The average GP patient list currently stands at just under 10,000 – a finding contained in a newly-published article that is based on an analysis of three national primary care datasets.

And while the total NHS general practice workforce grew 20 per cent from 2015 to 2022 – as a result of increases in admin staff and other practitioners – the number of GPs per 1,000 patients fell by 15 per cent over the same period, when accounting for working hours, the analysis shows.

A team of researchers, whose article is published in the open access journal BMJ Open today (3 September), also found that the number of NHS general practices in England has shrunk by 20 per cent during the past decade.

The article – whose first author is Luisa Pettigrew*, from the Department of Health Services Research and Policy, Faculty of Public Health and Policy at the London School of Hygiene & Tropical Medicine – states that patient list sizes have expanded by 40 per cent in the same timeframe.

While major structural and organisational changes have taken place in general practice in England over the past decade, it’s difficult to get an overall picture because information about different aspects of general practice is dispersed across multiple datasets, Dr Pettigrew and colleagues explain. 

Fewer GP practices as patient numbers rise 

Patient numbers rise as GPThe team therefore combined information from different national data sources to describe changes in the organisational structure, workforce, and appointments provided by different types of staff in English general practice, and to consider the implication of these trends. 

Dr Pettigrew and colleagues drew on general practice data collected by NHS England, the Office for Health Improvement and Disparities, and the Care Quality Commission, covering periods of between five and 10 years from 2013 to 2023. They found that the numbers of people registered with an NHS general practice in England grew by 11 per cent from 56,042,361 to 62,418, 295 from 2013 to 2023. And the average proportion of patients aged 65 and over rose from just over 16 per cent to 18 per cent.

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

The number of large practices with lists exceeding 20,000 patients also rose from 1 per cent (81) of practices in 2013 to 6 per cent (355) in 2023. 

From September 2015 to September 2022, the total number of qualified GPs working in NHS general practice in England rose from 34,474 to 36,492. But after taking working hours into account, the number of those working deemed as full-time equivalents fell from 27,948 to 27,321.

The average number of GPs fell from 0.53 to 0.45 for every 1,000 patients, representing a fall of 15 per cent. As to other staff, the average number of nurses remained relatively stable between 2015 and 2022, with, on average, 97 per cent of practices employing a nurse. But the average number of other roles – which include pharmacists, social prescribers, physician associates and paramedics – rose by 67 per cent, with the proportion of practices directly employing these other staff rising from 72 per cent to 89 per cent. 

… there is likely to be a tipping point in the near future where the majority of appointments in English general practice are no longer delivered by GPs [Luisa Pettigrew et al]

Fall in GP numbers

Admin roles also rose by 14 per cent over this period, making up over half of the NHS general practice workforce by September 2022. Using new national data, the researchers estimated that from 2018 to 2023 there were between 63 and 119 (average of 98) general practice appointments/week for every 1,000 patients, carried out by all types of practitioner.

Appointments peaked between September and November each year and dipped between April and August 2020 in the wake of the first Covid-19 lockdown. 

GP appointments ranged from 35 to 57 per week, per 1,000 patients, with no clear trend over time, after accounting for population increases. Appointments with nurses ranged from 18 to 28, per week, per 1,000 patients. Appointments with other practitioners ranged from 17 and 26 per week, per 1,000 patients. 

Both GPs and other practitioners represented the same proportion (19 per cent) of the NHS general practice workforce by September 2022, once working hours were accounted for. But GPs continued to provide half of all appointments despite the fall in their numbers, while other practitioners provided around a fifth.

‘Falling GP numbers delivering the same number of appointments/1,000 [patients] seems unsustainable; therefore, there is likely to be a tipping point in the near future where the majority of appointments in English general practice are no longer delivered by GPs,’ suggest the researchers.

Caveats and conclusions

The authors acknowledge that there are some limitations to their analysis – among them, the discrepancy in population data provided by NHS England and the Office for National Statistics, and the ‘experimental’ nature of NHS England’ appointments data.

Other general practice work, such as managing correspondence, prescriptions, reviewing test results, staff supervision, management and quality improvement activity isn’t captured by appointments data either. And online consultations delivered through separate messaging software may not be included while workforce data are unlikely to cover overtime, which is common in general practice, they point out. 

And they were unable to distinguish between practices that closed for good, and those which were taken over by another practice to become a ‘branch’ surgery.

‘The move towards larger-scale organisations has been encouraged by government policy and professional bodies to improve quality and generate economies of scale through shared back-office functions, joint service delivery, and standardised processes. However, the evidence regarding whether larger organisations deliver better-quality primary care or are more cost-effective is mixed,’ Dr Pettigrew and colleagues add.

Similarly, the diversification of the general practice workforce has also been driven by national policy and proposed as a solution to GP shortages, but concerns have been raised about the impact on continuity of care, cost effectiveness, equity in role distribution, and safety without sufficient GP oversight, they add.

*Dr Pettigrew is also based at the Research Department of Primary Care and Population Health at University College London.

To access the full version of the article – titled The changing shape of English general practice: a retrospective longitudinal study using national datasets describing trends in organisational structure, workforce and recorded appointments  Doi:10.1136/bmjopen-2023-081535 – click