Worsening GP shortages in disadvantaged areas likely to widen health inequalities

In a study published today in the BJGP Open, a team from the University of Cambridge looked at the relationship between shortages in the healthcare workforce and levels of deprivation. The team found significantly fewer full time equivalent (FTE) GPs per 10,000 patients in practices within areas of higher levels of deprivation. This inequality has widened slightly over time. By December 2020, there were on average 1.4 fewer FTE GPs per 10,000 patients in the most deprived areas compared to the least deprived areas.

The same was the case for total direct patient care staff (all patient-facing general practice staff excluding GPs and nurses), with 1.5 fewer FTE staff per 10,000 patients in the most deprived areas compared to the least deprived areas.

The lower GP numbers in deprived areas, was compensated, in part, by more nurses.

The analysis used data captured between September 2015 and December 2020 from the NHS Digital General Practice Workforce collection. They compared this workforce data against practice population sizes and levels of deprivation across England.

In addition to their report, the team have today launched an interactive dashboard that maps local-level primary care workforce inequalities to accompany the national-level analysis done in the paper. Clear local-level inequalities in GP distribution can be seen within West, North and East Cumbria, Humber, Coast and Vale, and Coventry and Warwickshire STP (Sustainability and Transformation Plan) areas, among others. 

Workforce shortages, especially in primary care, have been a problem for health care systems for some time now, and the gap between the growing demand for services and sufficient staff has been widening. Although the number of consultations in general practice has been increasing, staff numbers have not kept up with demand. The number of GPs relative to the size of population has been decreasing since 2009, and the GP workforce is ageing. Doctors are increasingly working part-time, which suggests that shortages will grow steadily worse.

In 2015, then-Secretary of State for Health Jeremy Hunt promised an additional 5,000 GPs for the NHS by 2020, but this was not achieved. Instead, it is predicted that there will be a shortage of 7,000 GPs by 2024.

Dr John Ford from the Department of Public Health and Primary Care at the University of Cambridge, the study’s senior author, said: “People who live in disadvantaged regions of England are not only more likely to have long-term health problems, but are likely to find it even more difficult to see a GP and experience worse care when they see a GP. This is just one aspect of how disadvantage accumulates for some people leading to poor health and early death.

“There may be some compensation due to increasing number of other health professionals, which may partially alleviate the undersupply of GPs in more socioeconomically disadvantaged areas. But this is not a like-for-like replacement and it is unlikely to be enough.”

The researchers say there are a number of reasons that may account for why GP workforce shortages disproportionately affect practices in areas of higher deprivation. Previous studies have suggested that the primary driver of GP inequality was the opening and closing of practices in more disadvantaged areas, with practice closures increasing in recent years.

Claire Nussbaum, the study’s first author, added: “The government has made reducing health inequalities a core commitment, but this will be challenging with the increasing shortage of GPs in areas of high socioeconomic disadvantage, where health needs are greatest. The primary care staffing inequalities we observed are especially concerning, as they suggest that access to care is becoming increasingly limited where health needs are greatest.

“Addressing barriers to health care access is even more urgent in the context of COVID-19, which has widened pre-existing health and social inequities.”

The researchers say that the imbalance in recruitment of staff within primary care must be addressed by policymakers, who will need to consider why practices and networks in disadvantaged areas are relatively under-staffed, and how this can be reversed. Potential options include increased recruitment to medical school from disadvantaged areas, incentivisation of direct patient care posts in under-staffed areas, enhanced training offers for these roles, and offering practices and networks in under-staffed areas additional recruitment support.

Expanded use of additional roles under the Additional Roles Reimbursement Scheme, designed to provide financial reimbursement for Primary Care Networks to build workforce capacity, may partially alleviate GP workload in overstretched practices, but the report’s authors argue that there is a risk that additional workforce will gravitate to more affluent areas, further perpetuating inequity in primary care staffing.

Dr James Matheson, a GP at Hill Top Surgery in Oldham, said: "People living in socioeconomically disadvantaged areas shoulder a much higher burden of physical and mental health problems but have less access to the GPs who could support them towards better health. For the primary care teams looking after them this means a greater workload with fewer resources - a burnout risk which can further exacerbate the problem.

“General Practice in disadvantaged areas is challenging but also enjoyable and professionally rewarding but now, more than ever, we need to see a more equitable distribution of workforce and resources to ensure it is sustainable."

Reference
Nussbaum, C et al. Inequalities in the distribution of the general practice workforce in England. BJGP Open; 18 Aug 2021; DOI: 10.3399/BJGPO.2021.0066