Recruitment crisis at the NHS frontline? Why we should be concerned for deprived areas.
by Breannon Babbel
Findings from a recent British Medical Association (BMA) poll have alarm bells ringing for general practice as a whole in the UK, and particularly for general practice in deprived areas. While the poll of 15,560 GPs doesn’t warn of a mass exodus out of general practice, it does indicate that over a third (34%) of GPs plan on retiring in the next five years. Add to that a further 17% that plan on reducing to part-time work and there’s a potential recruitment crisis in the foreseeable future.
Additionally, the GPs surveyed ranked workload (71%), ‘inappropriate and unresourced transfer of work into general practice’ (54%), and inadequate patient time (43%) as barriers to their work with patients. It should come as no surprise that general practice is a demanding profession, but when the workload increases to the point that GPs are planning to: 1) retire a bit earlier than expected, 2) reduce their hours to part-time, or 3) leave the UK to work overseas (found to be around 9% of survey participants), it’s clear the current demands placed on GPs is unsustainable.
In terms of GP stress, some might argue that GPs working in very deprived areas suffer more than their counterparts working in affluent practices. Yet, stress can be somewhat subjective, as many of the GPs I’ve spoken to point out, and can be experienced by practitioners working in practices with very different profiles. One thing that can be argued, however, is that GPs working in deprived areas have more challenging caseloads, represented by the complexity of problems their patients present. Not only do individuals in deprived areas face poorer health outcomes than those in affluent areas, they’re also more likely to suffer from multimorbidity (i.e. the presence of 2 or more illnesses) at a much earlier age. Yes, affluent practices also face similar challenges in terms of aging populations. But in deprived areas these challenges are further compounded by problems related to social deprivation such as higher levels of unemployment, fewer financial and other material resources, and higher rates of addiction.
So how does this relate back to issues of recruitment? Well, for starters we should by no means downplay the challenges facing general practice as a whole. Fewer GPs has potential negative implications for everyone. But if you think of it in terms of who has the most to lose, deprived areas should take the focus. Why we should be particularly concerned for very deprived areas is essentially two-fold—issues of recruitment will potentially be magnified in deprived areas, which will consequently have a negative impact on patient continuity. In terms of recruitment issues a shortage of GPs means all practices—in affluent areas, deprived areas and in between—will be competing for GP trainees. Just because deprived areas are more challenging in terms of patient complexity doesn’t necessarily mean new GPs won’t want to work there, that is unless the ‘pay-out’ doesn’t keep up. It shouldn’t all come down to a matter of money, BUT financial compensation must be acknowledged. Take the example of two GPs, both with a registry of 2,000 patients, one working in an affluent area, and the other working in a deprived area. If the GP working in the affluent area has less than a quarter of their patients living in the most deprived datazones (according to the Scottish Index of Multiple Deprivation) and the GP in the deprived area has more than three-quarters of their patients living in the most deprived datazones, we can take a guess which caseload might be more challenging. If workload is perceived to be more challenging in deprived areas, new GPs may be reluctant to work in these areas. Individual social justice values aside, deprived areas may be the first to feel the effects of the recruitment crisis simply based on workload and corresponding income.
The second issue of continuity can be re-stated in terms of who has the most to lose, patients in deprived areas. Developing an on-going GP-patient relationship is integral in any setting, but once again is especially vital in deprived areas. As noted earlier individuals in deprived areas are more likely to suffer from multiple illnesses in addition to the presence of social problems related to deprivation. If a GP has only 10-minute consultations to work with a patient, time efficiency becomes critical. Thus, if the GP already has an understanding of the patient’s context (i.e. the patient’s history, family situation, and socioeconomic circumstances), they will be able to make the most of a 10-minute consultation in terms of enabling patients to participate in decision-making as it relates to their health. If there is an increase in GPs working part-time, a higher turnover of GPs working in the profession, or even an increase in the use of locum GPs (i.e. a freelance GP working short-term in a practice) this time efficiency is lost and 10-minutes becomes nearly impossible to 1) adequately address the needs of a patient with a complex background and 2) allow them to participate in decision-making about their own health .
So where do we go from here? While we shouldn’t negate the GP recruitment crisis as a whole, an increased focus must be placed on deprived areas. It’s no secret that Scotland faces stark health inequalities with males living in the most deprived areas of Scotland living on average about 13 years less than their counterparts in the least deprived areas and the difference amongst females dropping slightly to almost 9 years  . While important, the role of general practice in tackling these dramatic health inequalities is only part of the solution. However, the strategic position GPs play in positively impacting on health inequalities is one that demands attention and further exploration.
For more information on Breannon’s research, you can find her podcast on the Policy Scotland feed or watch her video here: http://policyscotland.gla.ac.uk/wp-admin/post.php?post=2673&action=edit
 ICM Limited on behalf of the BMA. (2015). British Medical Association National survey of GPs: the future of General Practice 2015, Second Extract of Findings. http://bma.org.uk/working-for-change/negotiating-for-the-profession/bma-general-practitioners-committee/surveys/future-of-general-practice
Life expectancy rates calculated for the 2011-12 calendar year
 Scottish Government. (2013). Statistical Bulletin: Health & Social Care Series – Long-term Monitoring of Health Inequalities October 2013 Report. The Scottish Government (pp. 1-60).