Written evidence from John Gooderham (FGP0005)

 

EQUITABLE DISTRIBUTION OF GENERAL PRACTITIONERS IN ENGLAND

EVIDENCE TO HOUSE OF COMMONS HEALTH AND SOCIAL CARE SELECT COMMITTEE ENQUIRY ON THE FUTURE OF GENERAL PRACTICE

INTRODUCTION

This submission relates solely to the need for a fairer distribution of GPs in England, to allow a more even spread and therefore improved access for more patients.  The proposal is to restrict GPs from working in more than adequately areas, so that some work in less than adequately doctored areas.

2 There has been no way of ensuring the equitable distribution of GPS throughout the country since 2001. Deprived areas are worst affected by the national shortage of GPs, that trend is increasing, and is widening health inequalities, according to recent research published by the University of Cambridge.  Having identified the problem, this submission offers a solution. 

3 This paper does not tackle the issue of the current shortage of GPs; HMG hopes to increase the GP workforce by 6,000 but that is not going according to plan.  In the meantime, within the next 5 years, a mechanism is required that will distribute the available number of doctors more fairly for patients. Nor does this note deal with the separate but related issues that some patients have of getting to see GPs in person, or of contacting practices by phone.

4 Data from various sources show the average list for Fulltime equivalent (FTE) number of GPs in different areas ranges from more than 4,000 to less than 1,500 while the England average is 2,200 per FTE GP.  There is a gross disparity between areas that are severely under-doctored and to those that are more than adequately doctored. A mechanism preventing the latter having extra GPs would work in favour of the former, by means of ‘negative direction’.

 

HISTORY

5 From the start of the NHS in 1948, continued efforts were made until 2001 to mitigate the obvious inequity for patients produced by the previous total freedom enjoyed by GPS to work anywhere. There were some GPs with lists of over 4,000 in deprived areas while others had lists of fewer that 1,000 in affluent areas.  To address this situation the NHS Act 1946 set up the Medical Practices for England and Wales (MPC).

6 The MPC’s function was to ensure that there was an equitable distribution of GPs and that every area had an adequate number of GPs.  The term ‘adequate’ was never defined but there was tacit agreement between HMG and the profession that the word described a local average that was less than the national average.  After a few years, the national average settled at about 2,000 patients per GP, fluctuating between 2,200 when there was a national shortage of GPs and about 1,800 when there was – relatively speaking – no shortage.  The GP national average list is now 2,200 patients, and is increasing inexorably as the number of GPs decreases and the population grows.

7 Staring in July 1948, the MPC met weekly to consider cases from GPs:  applications to join the local medical list; requests to replace an outgoing partner; requests for additional partners; and requests to declare vacancies or disperse lists when a single-handed GP retired.  The MPC assessed every area as being: severely under-doctored (where the average was over 2,500); less than adequately doctored (where the average was between 2,100 and 2,500; adequately doctored (where the average was between 1,800 and 2,100) and more than adequately doctored (where the average was less than 1,800). 

8 There were about 1,250 areas in England, about the same number of Primary Care Networks now.  The MPC had a discretionary power to refuse applications from doctors if the area was more than adequately doctored on adequately doctored. The MPC had no power to refuse application from suitably qualified GPs to work in severely under-doctored areas or less than adequately doctored areas.  The system worked to the extent that there were no severely under-doctored areas by February 1986, and only a handful of less than adequately doctored areas by October 1999.

9 The MPC was abolished in 2001 by the Health and Social Care Act of that year. The reasons are unclear. Nothing was put in its place, and the outcome was entirely predictable.  The so-called Carr-Hill funding formula that was introduced at that time was explicitly designed to pay GPs more for working in certain areas, but was never intended to have any influence over where GPs worked.  The formula has been revised, and is due to be revised again, though there is little support for its continuation. The re-introduction of some form of control on where GPs are allowed to work seems necessary if an otherwise inevitable return to pre-NHS conditions is to be avoided.

 

RESEARCH

10 Published in May 2021, research by the University of Cambridge’s Department of Primary Care found that significant GP workforce inequalities exist now, and are increasing, with shortages disproportionately affecting deprived areas.  The study concluded that policy solutions were urgently needed to produce an equitably distributed GP workforce, thereby helping to reduce health inequalities. 

11 Think tanks - the Health Foundation, the Social Market Foundation, the Kings Fund, and the Nuffield Trust – and other commentators - have reached similar conclusions.  Over the past 15 years, other universities have drawn attention to the effect of a total absence of controls since the MPC was abolished in 2001.

 

PROPOSAL

12 The opportunity should be taken when the Health and Care Bill reaches Lords Committee Stage in early 20221 to consider an amendment that would oblige HMG to create a new body charged with ensuring the equitable distribution of GPs in England. 

13 The body - General Medical Practitioners Equitable Distribution Board – would have functions set out in Regulations, but in essence would have the same discretionary powers as once exercised by the MPC.  The new body should be allowed to refuse requests from GPs to work in over-doctored areas. 

14 Unlike its predecessor, the new body should do its work by email or online meetings to reduce running costs.  The data it requires are available from NHS Digital.  The financial implications of its work are neutral, as the body is to be tasked with redistribution of the workforce, not expanding the number of GPs.

15 The requests the new body receives should perhaps not come from individual practices or doctors but from PCNs.  Most importantly, unlike the MPC, the new body should not be asked to consider where there are no changes in the number of GPs, only increases or reductions, so that like for like replacements are outside the new body’s remit.

 

John Gooderham                                                                                   

Nov 2021