and thus could be more readily recognised as under-doctored.
When the MPC was abolished in 2001, the whole system was swept away, and nothing was put in its place. The Carr-Hll funding formula introduced at that time was explicitly designed to ensure that GPs were paid more for working in certain areas, for instance where there was a greater than usual percentage of elderly patients, though this was not IMD weighted. The formula, which has been revised more than once, and had been due to be reviewed again, was never intended to have any influence on where GPs decided to work, only to recognise that those who worked in certain areas should be better rewarded.
Research
Recent research by the University of Cambridge’s Department of Public Health & Primary Care has found that significant GP workforce inequalities exist now, and are increasing, with workforce shortages disproportionately affecting deprived areas. The researchers conclude that policy solutions are urgently needed to ensure an equitably distributed GP workforce, and reduce health inequities. Other researchers including the Health Foundation, the Kings Fund and the Nuffield Trust, have reached similar conclusions.
The total number of FTE GPs including locums in England has fallen to 27,600 in August 2021 which is a drop of 3.9% since 2016. The registered patient population is 61,024,953 which means that the average list of patients per FTE GP is now 2,211 in England. That national average per FTE GP is the highest for 40 years, and is indicative of the national shortage. A possible recognition of “adequacy” would be for any area having an average FTE GP list size below 1,800 being regarded as more than adequately doctored, any area with an average FTE GP list size of between 1,800 and 2,211 being regarded as adequately doctored, and areas with average FTE GP list sizes of above 2,211 being regarded as less than adequately doctored. These three categories are probably all that is needed as a starting point for assessing adequacy, but the ranges for each is subject to debate.
Proposal
The Health and Care Bill, currently before Parliament, presents an ideal opportunity to introduce a system in some ways akin to that previously operated by the MPC.
This should be done by inserting a new clause to the effect that
‘The Secretary of State for Health and Social Care shall require an executive non-departmental public body to ensure that there is an equitable distribution of the Full Time Equivalent number of general medical practitioners throughout England, and that all areas of England are served by an adequate Full Time Equivalent number of general medical practitioners.”
No doubt that wording can be improved by Parliamentary Counsel. The detail of how the central body might function is probably best left to regulations, to be made after the Bill has been enacted. What follows, therefore, are suggestions that might be implemented in the near future.
Process
The process by which this central body would operate should be very straightforward and transparent. There would be no need for example for anyone to submit an application to replace an outgoing FTE GP by another FTE, or a halftime GP by another halftime GP. For any change in the number of FTEs, however, the relevant PCN should assess the adequacy of the area, and should recommend with reasons whether there should be an increase or decrease in the FTE number of GPs.
The central body would have discretionary power to refuse increases in FTEs in over-doctored PCNs without good reason, and to refuse decreases in FTEs in under-doctored PCNs, until the PCN produced plans for replacements for GPs who were leaving.
There are about 1,250 PCNs in England now. Whether PCNs should take on responsibility for submitting to the central body, or submissions be sent via one of the 20 or so Integrated Care Boards (ICBs) is for discussion. Perhaps the submission should be made by the practice, via either the PCN or the ICS but not both. What data are supplied should not be prescribed by the central body. Obviously, however, these data should be based on weighted list sizes, including with deprivation adjustments.
The central body would decide whether to accept, decline with reasons, or defer for further data. The decision should be made within 7 days by the central body, which should comprise 5 or 7 members, including a lay chairman, and should be supported by a secretary and two deputies. The secretariat would be responsible for receiving submissions from PCNs by email and for sending them by email to members requesting a response within 48 hours. A majority of votes to accept, decline or defer would determine the case, with email exchanges between members, or online meetings if necessary.
There is a case for taking account of the contribution of other patient-facing staff, not only practice nurses and nurse practitioners but also including physiotherapists, phlebotomists, dispensers, paramedics etc. The impact of those Additional Roles Reimbursement Scheme staff was studied in the research published recently by the University of Cambridge, though the effects were harder to discern. There is an argument for limiting the central body’s task to the consideration of FTE number of GPs only, as is proposed here.
How GP trainees/registrars are counted is also for debate. They might be regarded as extra GPs or disregarded. The former is probably better and accords with the view of Health Education England (HEE). A different approach to the problem of inequitable distribution of doctors in training – more widely, not just for GPs – has been taken by HEE, which recognises that there is inequity in the distribution of the medical workforce. HEE says it seeks to ensure the training of the future medical specialty workforce aligns to corresponding areas of patient need and demographics. HEE recognises that where doctors are trained corresponds closely with where they settle in the long term.
The Medical Schools Council considers that where medical schools are located has broadly the same effect, and that is why the five new medical schools are sited where they are: Chelmsford, Lincoln, Sunderland, Ormskirk and Canterbury. They were created with the specific purpose of encouraging doctors – not just GPs – to train and remain in areas with medical workforce shortages. HEE’s changes in GP training mean that trainees now spend two of the three years within primary care settings, increasing the available GP workforce in any given area. As with the proposed central body, HEE’s policy weights for deprivation. Both systems aim to produce an equitable distribution of GPs, and there is no reason why they should not exist in parallel. And the Targeted Enhanced Recruitment Scheme for GP trainees has the same aims, as does the Office for Health Improvement and Disparities.
Conclusion
The central body would be subject to the direction of the Secretary of State, to a greater or lesser extent, to be determined in Regulations made under the yet to be enacted Health and Care Bill. The body might be called OFEDGE – Office for Equitable Distribution of GPs in England. Given the minimal staffing etc envisaged, OFEDGE would have running costs of less than £250,000 a year. The financial implications of OFEDGE’s work would be neutral, as the intended effect is to redistribute rather than increase the GP workforce. An increase would be the result of the Secretary of State’s initiatives.
The views expressed in this essay are entirely mine, following discussions with several interested parties. I was Secretary of the MPC from April 1981 to December 1983, and from May 1995 to October 1999.
John Gooderham is a former civil servant at DHSS, where he worked from 1971 to 2004 before taking early retirement. Among the fourteen posts he held, two were spells as Secretary and Chief Executive Officer at the Medical Practices for England and Wales, from 1981 to 1983 and from 1995 to 1999. The MPC was an executive non-departmental public body that was abolished in 2001. Married with three daughters and seven grandchildren, John’s only paid employment now is as a school lollipop lady. Since 2004, he has been heavily involved in NHS patient and public activities, being a member of many local, regional, and national groups.. He is currently a Cancer Champion at the Surrey and Sussex Cancer Alliance and a Vaccination Champion at the Sussex Health and Care Partnership. He is a volunteer NHS Responder, and a volunteer driver for Billingshurst Community Transport, mainly taking patients to hospitals.”
