a review of general practitioner recruitment and retention

A REVIEW OF

GENERAL PRACTITIONER

RECRUITMENT AND RETENTION

IN WALES

Dr Jane Harrison

September 2003

Department of Postgraduate Education for General PracticeSchool of Postgraduate Medical and Dental Education

University of Wales College of Medicine

For the All Wales Non-Principal Network Team

Acknowledgements

Many have contributed to this review and I am most grateful for their expertise andguidance. I would like to express special thanks to Dr Malcolm Lewis and Dr David Woodfor their advice in planning The Way Forward Symposium and to all the delegates whoseopinions provided the foundation for this work. I am indebted to Dr David Bailey, DrAndrew Dearden, Dr Annie Delahunty, Professor David Haslam, Dr Mike Jeffries, DrBryn John, Dr Kay Saunders and Professor Tim van Zwanenberg who all gave sogenerously of their time, experience and knowledge during the drafting of this report.

Foreword

For several years there has been a shortage of GPs working in Wales.1 This deficiency has resulted inincreased pressure on Primary Care and the remaining GP workforce is increasingly overburdened anddemoralised2. As a result, General Practice has become a less attractive career option for newlyqualified doctors and senior GPs are retiring earlier3.

Adequate capacity within the Primary Care workforce is essential to the provision of high quality carefor the people of Wales. The aims of this report are to provide an objective and comprehensive reviewof the issues impinging on the current workforce, to offer prioritised solutions to resolve the difficultiesand to inform future policy decisions affecting workforce planning.

The review augments the findings of the ‘Way Forward Symposium’4, hosted by the All Wales Non-Principal Network* in February 2003, when representatives of the Welsh Assembly Government, themedical profession and NHS management met to share current initiatives to remedy GP shortages andto discuss other measures to address the recruitment and retention difficulties. The resulting proposalswere innovative, multifaceted, and acknowledged the complexity of the issues under discussion. Theywere documented for circulation to the stakeholders whose feedback and further ideas have beenincluded in this report, together with those of other colleagues who have shared their insights into therecruitment crisis.

The Review of Health and Social Care in Wales (the Wanless Report, June 20035) examined howresources should be translated into reform and improved performance. A high proportion of therecommendations in that report impinge on the issues of recruitment and retention within the NHSWales workforce, and those relating to Primary Care have been incorporated into this document. It isencouraging to find many similarities in proposals arising from ’The Way Forward’ and the WanlessReport: this reflects the determination of those working for NHS Wales to find practical, lastingsolutions to the present difficulties.

I am most grateful for the time, interest and experience of all those contributing to the consultationphase, and particularly to my colleagues in the All Wales Non-Principal Network Team for their inputand involvement.

* The All Wales Non-Principal Network is an organisation set up to provide education and supportfor Non-Principal GPs (now known as Freelance GPs) working in Wales

Contents

Page

Introduction 5

The Wanless Report 6

Solutions to increase capacity within 2 years 7

Priorities for increasing capacity within 2 years 13

Solutions to increase capacity within 5 years 14

Priorities to increase capacity within 5 years 17

Longer term strategies and policy development 18

Conclusion 19

Appendix 1 : Bibliography 20

Appendix 2 : Glossary of abbreviations 25

Appendix 3 : Current pressures underlying GP workforce shortages in Wales 26

Appendix 4 : Future pressures on GP workforce in Wales 28

Appendix 5 : Proposals for increasing Primary Care capacity 29

Appendix 6 : Report for the All-Wales Manpower Planning Advisory Group 34

A Review of General Practitioner Recruitment and Retention in Wales 5

Introduction

There is an urgent need to remedy the current severe shortage of GPs in Wales. Without early effectiveintervention, the increasing burden on those remaining is likely to drive many of them into earlyretirement or resignation, further exacerbating the shortages and risking breakdown of Primary Careservices in some areas of Wales. The resultant burden on Accident and Emergency departments andother hospital services would have severe consequences for patients living in these regions6.

Solutions to the shortage must, where possible, be based on evidence from the collective experience ofsenior NHS professionals or from research. We cannot afford to waste valuable time and resources onactions that do not produce significant benefits to the Primary Care workforce. Solutions proposedbelow are therefore evidence-based wherever feasible.

The influences which have resulted in a depleted workforce, as listed in Appendix 1, are many andvaried, and in addressing the problem it is essential to understand the complexity of the task ahead.There is no single solution to the current crisis - rather the remedies will need to be multifaceted,incorporating innovation and additional resources in geographical areas with severe staffing difficulties.This report proposes methods to:

o increase actual GP numberso increase numbers of substantive GP posts heldo increase efficiency of the Primary Care workforceo reduce inappropriate workload of GPs

Potential solutions have been prioritised and differentiated into those having beneficial effects within 2years or within 5 years, in order to assist implementation. It is essential that the foundations for longer-term actions and policies are laid down as soon as possible to counter future influences which willdeplete GP numbers.

Successful management of change is dependent on involvement and support of the clinical teamsinvolved, equipping them with the understanding and skills required for transition to new ways ofworking7. Effective leadership and team-building are essential to implement the changes which willlead to the desired results. Workforce planning must be robust and long-term8, based on a system usingsophisticated data collection tools which incorporate all potential influences on capacity within PrimaryCare9.

It is not within the remit of this report to estimate the financial and manpower resources required toremedy the current workforce deficit. However, the report for the All Wales Manpower PlanningAdvisory Group (Appendix 3), submitted in December 2002, predicts the increases in GP numbers thatare necessary to ensure high quality Primary Care services.

The Wanless Report highlights the need for clear, evidence-based and costed strategies that result inbalanced health-care provision operating in a ‘whole systems’ way10. We are optimistic that the NHSWales of the future can provide first class Primary Care services, but this can only be achieved withadequate capacity of a skilled and motivated workforce, working in high quality premises with access tofirst rate information systems.


The Wanless Report

The findings of this report, published in June 2003, include the following:

1. The health of people in Wales is relatively poor compared with the rest of Europe and unhealthylifestyles contribute to increased morbidity and demand on the health and social services.

2. In the most deprived areas of Wales, where health needs are greatest, statistics show that GP listsizes are largest, numbers of female GPs are lowest and the numbers of GPs who are single-handed or planning to retire soon are highest.

3. Current service provision places an insupportable burden on the acute sector and its workforce,requiring a rebalancing of the system to meet need earlier in the care pathway.

4. Between 1996 and 2002, Primary Care’s share of primary and secondary funding barelychanged, despite several policy documents stating a commitment to a preventative, PrimaryCare-led NHS.

5. Workforce planning and service planning often operate under very different timescales. Newservice initiatives have shorter targets, whereas workforce planning requires longer timescalesfor education and training of staff.

6. There is a need to develop capacity – workforce, skills, and infrastructure – within non-acutesettings to create new service models. The Primary Care sector requires considerabledevelopment to take on this enhanced role.

7. A central question is how to support the right balances of health and social care, primary andsecondary sectors, treatment and prevention/promotion. Experience has shown that new servicemodels are best achieved by clear strategic direction, linked to dedicated resources.

8. Integrated thinking across social care and health services, with organisations operating in a‘whole systems’ way, is required in order to develop the best possible local solutions for thedelivery of health care.

9. Investment should be focused on delivering patient care in the most resource-effective way.

10. Good policy-making is based on robust evidence and sound costing, subject to rigorousevaluation criteria to inform subsequent policy development.

It is encouraging to note that the Secretary for Health and Social Services has broadlywelcomed the Wanless report and, in particular, has stressed that the future workforce planningprocess will be based on actual identified need rather than affordability criterion as used in thepast11.


Solutions to increase capacity within 2 years

1. Workforce Planning

1.1 This needs to be of the highest quality and ensure an appropriate balance of resources betweenlocalities12. All current and predicted influences must be taken into account, including morbidity,increasing numbers of GPs wishing to work part-time, attendance patterns and cultural influences.

1.2 Only by the use of sophisticated electronic data collection tools, such as those cited in theElectronic Staff Records project13, can workforce planning be responsive to the health care needs ofthe population. Information on numbers of GPs working, whole time equivalents (WTEs), types ofpost held, vacancy figures and numbers of GPs offering additional and enhanced clinical serviceswill need to be incorporated. Workforce planning and service planning need to operate within thesame timescales to ensure that staffing requirements are adequate for new initiatives14.

1.3 Innovative workforce planning is required in areas with particular recruitment difficultiesthrough the development of local schemes and partnerships between the public, Primary Care staffand Local Health Boards (LHBs)15, 16.

1.4 There are considerable differences in the ability of local areas to match demand and supply in theGP labour market across the UK16. The workforce potential in Wales could be improved by readyaccess to data that indicates both the availability of Freelance GPs and the specific staffingrequirements of practices, perhaps utilising a local co-ordinator or national agency in a matchingprocess.

2. Education and Training

2.1 The initiatives set up by the University of Wales College of Medicine (UWCM) PostgraduateDepartment for General Practice17, with extended and higher training posts for undergraduates andpostgraduates respectively, have been successful in providing the skills required in Primary Care.They should therefore be extended to assist in the retention of GPs training in Wales and to attractGPs from outside Wales.

2.2 Flexible training options, recently introduced for hospital training posts, must be made availablefor Primary Care training posts to enable future GPs to benefit from these initiatives18,19..

2.3 There is a need to re-establish and fund both medical school placements and vocational trainingschemes in rural and deprived areas, providing valuable experience to new generations of GPs andextending the opportunities for trainers in these localities20, 27.

2.4 The Retainer Scheme in Wales21 has been very successful in supporting and retaining GPs whocombine general practice with raising a family or other working commitments. A Flexible CareerScheme (see 6.4), offering educational support and flexibility around the number of sessionsworked, would further enhance the workforce potential within this group of doctors. Ensuring thatall the schemes are well-advertised and easily accessible, with fair terms and conditions of service,is imperative.

2.5 A proactive approach to identify doctors who are not currently working is required, providingthem with information about job, education and financial opportunities in Primary Care. Returning


doctors need support and training in skills to secure jobs22, in addition to refreshing their clinicalacumen, and their requirements for regaining skills and confidence must be identified and addressed.

2.6 An appraisal system which is inclusive of all GPs working in Wales has been developed by theDepartment of Postgraduate Education for General Practice, UWCM, with funding from the WelshAssembly Government. The provision of both protected learning time and resources for ContinuingProfessional Development (CPD) is important for recruitment and retention, especially in rural anddeprived areas. Protected Learning Time Schemes for Primary Care, such as the PT4L schemedeveloped in Neath Port Talbot23, have been successful in improving the quality of patient care inaddition to increasing job satisfaction and should be extended throughout Wales.

2.7 It has been shown that GPs who are given support and education locally are more likely to remainin the vicinity24, and therefore these resources must be readily accessible to doctors from thecompletion of their vocational training schemes.

2.8 Senior GPs are an essential part of the workforce, with expertise that must be utilised to the full.In the short-term, particularly, their experience and efficiency in patient management are invaluablein the maintenance of adequate workforce capacity. Support should be available for managing changeand to ensure that appraisal/revalidation processes are positive and non-threatening experiences.

2.9 Research into the retirement intentions of GPs25 indicates that job satisfaction is an importantfactor in deciding when to leave general practice. In the longer term, therefore, opportunities todevelop new skills including those required for leadership and management, with less ‘front-line’work, may encourage GPs to defer retirement.

2.10 In the drive to retain the current Primary Care workforce, it is imperative that LHBs fulfil theirresponsibilities to support local GPs, providing the appropriate guidance, training and financialbacking to enable practices to develop high quality patient services. Understaffed practices are inparticular need of support.

3. Innovation and Research

3.1 The Innovations in Care Team within the Welsh Assembly is responsible for promoting thesharing of best practice at all levels of service development26 to ensure that high quality care isoffered to all patients throughout Wales. A range of models of service provision by LHBs acrossWales would enable health care to be tailored to local requirements.

3.2 Involving GPs in the planning and implementation of local schemes, such as the development ofsalaried post schemes in the Rhondda and Gwent Valley27, have been reported to promote ownershipand commitment to initiatives. As a result, it is likely that more doctors will apply for substantiveposts in practices in these areas.

3.3 The use of skill-mix, based on sound research into transferable skills and cost-effectiveness 28, 29,is critical to achieving adequate capacity within Primary Care30. However, the shortage of practicenurses imposes restrictions on the development of such schemes31. An extended role for communitypharmacists is currently being explored32.

3.4 When setting up new initiatives within Primary Care, it is essential not to lose sight of theparticular expertise of the general practitioner. The clinical skills of the GP are adapted to theundifferentiated nature of the problems presented in primary care, the clinical probabilities and


dangers that arise, the low technology setting, and the potential for using time as a diagnostic tool33.These skills must be valued, respected and put to the best possible use in all future developmentswithin Primary Care in Wales.

3.5 Developing alternative care pathways to acute hospital admission will be imperative to relievepressure on the acute sector6. Methods to reduce waiting times for secondary services, perhapsutilising resources outside Wales in the short-term, must be explored. It is vital, however, that noneof these methods should place further strain on the Primary Care system. Any transfer of workloadmust be planned, resourced and supported with new staff.

4. New Contract Initiatives

4.1 On the whole, the benefits to the Primary Care workforce resulting from the negotiations for theNew Contract are anticipated to result in some increased capacity in Primary Care by providing amore flexible and attractive career for GPs34, but these improvements will only become manifest inthe longer term.

4.2 Research into the career aspirations of young GPs highlight a desire for choice and flexibilitywithin a GP career structure35, 36 and the new funding streams will promote a range of GP posts.

4.3 It is anticipated that the removal of out-of-hours (OOH) responsibilities from General MedicalServices (GMS)37 will assist in recruiting and retaining GPs within the profession. GPs will still begiven the option of working OOH and the system will provide further opportunities for flexibleworking. It is essential that LHBs set up and implement OOH schemes well before the date set in thenew contract38.

4.4 Many senior GPs are now choosing to take early retirement and a reversal of this trend isessential if there are to be sufficient numbers of GPs in the very near future. Research has revealedthat reduced hours, phased retirement through part-time working, a reduced administrative role andimproved managerial support might encourage later retirement, as would protection of earnings andpension rights if duties or hours changed3. The New Contract will allow senior GPs to take upflexible working in clinical, managerial and educational posts without a reduction in hours adverselyaffecting their pensions39, 40. Funded sabbaticals offer opportunities to explore Primary Care interestsin protected time41 and may provide the incentive to defer retirement.

4.5 Research looking into the factors which might encourage later retirement among GPs citedworkload as a key issue to be targeted2, 3. The new GP contract will assist GPs in controlling theirworkload by having the ability to say ‘no’ to unfunded work or to work that they do not have thecapacity to undertake safely.

4.6 The Wanless Report highlights the urgent need for a unified approach across the medicalprofession to demand management, with a drive to educate the public about their responsibilities inaccessing health care42. The media and other forms of communication could be more effectively usedto inform and motivate the public about health issues, including the promotion of healthy living.NHS Direct has a key role in educating the public about self-help and the appropriate use of services,so reducing demand and dependency on the health services.


5. Financial Incentives

5.1 These will play an important function in the recruitment and retention of GPs in the near future.Financial packages need to reflect the value of doctors in NHS Wales, and setting the right level ofincentive is critical to their success.

5.2 Methods of attracting GPs to work in Wales should include a weighting allowance,acknowledging the increased workload arising from higher rates of morbidity and consultationcompared to the UK average43, and it is hoped that the new contract allocation formula will besufficiently robust to reflect this.

5.3 Pilot schemes carried out in areas with recruitment and retention difficulties, such as in theRhondda Valley, have shown that financial and educational incentives are successful in attractingdoctors onto salaried schemes. Secondments of experienced GPs would be beneficial in these areasas the clinical and management problems are often complex but, to date, the financial incentives havebeen insufficient to attract senior GPs onto the current scheme. Targeting additional funding to LHBswith understaffed Primary Health Care Teams would enable them to develop schemes particularlysuited to their patient populations.

5.4 ‘Golden Hellos’ to encourage newly qualified GPs to take up substantive posts in Wales44 havehad limited success and should be increased to have a significant impact on the workforce. Thereshould be flexibility around the financial incentives offered to those on the Retainer and ReturnerSchemes, and a future Flexible Career Scheme, to encourage more GPs to maximise their workingpotential.

5.5 The financial packages offered to senior GPs to discourage early retirement45 have also beeninsufficient to have an impact on numbers leaving the profession. A significant increase in theincentives would assist in retaining this group of doctors, who are vital to maintain Primary Carecapacity. Recent research2, carried out as part of the New GP Contract negotiations regardingretention initiatives, indicates that GPs over 60 years old would be willing to work for an average 1.9years longer in service with additional £15,000 payment per annum.

5.6 Financial incentives to improve performance, eg by providing extra funding for servicedevelopments within LHBs, could be introduced to encourage innovation and good practice.

6. Policy developments

6.1 There is an urgent need for nationwide implementation of the WAG policy to deal with violentpatients, to promote primary care staff safety, avoid the loss of GP time from injury and/or stress andto retain GPs in the workforce46. Measures should be taken to ensure that all areas of Wales haveadequate systems in place to protect their Primary Care staff47.

6.2 A ‘rescue’ service for Primary Care is currently being set up as part of a comprehensiveOccupational Health Service48, providing counselling and direct referral paths for all GPs, dentists,pharmacists and optometrists in Wales. This service is long overdue and is vital to the health andwell-being of these key professionals, who are known to be slow to acknowledge and seek help forstress and other problems49. A generic Occupational Health Service, underpinned by principles ofhealth promotion and training, is essential if we are to have a healthy and motivated workforce withadequate capacity.


6.3 The practicalities and financial costs of childcare provision are preventing a substantialproportion of the NHS Wales workforce from maximising their working potential50, particularlyfemales who now represent more than 50% of GPs in training51. Offering childcare vouchers linkedto GP posts would be an incentive to return to work or to increase working hours by reducingfinancial losses, and could be introduced speedily, but is dependant on sufficient capacity in the localchild care services.

6.4 A Flexible Career Scheme52 for Wales, tailored to meet our workforce needs53, would assistdoctors in maintaining a work/life balance35. It would be helpful to publish a guide to flexibleworking within Primary Care in Wales, providing information on the variety of posts andopportunities available for different ways of working.

6.5 There is at present a loss of Freelance GPs working in border regions because of differences inSupplementary List criteria54 for England and Wales, and because of the necessity to duplicatesubmissions if working in both countries. Setting up a fast-track system and standardising entrycriteria for lists would remedy this situation.

6.6 The WAG policies for international recruitment are based on the Department of Health’s Code ofPractice55 that aims to discourage inappropriate practices which would be harmful to other countries’healthcare systems.

6.7 There is a need for a Director of Primary Care to be appointed within the WAG Directorate, witha role equivalent to that of the directors of Public Health, Mental Health and Paediatrics. Theappointment would provide a ‘voice’ for all Primary Care staff and secure recognition for the art ofPrimary Care at government level56.

6.8 Managerial involvement and administration arising from new and current policies should be keptto a minimum, to ensure that the skills of those working in Primary Care can be put to the bestpossible use.

7. Information systems

7.1 The ICT Foundation Programme for General Medical Practices57 was established with Assemblyfunding, and the Wanless report cites the need for urgent investment to develop an integrated ICTsystem across NHS Wales58. High quality ICT is invaluable in enabling health care workers to keepup-to-date and communicate effectively across primary, secondary and tertiary sectors59.

7.2 It is essential that the information underpinning decision-making within NHS Wales is evidence-based and that best practice is disseminated to raise standards of care nationwide.

7.3 It is important to keep bureaucracy and paperwork for GPs to a minimum in order to increase theefficiency of Primary Care. Senior GPs cite the burdens of administration and inappropriate non-medical work as factors underlying early retirement3, so these must be lifted to encourageexperienced GPs to continue working.

8. Guidelines

8.1 As waiting lists for Secondary Care have grown, so the workload of Primary Care hascorrespondingly increased. Clear guidance to differentiate responsibilities of Primary and SecondaryCare, with details of the consequences of waiting lists on Primary Care resources, would support GPswho are currently forced to take clinical responsibility for patients awaiting appointments and


treatment in the Secondary sector. Shifts in prescribing from Secondary to Primary Care withoutadequate planning or funding, are unacceptable and guidelines should clarify where the responsibilityfor specific treatments lies.

8.2 Primary Care is overburdened with lengthy NSFs, guidelines and protocols. It is important thatthey are rationalised to aid the provision of adequate funding, avoid duplication, be written in a user-friendly style and that content is kept to a minimum.

8.3 Resources should be re-directed towards treatments which are proven to be cost-effective andaway from relatively unproductive care60.

8.4 It would be helpful to share best practice in reducing the workload within Primary Care by theuse of guidelines to outline systems which operate efficiently.

8.5 Welsh Assembly guidelines for patients in the appropriate use of health services would, if widelypublicised, assist in reducing inappropriate demand on NHS Wales’s resources.


Priorities for increasing capacity within 2 Years

Initiatives to retain doctors within the Primary Care workforce are essential to ensuring adequate capacityin the short-term.

1. Increase financial incentives to recruit and retain (5.1-5.6)

2. Introduce Flexible Career Scheme (6.4)

3. Increase career opportunities for senior GPs, with reduced workload pressures (4.4-4.5)

4. Identify potential GP Returners; extend the Returner and Retainer Schemes (2.4-2.5)

5. Introduce childcare vouchers linked to jobs within Primary Care (6.3)

6. Increase numbers of extended and higher GP training posts (2.1)

7. LHBs to set up and implement OOH services well before the date set by the new contract (4.3)

8. Reduce administration and inappropriate non-medical work (7.3)

9. Utilise skill-mix, ensuring initiatives are evidence-based and cost-effective (3.3)

10. Reduce burden on Primary Care from Secondary Care deficiencies (8.1)

11. Implement effective system to cope with violent patients across Wales (6.1)

12. Innovation in finding alternative care pathways to acute admissions (3.5)

13. Introduce properly evaluated Protected Time for Learning Schemes nationwide (2.6)

14. Sustained and comprehensive education on patient responsibility (4.6, 8.5)

15. Introduce Wales weighting allowance (5.2)

16. Support and fund local LHB schemes to address problems of understaffing (2.10, 5.6)

17. Fast-track and standardise Supplementary List submissions in border regions (6.5)

18. Fund effective Occupational Health rescue service (6.2)

19. Rationalise clinical guidelines (8.1-8.3)

20. Develop systems for sharing best practice (3.1)

21. High quality workforce planning systems (1.1- 1.4)


Solutions to increase capacity within 5 years

9. Workforce planning

9.1 A significant increase in numbers of doctors and nurses is needed to ensure adequate capacitywithin Primary Care61, with opportunities for part-time and portfolio working in jobs with flexibilityand variety62, 63. In addition, the public call for a wider range of care options and increasedinvolvement in management choices requires a remodelled health service 64, 65.

9.2 The increasing complexity of patient management, with multiple pathologies and a highincidence of social problems66 compounded by earlier Secondary Care discharges, requires longerconsultation times and sufficient Primary Care staff if patients are to receive high quality care.

10. Education and training

10.1 The drive to recruit more doctors must start by providing school pupils and teachers withcomprehensive information about careers in medicine and allied disciplines, including options andguidance about jobs in NHS Wales.

10.2 Selection criteria for medical programmes need to ensure that students have the qualitiesnecessary for working in Primary Care. Recent increases in the number of medical students will haveimplications for capacity within postgraduate training schemes from 2004, when graduate numberswill rise substantially.. Undergraduate and graduate programmes designed to meet the needs of futureGPs are essential, with promotion of job opportunities and adequate practical experience of workingin General Practice during training67, 68.

10.3 Vocational Training Schemes also need proportionately more doctors in training, withprogrammes designed to select and train GPs who are ‘fit for purpose’ in addition to meeting theneed for flexible training options. A reform of current SHO posts incorporated into VTS is underwayto ensure that these jobs are appropriate for the training needs of future GPs69.

10.4 Research has shown that medical school and VTS placements that provide experience ofworking in rural and deprived areas assist in attracting doctors to work in such areas later in theircareers70. ‘Bonded placement’ schemes, linking training posts in hard-to-recruit areas with financialassistance, would combine incentives to work in under-doctored areas with opportunities to broadenPrimary Care experience.

10.5 Staff working in rural regions of Wales can become isolated and require accessible educationalcentres to provide support and training. Adequate cover for education, specialised work and annualleave in remote or deprived areas is essential in the drive to recruit in these areas. The Institute ofRural Health has been active in addressing the particular difficulties of providing high-quality,accessible education in rural areas of mid-Wales71; support and funding for such initiatives wouldassist in retaining and attracting GPs to work in rural Wales.

10.6 A high standard of practice premises, providing a pleasant, professional environment andadequate equipment, has important implications in the training of all primary care staff.

11. Innovation and research


11.1 Innovation in the marketing and promotion of General Practice in Wales would assistrecruitment, eg by publishing a guide to GP job opportunities in Wales. The Welsh Tourist Board iswell-placed to promote NHS Wales and the many benefits of living and working in Wales.

11.2 Solutions to the problems of recruitment and retention in Primary Care can be facilitated by amulti-professional approach to the provision of patient services, with a variety of models beingdeveloped to suit local needs. Areas with unique difficulties, eg border regions, need particularattention and resources to develop workable remedies to problems of understaffing.

11.3 Promoting new ways of working within Primary Care teams, developing innovative methods ofdelivering patient-centred care and finding alternatives to acute hospital admissions are key to thesuccess with which NHS Wales will cope with demand1, 30. It is imperative, as the recent WanlessReport confirms, that any new Primary Care services are adequately funded, and this includes allIntermediate Care services72.

12. New Contract Initiatives73

12.1 The New Contract will, in the long term, address some issues underlying the recruitment andretention problems in General Practice. Global sum funding will enable Primary Care Teams to workin innovative ways; flexible pension arrangements will provide incentives to defer retirement; therequirement to cover OOH has been removed; quality work will be rewarded; there will be choicearound the services GPs offer their patients.

12.2 The urgency to increase capacity introduces complexity into measures designed to attractdoctors into Primary Care. Research indicates that some GPs would welcome opportunities tospecialise within a clinical area alongside the provision of GMS, and posts are being developed tothis end74. However, with Primary Care capacity at such critical levels, it is important that we do not,in the immediate short-term, lose significant numbers of GP working hours to specialised orintermediate care work traditionally managed by the Secondary sector75.

13. Policy developments

13.1 The provision of accessible and funded childcare facilities for Primary Care staff wouldincrease the workforce potential63 by encouraging Returners back into the workforce and byincreasing the number of sessions worked by part-timers.

13.2 It is essential that a robust Generic Occupational Health Service is developed to support GPsunder pressure from work or illness76. The ‘Rescue Service’48 will be implemented in the near future,but it is vitally important that the other two components of the service are made available to all NHSWales workers within 5 years.

13.3 Stress and time lost through complaints and medico-legal claims are costly to the Primary Careworkforce and improvements are long overdue:a) Vexatious complaints incur a considerable drain on doctors’ time, energy and job satisfaction in

addition to wasting valuable NHS financial resources, with no penalties for patients to preventfurther similar damaging actions77. Methods to deter vexatious complainants are required and theLaw Society should be informed of solicitors who bring to court prima facie cases of no merit.

b) ‘Trials by media’ prior to court cases can irreparably damage a GP’s reputation and generatefurther complaints, highlighting the need for anonymity unless there is a conviction as a result ofcourt action.


c) Proposals to reform the clinical negligence processes in Secondary Care through the NHSRedress Scheme78, offering ‘no-fault’ compensation to patients and protecting clinicians whoreport adverse incidents from disciplinary action, currently exclude GPs. Although it is unclearexactly how the scheme might work for GPs, as defence organisations rather than the NHSLitigation Authority handle claims against GPs, this should not deprive GPs of similar benefitswhich could be incorporated into defence body schemes.

14. Estates

14.1 Significant investment in premises throughout Wales is essential to enable Primary Care teams toprovide good patient care79. Research in Rhondda Cynon Taff has provided valuable insight into the currentproblems and funding required to develop primary care premises capable of delivering strategic change andcontributing to overall service performance. The success of Primary Care Resource Centres highlights theimportance of integrated estates planning and health care service provision, with adequate numbers of trainedstaff employed, and provides a model for future development across Wales.

14.2 A national strategy to promote the effective strategic planning and management of premises,with training available for LHB staff, would assist in achieving and maintaining the requiredstandards of estates across NHS Wales80, 81.

14.3 Surveys have indicated that the financial commitment required to buy-in to practice premises isa deterrent to young doctors entering General Practice 36, 82. In addition, GPs are becomingincreasingly reluctant to take on the longer-term legal and financial commitments associated withpremises provision, particularly in areas of deprivation where property market growth is limited.LHBs should encourage diversity of ownership and management of premises within their localities,along with guidance and support to GPs. Protection from negative equity would further encourageinvestment in premises. The new flexibilities within the new GP contract73 will greatly help with this,if they are appropriately funded.

15. Demand management

15.1 Health Education should be given much greater prominence in the curriculum at Primary andSecondary school levels. It should incorporate health promotion, self-help remedies and theappropriate use of NHS resources, so that the public are educated at an early age about theresponsible use of the Health Service83.

15.2 Research is needed into the relative success of methods in raising public awareness andunderstanding of health promotion and disease prevention, so that resources can be targetedeffectively84.

15.3 Inappropriate non-medical work must be re-directed away from General Practice to reduce theworkload and promote more efficient use of the Primary Care workforce. Careful analysis of thoseGP skills which are most effectively and efficiently used in patient care would identify those whichcould be transferred to other Primary Care workers. Areas of management requiring skills which canonly be acquired through in-depth medical training and from experience in managing complexity arecritical to the role of ‘risk manager’, and should remain the responsibility of the GP. Howeverstraightforward measurements and recording, along with other administrative work, are skills whichcould more safely be transferred to other practice team members to reduce the excessive workloadcurrently burdening GPs83, 33.


Priorities to increase capacity within 5 Years

1. Increase numbers of doctors and nurses in training (9.1)

2. Fund nationwide investment in premises alongside health service development (14.1)

3. Develop national strategy for promoting effective management of premises, with LHBtraining (14.2)

4. Design training programmes to ensure adequate numbers of GPs ‘fit for purpose’(10.2-10.3)

5. Extend training placements to include experience in rural and deprived areas (10.4)

6. Set up access to childcare facilities for Primary Care staff (13.1)

7. Implement robust Generic Occupational Health Service (13.2)

8. Continue patient responsibility campaign and improve health education within schools toeducate about self-help and use of resources (15.1)

9. Develop posts for GPs with Special Interests (12.2)

10. Review of complaint and medico-legal systems for Primary Care (13.3)

11. Innovative marketing of working in General Practice in Wales (11.1)

12. Promote careers within NHS Wales in schools (10.1)


Longer Term Strategies and Policy Development

Wanless Report recommendations

� Provide opportunities for full involvement of patients and the public in decision-making aboutfuture service provision.

� Policies for commissioning and delivering services should be based on clear principles and onpublished evidence of benefits, including costings and evaluation criteria.

� Developing innovative and flexible training is essential to produce sufficient staff for the futureneeds of NHS Wales.

� Incentives to improve performance are of critical importance to stimulate best practicedevelopment and dissemination.

� Services should focus on prevention and early intervention in patient care, so reducing costs andimproving quality of life.

� Develop robust disease management services in Primary Care settings.

� Promote public health, including better diets and increased exercise.

� Whole system performance management across health and social care is essential to measureinputs, outputs and assessment of performance.

� Workforce planning needs to look 20 years ahead, with clear objectives and milestones. A strongcentral lead with sufficient resources is necessary for effective planning.

� Strategies should reward success through stronger incentives and sanctions, rather than fundingdeficits.

� Develop systems to share best practice in delivery of health care across Wales.


ConclusionThe strength and reserves of the Primary Care services and workforce of NHS Wales are critical to theprovision of a high quality Health Service for the people of Wales. In researching the issuessurrounding the current shortage of GPs, the complexities and urgency of the present difficulties havebecome evident. There is no simple solution to the problem – strategies to improve capacity will need toaddress the wide diversity of needs within the workforce using a variety of incentives andimprovements. It is essential that the remedies put in place are evidence-based and make a timely andsignificant impact on capacity, in addition to being cost-efficient.

Although the solutions have been differentiated into 2 and 5 year priorities, reflecting the anticipatedspeed of impact of the proposed measures, it is imperative that action is taken as soon as possible toimplement all improvements. This will ensure that those taking longer to have an impact on capacitywill have a sound foundation at an early stage, and be successful in bringing the anticipated benefits tothe workforce.

Notwithstanding the size and complexity of the task ahead, a number of initiatives have come togetherover the past few months which present a unique opportunity to address the workforce issue:

� The announcement by the Welsh Assembly Finance Minister in October 2002 of a substantialincrease in resources for health services in Wales.

� The new GP contract, accepted by the profession in June 2003, comes with national funding toimprove working conditions within Primary Care and to offer the financial incentives needed torecruit and retain GPs.

� The contract opens up job opportunities within General Practice which give variety andflexibility, providing doctors at all stages of their careers with unprecedented choice in the waythey work.

� The Wanless Report provides invaluable insight into improvements that are essential in NHSWales in order to provide a first-rate health care system in Wales.

� The Welsh Assembly Government has broadly welcomed the Wanless Report, and the Ministerfor Health and Social Services has promised that staff recruitment for NHS Wales will, in thefuture, be based on actual identified need rather than on affordability criterion.

� Commissioning this report for the All-Wales Medical and Dental Workforce DevelopmentExpert Advisory Group reflects the interest by the Welsh Assembly Government in the views ofthe medical profession on the recruitment and retention of GPs in Wales.

It is imperative that urgent action is taken and that improvements are maintained in order to gain fulladvantage from the current impetus for change. By so doing, Wales will become pre-eminent within theUK in building a Primary Care workforce that can meet the health demands of its population in theyears ahead.


APPENDIX 1BIBLIOGRAPHY

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40 Sligsby, C.(2002) Keeping you in general practice. Medeconomics, 23, 1.

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48 Delahunty, A. (2002) An occupational health service for general medical and dental practitioners andtheir staff in Wales: a discussion paper. Cardiff, Welsh Assembly Government.

49 Firth-Cozens, J. (2003) Doctors, their well-being and their stress. BMJ, 326, 670-1.

50 Sinden, N.J., Sheriff, J.M., Westmore, S.E.L., Greenfield, S.M. and Allan T.F. (2003) Patterns of child-bearing behaviour amongst female hospital doctors and GPs. Family Practice, 20, 486-8.


51 Department of Health. (2002) NHS workforce statistics 2001-2002. General and medical servicesEngland and Wales. London, Department of Health.

52 General Practitioners Committee. (2002) Briefing Paper – GP Returners’ Scheme and Flexible CareerScheme (England). London, British Medical Association.

53 Harrison, J. and Wilson, S. (2002) Survey of factors influencing working conditions of GPs working inWales. Presented at RCGP Wales Clinical Effectiveness Day, 04th Dec 2002. Cwrt Bleddyn, Usk.

54 British Medical Association.(2003) BMA response to consultation on supplementary list regulations forNon-Principal GPs. London, British Medical Association.

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68 Wilton, J. (2003) Pre-registration House Officers in general practice. Education for Primary Care, 14,288-92.

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75 Kernick, D. (2003) Developing intermediate care provided by general practitioners with a special interest:the economic perspective. British Journal of General Practice, 53, 553-6.

76 Firth-Cozens, J. (2001) Interventions to improve physicians’ well-being and patient care. Social Science& Medicine, 52, 215-22.

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78 Department of Health. (2003) Making amends: a consultation paper setting out proposals for reformingthe approach to clinical negligence in the NHS. London, Department of Health.

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80 Welsh Assembly Government. (2003) Guidance for the development of an integrated healthcare estatestrategy for primary care premises. WHC (2003) 017. Cardiff, Welsh Assembly Government.

81 Welsh Assembly Government. (2002) National estates strategic framework. Cardiff, Welsh AssemblyGovernment.

82 Godden, S., Pollock, A. and Player, S. (2001) Capital investment in primary care – the funding andownership of primary care premises. Public Money & Management, 21, 4, 43-9.

83 General Practitioners Committee. (2001) Response to the NHS Plan: valuing general practice. London,British Medical Association.

84 Wanless, D. (2002) Securing our future health: taking a long-term view. London, HM Treasury.


APPENDIX 2

Glossary of Abbreviations

CPD Continuing Professional DevelopmentFCS Flexible Career SchemeGMS General Medical ServicesGP General (Medical) PractitionerGPC General Practitioners CommitteeICT Information and Communication TechnologyIT Information TechnologyLHB Local Health BoardLHG Local Health GroupLMC Local Medical CommitteeMPC Medical Practices CommitteeNAFW National Assembly for WalesNHS National Health ServiceNSF National Service FrameworkOHS Occupational Health ServiceOOH Out-of-HoursUWCM University of Wales College of MedicineVTS Vocational Training SchemeWAG Welsh Assembly GovernmentWTE Whole Time Equivalent


APPENDIX 3

Current Pressures underlying GP workforce shortages in Wales

1. Increased workload

Increased administrative workGreater workload from medical advances and technologiesIncreasing numbers of patients, with more investigations and treatment provided by Primary CareIncreasing patient demand and expectations, with rise in consultation ratesMove towards longer consultation times to deal with management complexity and multiplepathologiesTime taken up by NSFs, targets, etcShifting of work from Secondary to Primary Care, through lengthening waiting lists, earlier dischargesand blurring of lines defining clinical responsibilities.Reduction in bed numbers pushing more work into communityShortage of other staff available to treat patients, eg occupational and speech therapists,physiotherapistsGreater demands for OOH care without backup of Secondary Care services, eg pathology, radiologyDemographic shift towards more elderly populationIncreasing expenses reducing income

2. Changes in ways of working

Increasing percentage of female GPs qualifyingChoice of part-time employment by both male and female GPsIncreasing unwillingness to take on OOH workChanges in the infrastructure of NHS Wales, with less integrated systemsInexperience and understaffing within LHBs leading to lack of proactive support for Primary CareTeamsReluctance to buy-in to premisesReluctance to become principals

3. Loss of GP time

Delay in taking up substantive GP posts after completing VTSGPs employed in LHB posts and other management rolesInvolvement of GPs in Secondary Care provision, eg special interest and intermediate care postsClinical Governance requirements, eg auditAppraisal & Revalidation – time taken as appraisers or for appraisal processTime off for illness/stressIncrease in numbers of training posts, with GP time needed for undergraduate / postgraduate teachingTime lost through coping with violent patientsMedico-legal procedures with lengthy reports and stress

4. Retirement

Earlier retirementHighest numbers of GPs nearing retirement in areas with greatest need


5. Rural or deprived areas

Isolation of staffPoor working conditionsHighest list sizesLowest numbers of female GPsHighest numbers of single-handed practicesHighest numbers of GPs nearing retirement

6. Inadequate Workforce Planning

Lack of accurate and consistent workforce planning dataInadequate workforce planning systems for Primary CareCurrent understaffing of Primary Care by GPs and Practice NursesIncreasing GP vacancies in practicesInsufficient GPs in training for current and future requirementsDifferent timescales for workforce planning and service planningIncreasing desire for treatment choice by patients

7. Loss of GPs from Wales

Moving across border – to rest of UK or abroadLeaving medicine for other careersLeaving GP for another medical specialityReluctance to return to GP workforce after career breakOversees doctors returning home


APPENDIX 4

Future Pressures on GP Workforce in Wales(Report for All Wales GP Manpower Advisory Group)

1. New contract, especially if workload-limiting elements.

2. Loss of the MPC.

3. LHBs’ future role in commissioning and providing.

4. Trusts in Wales have flexibility to increase wages of consultants to attract suitable staff to Wales.Although the common complaint is that these consultants will jump from Trust to Trust, they are stillworking within Wales.

5. The NAFW and Health Authorities have not had the same degree of flexibility in attracting new GPsin to Wales, as payments were nationally set and not subject to local flexibilities. In England PrimaryCare Trusts may, in the future, have the ability to attract GPs through salary incentives and in Walesthis may also be possible post-April 2004, when there is no ceiling on salaries for LHB-employedGPs.

6. The National Assembly for Wales, in collaboration with GPC Wales, has recently announcedrecruitment and retention initiatives throughout Wales. The general opinion of these in the GPcommunity is that the ideas are good, but that the funding is inadequate. The National Assembly forWales will therefore have to address the issues of inadequate funding and look to increase the amountof financial award available to improve both recruitment and retention in Wales.

7. European Working time directive on GP Registrars.

8. New proposals for three-stage death certification process, controlled drug checks and other post-Shipman measures.


APPENDIX 5

Proposals for Increasing Primary Care Capacity

1. Reduce workload

a) Demand management• Unified approach across the medical profession to demand management• Health Education in schools to include self-help remedies and appropriate use of NHS resources• Drive to educate the public about their responsibilities in accessing health care• NHS Direct to educate the public about self-help and appropriate use of services• Research and implement actions which successfully raise public awareness and understanding of

health promotion and disease prevention• Better use of the media and other communication to inform and motivate the public about health

issues

b) Bureaucracy• Administration to be reduced to a minimum; redirect inappropriate non-medical work• Draw up guidelines on methods of reducing workload within Primary Care for PHC teams

c) Clinical work• NSFs, guidelines and protocols to be rationalised to user-friendly, time-efficient documents• Clear guidelines on patient management responsibilities of Primary and Secondary Care, with

detail on consequences of Secondary Care prescribing and waiting lists on Primary Care resources• Reduction of waiting times for secondary services, including outpatient, inpatient, diagnostic and

therapeutic services• Explore options outside Wales to reduce long waiting times in short term• Reduction of list sizes of Primary Care teams• Innovation in approaches to patient care, eg opportunities for patients to take responsibility for

chronic disease management, alternatives to hospital admission• Redirect resources towards treatments that are proven to be cost-effective

d) ICT• Develop systems which assist GPs to keeping up-to-date and communicate efficiently and

effectively• ICT investment requires ring-fenced funding and regular auditing

2. Maximise working potential within Primary Care

a) Maximise working potential• Research factors which would encourage GPs to maximise their working potential• Facilitate matching of Freelance and salaried GPs to job vacancies, eg by IT, local schemes,

agency• Encourage retiring GPs to stay, possibly to take up flexible working including clinical, managerial

and educational posts• Comprehensive set of costed, evidence-based NSFs

b) Support• Support newly trained GPs; provide financial and educational incentives for substantive GP posts


• Provide accessible childcare services for Primary Care staff• Develop effective OHS to reduce time lost through illness/stress• Develop effective scheme for dealing with violent patients throughout Wales• Reform of complaints and medico-legal systems for Primary Care

c) Administration• Reduce bureaucracy and paperwork for GPs• Improve quality of information which underpins decision-making at every level of NHS Wales• Enhance communication systems between all sectors of primary and secondary care

3. Doing Things Differently

a) Flexible working• Increase flexible options for those training to become GPs• Introduce a Flexible Career Scheme in Wales, incorporating the benefits of the current Retainer

Scheme and English FCS• Publish a guide to flexible working within Primary Care in Wales, providing information on the

variety of posts and different ways of working

b) Skill-mix• Plan for skill-mix and explore transferable skills in Primary Care, eg through Nurse Practitioners,

Community Pharmacists• Increase in numbers of Primary Care staff to provide greater options for patient management

c) Innovation• Provide opportunities to develop special interests within GP• Provide training and working environments for developing team-working and leadership skills

within Primary Care

d) Infrastructure• LHBs to develop effective OOH services across Wales• Develop alternatives to acute hospital admissions• Develop systems to share best practice in delivery of health care across Wales

4. Delay RetirementRetaining our Primary Care workforce is essential if we are to maintain and develop services.

a) Financial incentives• Provide financial incentives to prevent early retirement• Offer flexible retirement pension packages, allowing reduction in hours without adversely

affecting pensions

b) Job opportunities• Provide variety of job opportunities for GPs nearing retirement• Offer opportunities to develop new skills, eg leadership or management roles

b) Reduce stress• Reduce administrative workload and/or clinical responsibilities for senior GPs• Develop opportunities for funded sabbaticals• Reduce stress from violent patients, medico-legal claims


• Support senior GPs in managing change• Remove OOH responsibilities• Support GPs under pressure from work or illness through effective OHS• Support senior GPs through appraisal/revalidation, ensuring processes are non-threatening and

appropriate matches made with appraisers• Keep political changes to a minimum

c) Working conditions• Improve premises and working conditions throughout Wales

5. Support and Innovation in Rural and Deprived Areas

a) Financial incentives• Placements from medical schools and VTS to provide experience of GP in these areas• Realistic financial incentives to work in under-doctored areas, eg secondments• Schemes such as ‘bonded placements’ to resource these areas whilst assisting repayment of student

debt• Target funding and support for local schemes in areas with recruitment / retention difficulties

b) Innovation• Multi-professional approach to local innovation in provision of patient services, developing a

variety of models in areas with recruitment problems• Areas with unique difficulties, eg border regions, need particular attention and resources to

develop workable remedies to recruitment / retention problems• Develop systems to enable best practice in developments to be shared between LHBs• Offer incentives to improve performance, eg extra funding for service developments• Involve GPs in development of local schemes to promote ownership and commitment

c) Working conditions• Improved premises, developed in line with future provision of Primary Care

d) Education and support• Overcome isolation in remote or deprived areas through schemes to promote support and provide

necessary skills• Accessible Educational Centres in rural areas• Adequate cover for education, specialised work and annual leave

6. Attract GPs to work in Wales

a) Innovation• Proactive approach to encouraging and supporting innovation within Wales• Innovative schemes to retain GPs at all career stages, eg GPs with a Special Interest, salaried

schemes

b) Marketing Wales• Market working as a GP in Wales; guide to GP job opportunities in Wales; liaise with Welsh

Tourist Board to promote NHS Wales• Introduce Wales weighting to allow for increased workload and recruitment / retention problems• Increase recruitment grant to attract GPs to Wales


• Avoid loss of Freelance GPs to England by standardisation of Supplementary List criteria and fast-tracking applicants working across the border

• International recruitment using ethical policies to avoid depletion of GPs from countries needing toretain their workforce.

c) Flexible working• Recruitment drive aimed at Returners; provide financial incentives to Returners to work in Wales;

support and train Returners in skills needed to secure posts• Increase number of Retainers eligible to claim recruitment / retention packages• Provide Flexible Careers Scheme, tailored to the workforce needs in Wales

d) Working conditions• Improve working conditions, including significant investment in premises, with funding available

to ensure minimum standards for buildings, access and equipment• Introduce protection from negative equity and diversity in ownership and management of premises• Diversify buying-in schemes, with guidance/support to LHBs in assisting GPs• A national strategy to promote effective management of premises, with LHB training, is required• Provide an effective ICT system across Primary Care through development of the ICT Foundation

programme

e) Education• Maximise workforce potential with local schemes to support and educate all GPs• Increase national undergraduate and postgraduate training posts (extended and higher) which

support GPs in Wales• Protected time and funding for CPD and appraisal for all GPs in Wales

f) Support• Develop a robust Occupational Health Service for Primary Care in Wales• Childcare provision, eg vouchers, access to childcare facilities

7. High Quality Workforce PlanningNeeds to be more sophisticated, robust and long-term, based on future models of service provision.

a) Workforce planning• Accurate, up-to-date workforce data (include actual GP numbers, WTEs, types of posts held,

number of vacancies, numbers offering additional and enhanced clinical services)• High quality workforce planning systems, taking all current & future influences into account, with

capacity mapping and monitoring (include morbidity attendance patterns and cultural influences)• Electronic data collection tool to inform workforce planning• Innovative workforce planning in areas with particular recruitment and retention difficulties• Workforce and service planning need to be in step

b) Training• Increase in numbers of medical students, with selection criteria of medical students to include

adequate numbers with qualities required for working in Primary Care• Increase in numbers of trained GPs , with medical school programmes and VTS designed to

provide doctors who are selected and trained to be ‘fit for purpose’


c) Maximise workforce potential• Innovation in skill-mix within Primary Care, challenging traditional ways of working• Remodelling of the workforce to deliver modern, flexible high quality care• Maximise workforce potential by facilitating GP applicant-vacancy matches. Local/national

agency or co-ordinator to match practice vacancies with available GPs

8. Market General Practice in WalesA proactive approach to promoting NHS Wales is required, marketing the benefits of living inWales and making Wales a more attractive place for GPs to work.

a) Marketing General Practice• Innovative methods of marketing and promoting GP in Wales• Career structure within GP offering choice and flexibility• Significant investment in premises to facilitate delivery of health services across Wales

b) Careers advice• Improve careers information, options and guidance in schools.• Closer liaison with teachers to attract students into medicine• Medical schools programmes to highlight benefits of working as GP, with promotion of job

opportunities and more practical experience of working in GP

c) Training• Undergraduate programmes designed to promote and meet the needs of future GPs• Vocational training schemes which recruit and train GPs to be ‘fit for purpose’


APPENDIX 6

REPORT FOR THE ALL WALES MANPOWER PLANNING ADVISORY GROUPDecember 2002

General Practice Issues

1. Current situation

1.1. There are currently between 1800 and 1900 general practitioners working in Wales. It has beenrecently reported that there are currently 130 GP vacancies in Wales. This is a vacancy rate ofaround 7%, but this figure is only an average. Some areas such as Cardiff report very fewvacancies, whereas others such as the South Wales Valleys have reported vacancy rates ofbetween 30 and 40%.

1.2. The actual number of GPs working in Wales has increased over the past ten years by 6%. Thisincrease is grossly inadequate when account is taken of the increased workload in general practiceover the same time period (eg consultation rates have increased by 50% in the last decade).

1.3. The number of full time GPs has actually dropped by 6% between 1991 and 2001 (from 1529 to1443).

1.4. The demography of GPs has also changed over the past decade, with decreased numbers of GPsaged less than 35 and over 60. This would suggest that GPs are not entering general practice asearly as they were and are leaving much sooner (in the past it was expected that a GP would enterpractice as a full time GP aged 27 or 28 and work until the age of 65 or even longer). The patternnow seems to suggest that GPs enter practice five years later and retire five years earlier, thusdecreasing the working life of an average GP from 40 to 30 years. This is a loss of 10 years perGP!

1.5. The percentage of GPs currently over 55 and therefore likely to retire in the next five years isincreasing. The percentages of GPs in this category range from 11% in North Wales to 25% inGwent. There are areas (eg Cynon Valley in South Wales) where over 50% of the current GPpopulation are aged 55 or older.

1.6. The proportion of GP registrars that are now women, and more likely to want to work part time, isalso increasing. Recent estimates are that women make up more than 75% of the current GPregistrar workforce.

1.7. If we assume that there should be 2000 - 2100 GPs working in Wales and that they work anaverage of 30 years each, there will be roughly 70 retirements per year. If we train registrars on aone to one basis, to replace the retiring GPs, we would need to have qualified 70 new GPs everyyear. However, studies have suggested that we should be training GP registrars at a rate of 1.5 or1.7 to every GP retirement. This takes into account increasing numbers of new GPs wanting towork part time, new GPs taking longer between qualifying and entering GP as a principal, shorterworking lives (as shown above) and those currently training who originate from overseas whohave been reported as having less of a commitment to work in the UK after completing trainingand often return home. This would suggest that we should be training 120 GP registrars in Walestoday to replace those expected to retire each year. At the end of 2001 we were training 119.


1.7.1. If we anticipate GP workforce requirements 5 years from now, recognising the currentpressures on general practice, it would be fair to conclude that we will need to aim to betraining 2 GP registrars for ever one GP retiring. This means we will need to aim for 140registrars qualifying each year 5 years from now.

1.7.2. The current number of places for registrar training for which funding will be madeavailable is 2001 – 119, 2002 – 127 and 2003 - 136. We need to ensure that all of theseavailable posts are filled if we are to have any hope of fulfilling future GP needs.

1.8. There is another issue we need to factor into our calculations. The above figures assume that allGP registrars trained in Wales will stay in Wales. There are reported over 1000 GP vacanciesthroughout the UK. A recent article in the BMJ stated, “If the (English) government’s ambitioustarget for 2000 more general practitioners (in England) is to be met, then the 550 promised newtraining posts will not be enough”. Even if we train registrars at a rate of 2:1 some of them willinevitable move away from Wales and work in England. We will need to be able to compete interms of working conditions if we are to encourage GPs to either stay or come to Wales to work.

1.9. We also need to remember the 130 vacancies currently in Wales. If we are to fill all these over thenext 3 years, we will need to train or recruit an extra 40 – 45 GPs each year.

1.10. Taking into account all of the above factors, we would estimate that in five years from now weshould be aiming for a minimum of 160 fully funded, fully filled registrar training posts in Wales.

1.11. All the above assumes a nice steady average retirement rate of 70 per year. With such a highproportion of Welsh GPs over 55 years old and so “able” to retire, if they all decided to go in thenext 2-3 years we would need to replace not 70 per year over the next 5 years but between 100and 120. This is impossible without importing significant numbers of doctors from outside Wales.

1.12. This figure of 160 will allow us to replace existing GP as they leave practice. If we are to expandthe GP workforce throughout Wales then we need to increase this number accordingly e.g. to 180– 200 per year.

2 Implications

2.1 The above projections suggest that in five years time we will need a 50% increase in the number ofSHO posts available for GP training, 50% more VTS places, a significant increase in the numberof training practice places and possibly doubling the current number of GP trainers.

2.2 This paper demonstrates a considerable shortfall in the workforce being trained to replace GPs.This is likely to get worse and we need to begin planning for that now.

3 Current pressures facing General Practice

3.1 Increased patient demand and expectation, eg a 50% increase in consultation rates among WelshGPs over the past ten years. (At least 75% of people and 90% of families consult a GP at leastonce a year.)

3.2 Increased time commitment to undergraduate and postgraduate teaching, eg registrars and pre-registration house officers.

3.3 Increased involvement in administration and management of the NHS eg LHGs and LHBs.


3.4 Increased need and requirement for audits.

3.5 Clinical governance and the associated time required for this within practices.

3.6 GP appraisal.

3.7 The demands of revalidation and accreditation.

3.8 Decreasing bed numbers pushing greater amounts of work into the community. (In Wales 23,500beds in 1979, 15,500 beds in 1997. NAfW June 2001.)

3.9 The impact of secondary care waiting times and waiting lists on primary care. (Waiting lists rose22% between 1979 and 1997). A recent study by Bro Taf LMC suggests that up to 9,000appointments are wasted in general practice in Wales every week by expediting appointments, re-referring or expediting inpatient work.

3.10 Attempts to involve general practitioners in secondary care provision eg GPs with a special interestand intermediate care.

3.11 Increased patient complaints and litigation involving GP time.

3.12 Increased NSF work and other clinical work being expected of primary care.

3.13 Increased number of patients, investigations and treatment provided in primary care.

3.14 New general practitioners not willing to buy in to practices or participate in out of hours work.

3.15 The desire by general practitioners to lengthen consultation time to improve the quality of patientcare.

3.16 The shortage of other staff available to treat patients e.g. Occupational, Speech and Physiotherapy.3.17 Increased demands by patients out of hours for general practice without the accompanying

secondary care services e.g. pathology, radiology

All the above factors contribute to significant pressure on the availability of GP clinical time to seepatients. The greater desire by the public and this government to have GPs involved in the above has adirect knock on effect on the amount of clinical time available for service delivery. Even if the abovecontributes to a 5% loss of clinical time throughout Wales, this is equivalent to 90 full time GPs.

4 Future Pressures

4.1 New contract. Especially if there is workload limiting elements.

4.1.1 Loss of the MPC.

4.2 The contribution of the National Assembly for Wales Primary Care Directorate.

4.3 The future LHBs and possibly their commissioning and providing roles.


4.4 Trusts in Wales have flexibility to increase wages of consultants to attract suitable staff to Wales.Although the common complaint is that these consultants will jump from Trust to Trust, they arestill working within Wales.

4.5 The NAFW and Health Authorities do not have the same degree of flexibility in attracting newGPs in to Wales, as payments are nationally set and are not subject to local flexibilities. In Englandthey have Primary Care Trusts that may, in the future, have the ability to do the same for GPsthere.

4.6 The National Assembly for Wales, in collaboration with GPC Wales, has recently announcedrecruitment and retention initiatives throughout Wales. The general opinion of these in the GPcommunity is that the ideas are good, but that the funding is inadequate. The National Assemblyfor Wales will therefore have to address the issues of inadequate funding and look to increase theamount of financial award available to improve both recruitment and retention in Wales.

4.7 European Working time directive on GP Registrars.

5 Problem list

5.1 The current 7% vacancy rate in Wales.

5.2 The long-term nature of some of these vacancies (eg one recently filled post had been advertisedfor the past three years).

5.3 The retirement “time bomb” eg 50% in Cynon Valley.

5.4 Wales is not training enough general practitioners for our current needs, let alone futurerequirements.

5.5 The increasing non-clinical pressures on general practitioners.

5.6 New clinical pressures on general practitioners.

5.7 The knock on effect of secondary care waiting times and waiting lists on general practitioners.

5.8 Other NHS pressures on GP time eg training.

5.9 Increasing patient demand and expectations.

5.10 Initiatives such as clinical governance, revalidation, reaccreditation and appraisals.

5.11 New GPs being increasingly unwilling to take on out of hours work.

6 Solutions

Short Term (within 1 year)

6.1 Retention packages.


• The National Assembly for Wales needs to review the funding arrangements for the retentionpackages. We suggested that the golden thanks begin at 50 and be paid at £2000 per year, asopposed to the current 55-year commencement at £1000 per year.

• To explore using pension and reduced commitment initiatives to encourage retention.• Need to slow retirement of GP must be one of main short-term priorities.

6.2 Recruitment.• To increase the current recruitment grant from £5000 to £7,500 to attract GPs into Wales. The

National Assembly for Wales should set a hard target of attracting 100 new GPs in to Wales overthe next two years, above those needed to replace retiring GPs.

6.3 The National Assembly for Wales to increase payments to trainers and VTS co-ordinators.

6.4 The National Assembly for Wales should increase the number of retainer posts in Wales and makeretainers eligible for the recruitment and retention packages.

Medium Term (within 5 years)6.5

• Increase the number of training places for registrars in Wales to 200. This to include primary andsecondary care provision.

• Establish a Wales weighting paid by the National Assembly for Wales to all GPs currentlyworking in Wales to recognise the increased workload and recruitment and retention difficulties.

• Increase the number of extended training and higher training posts in Wales in collaboration withthe Department of General Practice. The National Assembly for Wales should set itself a hardtarget to increase the numbers by a factor of 300%.

• Increase the number of medical student places in Wales above the current targets.• No patient in Wales should wait more than six months for any secondary care service including

outpatient, inpatient, diagnostic or therapeutic.

6.6 Long term (up to 10 years)

• We were unable to identify any initiative or ideas that could wait as long as ten years to beimplemented.

7 Summary

The National Assembly for Wales needs to achieve five things in the next five years.

7.1 It needs to slow the rate of retirement among older GPs.

7.2 It needs to increase the rate of recruitment among younger GPs.

7.3 In five years time it has to have sufficient training places for 200 registrars throughout Wales andmore extended and higher training places (by 300%).

7.4 It needs to make general practice in Wales attractive enough in terms of work conditions andincome to both attract and retain general practitioners.

7.5 Increase the number of other primary care staff available to see and treat patients.

Dr Andrew Dearden

a review of general practitioner recruitment and retention

Documents