Abstract
Background The 2018 Scottish GP contract established GP Clusters and multidisciplinary team (MDT) expansion. Qualitative studies have suggested suboptimal progress with these initiatives.
Aim To quantify progress since the introduction of the new contract.
Design & setting A cross-sectional postal survey of all qualified GPs was undertaken in Scotland in 2023.
Method GPs working lives, career intentions, and views on the new contract were compared with a similar survey conducted in 2018.
Results In total, 1385/4529 (31%) GPs responded to the 2023 survey compared with 2465/4371 (56%) in 2018. Job satisfaction and negative job attributes were similar in both surveys. Both positive job attributes (P = 0.011) and job pressures (P = 0.004) increased but the changes were small (effect sizes <0.2). Significantly more GPs were planning to reduce hours (P<0.001) and leave direct patient care (P = 0.008) in 2023 than in 2018. Quality leads’ views on Cluster working were unchanged, with 70–80% reporting insufficient support. Cluster knowledge and engagement was unchanged but there were small increases in knowledge of quality improvement. More than half of the GPs reported that access to MDT staff was insufficient to reduce their workload in all staff categories except vaccinations. Significantly more practices were trying to recruit GPs (P<0.01), and GPs reported worsening NHS services, higher workload, and lower practice sustainability in 2023 (P<0.001). Only 5% of GPs in the 2023 survey thought that the new contract had improved the care of patients with complex needs.
Conclusions GPs report few improvements in working life 5 years after the new contract was introduced, and are responding by planning to reduce their hours or leave direct patient care.
Introduction
Internationally, ageing populations, rising multimorbidity, austerity, and widening inequalities are posing major challenges to health services.1,2 General practice is fundamental to addressing these challenges.3 Strong general practice is associated with lower health inequalities and healthcare costs4,5 yet it is facing unprecedented crises globally.6 There are concerns about the future of general practice in the UK, with shortages of GPs, declining continuity of care, and reduced access.7 Internationally, responses to these challenges include reforms to manage increased demand while improving efficiency,8 although frequently without appropriate investment.9 A recent systematic scoping review found expansion of multidisciplinary teams (MDTs) was the most common reform in Organisation for Economic Co-operation and Development (OECD) countries.10
How this fits in
Scotland introduced a new GP contract in 2018, which aimed to improve local quality of care and integration through the formation of GP Clusters, and reduce GP workload by expansion of the multidisciplinary team (MDT). Qualitative studies have suggested that progress has been suboptimal but there are little quantitative data to support these suggestions. The authors quantified GPs’ working lives, career intentions, and views on the new contract progress by conducting a cross-sectional survey of all qualified GPs in Scotland in 2023 and comparing the findings with a similar survey conducted in 2018. GPs reported few improvements in working life in 2023 compared with 2018, with only small changes in cluster working. More than half reported that access to MDT staff was insufficient to reduce their work load in all staff categories except vaccinations, and significantly more were planning to reduce their hours (P<0.001) or leave direct patient care (P = 0.008) in 2023 than in 2018.
In 2014, the Scottish Government introduced legislation to integrate health and social care services, leading to the formation in 2016 of integrated authorities (IAs), and their delivery arm, Health and Social Care Partnerships (HSCPs).11 In April 2018, the first-ever Scottish GP contract was introduced,12 although elements of it began in 2016 when the Quality and Outcomes Framework was abolished and GP clusters were introduced. Clusters are geographical groups of 5–8 practices working together to improve their local populations’ quality of care (intrinsic role) and provide local leadership within the IAs and HSCPs (extrinsic role).12,13 Each practice has a Practice Quality Lead (PQL), and each cluster a Cluster Quality Lead (CQL). Clusters were expected to be functional by April 2017.14,15 The 2018 contract aimed to reduce GP workload by expanding the MDT workforce, allowing GPs to focus on patients with complex needs as expert medical generalists.12,13 As of March 2023, more than 4700 whole-time equivalent new MDT staff were working in primary care in Scotland.16
A 2018 survey of GP clusters in Scotland conducted by the Scottish School of Primary care reported a lack of support and training,17 similarly echoed in subsequent qualitative interviews in 2020–2021.18,19 Key barriers to effective cluster working included lack of time, poorly developed relationships, and limited data. Further interviews in 2022 with GPs and MDT staff found no perceived reduction in GP workload nor improvement in the care of patients with complex needs.20 MDT staff reported challenges in building new relationships, adapting to patient complexity, and the fast pace of primary care. Issues over MDT line management, training and professional development needs were also highlighted.
A patient survey (n = 1,053) in 12 Scottish practices across three health boards in 2022–2023 found patients in deprived–urban areas (compared with affluent–urban or remote and rural areas) had the most complex needs, but reported the poorest experience of GP consultations.21 In-depth interviews with patients highlighted concerns about access, consultations length, and continuity of care.22 Further evaluation revealed limited patient awareness of MDT roles, and concerns about reception staff signposting to MDT care, particularly for those with complex problems in high deprivation areas.23
The aim of the current study was to gather GPs’ views on primary care transformation in Scotland by conducting a new national survey of views on working life, future work intentions, cluster working and MDT expansion, and to compare these findings with the 2018 Scottish GP survey.
Method
Study design
Using the same process as the 2018 survey,17,24 a postal survey of GPs in Scotland in 2023. In both years, the survey was posted to all qualified GPs using their name and practice address.25 In 2023, 4529 surveys were sent in October 2023, with two reminders to non-responders. Each questionnaire contained a unique identifier, so that responders and non-responders could be identified for follow up. Data collection stopped in early March 2024.
Instruments used
The 2023 GP survey used the same validated measures of working life and future work intentions as the 2018 Scottish GP survey, as also used in the English National GP Worklife biennial surveys since 1999 (https://prucomm.ac.uk/), with the most recent being in 2021.26 The questions cover four domains of current working life; job satisfaction; job stressors; positive job attributes; and negative job attributes. Future work intentions relate to plans over the next 5 years to increase hours, decrease hours, continue medical work but outside the UK, leave direct patient care, or leave medical work entirely. (see Supplementary Box S1 for details of the questions asked and how they were scored). Additionally, data were collected on bespoke items on cluster working, also collected in 2018,17 and new items about MDT expansion based on the authors’ qualitative findings and a survey conducted by Public Health Scotland,20,27 as explained below.
Cluster variables
As described previously,17 GP Quality Leads (QLs: both CQLs and PQLs) were asked about their experiences of cluster meetings and level of support provided. All GPs were asked about their knowledge of and engagement with the Cluster and how it affected their knowledge of quality improvement (QI) (supplementary Box S2).
MDT variables
The 2023 survey asked GPs which MDT staff they had access to in their practice, what impact these staff had on their workload, and what the advantages and disadvantages of MDT staff were. The advantages were written as free text. GPs were also asked the following: 1) what percentage of their previous clinical work was now delegated to MDT staff; 2) what percent they felt could be safely delegated; and 3) which staff would be most important if additional investment was available: more GPs, more MDT staff, or more administrative staff (supplementaryBox S3).
Additional questions
Information was collected on GP demographics and employment details. GPs were asked whether their practice scheduled longer GP appointments for patients with complex needs (for example, those with multimorbidity and/or mental health problems) and if they felt the new GP contract was improving care for patients with multimorbidity who were either older people or living in deprived areas. Questions from previous English GP Worklife surveys about job changes seen in the past 12 months were also asked in both years (supplementary Box S4).
The 2023 survey questionnaire containing the questions reported in this paper is also shown in the supplementary file.
Data analysis
Standard parametric and non-parametric statistics were used, depending on the type and distribution of data for each variable. P- values of >0.05 were regarded as statistically significant. A Forest plot was drawn for the mean scores for the four domains which shows the effect sizes (Cohen’s d) of the differences between the 2023 and 2018 surveys. The free-text answers about the advantages of MDT working were analysed by five of the authors. They each individually coded the first 200 responses, and came together to discuss and agree on a coding framework. They then shared the coding of all the responses, and classified these as positive or negative.
Results
In total, 1385/4529 (31%) GPs responded to the 2023 survey compared with 2465/4371 (56%) in 2018.24 The characteristics of responding GPs were very similar in both years, and were broadly nationally representative (supplementary Table S1). However, given the differences in response rates in the two surveys, the distribution of two key individual characteristics — gender and ethnicity — by GP age, which showed a very similar distribution across age groups in both surveys (supplementary Figure S1). The distribution of two key practice characteristics were also explored — urbanicity and deprivation — by gender, which also which showed a very similar distribution by gender in both surveys (Supplementary Figure S2).
Table 1 shows the working practices of the GPs who responded to the surveys. GPs reported working significantly fewer sessions per week (P<0.001) and taking significantly fewer holidays per year in 2023 than in 2018 (P<0.001).
Table 1. GP working practices in 2023 and 2018 Current working life and future intentions
Table 2 shows the results for the domains of job satisfaction, job pressure, job attributes, and future work intentions. Although work pressures were significantly higher(P = 0.004), mean positive job attributes significantly improved in 2023 (P = 0.011) and negative job attributes remained the same. Mean job satisfaction was similar in both survey years. However, it should be emphasised that irrespective of P-values, the differences in mean scores in the 2 survey years were very small, with effect sizes of <0.2 (Figure 1).
Table 2. GPs current working life and future work intentions in 2023 and 2018a For individual item scores for the four domains — job satisfaction, job pressure, positive job attributes, and negative job attributes — see Supplementary Tables S2–S5.
In 2023, significantly fewer GPs intended to increase their hours, and significantly more intended to decrease hours (44% in 2023 versus 37% in 2018; P<0.001) or leave direct patient care entirely (26% in 2023 versus 24% in 2018; P = 0.008) than in 2018 (Table 2, Figure 2). For GPs aged <55 years, significantly more planned to reduce their hours (33% versus 26%; P<0.001), leave direct patient care (13% versus 10%; P<0.001), and leave medical work entirely (9% versus 8%; P = 0.002) in 2023 than in 2018 (Table 2).
Clusters
QLs’ views on cluster meetings did not change between the two surveys (seeSupplementary Table S6). There was no difference in the extent to which they felt supported overall with 70–80% feeling insufficiently supported, but individual items showed significantly less support for analysis (P = 0.006), and significantly more support for QI methods (P = 0.041 and leadership (P = 0.009) in 2023 than in 2018 (Supplementary Table S6). For all other GPs (neither CQLs nor PQLs), mean overall scores for knowledge and engagement with clusters did not differ between 2023 and 2018, but statistically significant improvements in individual items were found for ‘decisions’ (P = 0.003) and ‘queries’ (P<0.001)(Supplementary Table S6). There was a statistically significant improvement in mean overall QI score in 2023 (P <0.001), which reflected small increases in all six aspects of QI (Supplementary Table S6).
Multidisciplinary teams
In 2023, GPs reported that 8.5% of workload had been delegated to MDT staff, but estimated that 22% could, in principle, be safely delegated (P<0.001). In 2023, 82% felt that more GPs was the most important issue for any future investment, compared with 69% in 2018 (P<0.001) (data not shown).
Table 3 shows the 2023 GPs’ views on new MDT staff (these questions were not asked in 2018). Access to different MDT staff varied widely. More than half of the GPs reported that access was insufficient to reduce their workload in all staff categories except vaccinations.Free-text answer about advantages of MDT expansion were provided 84%, and 54.9% documented one positive comment, 28.9% two, and 9.8% three or more. Just under 1 in 4 (23.4%) documented both positive and negative comments.
For the positive comments, themes related to the additional clinical expertise and skill mix, better collaborative team working, learning from MDT staff, gaining new perspectives and ideas, better links with secondary care, better links with community resources, and improved patient care and patient safety. Comments on reduced workload was often qualified as ‘some reduction’ owing to increased patient demand and insufficient MDT workforce.
The negative comments largely related to the issues in the subsequent question about the disadvantages of the new MDT, including lack of clinical space (68% agreed), the need to provide training and supervision (61% agreed), and lack of control over what the MDT staff actually do (71% agreed) (Supplementary Table S7).
Table 3. GPs views on availability and impact on workload of new MDT staff - 2023a Recruitment, local NHS services, sustainability, and training
More GPs in 2023 reported that their practices were trying to recruit GPs than in 2018 (35.8% versus 30.5%; P<0.01), with more trying for longer than 12 months (42% versus 30.9%; P <0.001) (data not shown). In 2023, more GPs felt that local NHS services had significantly worsened in the past 12 months, that practice and personal workload was higher, and that the long-term sustainability of their practice was worse, compared with 2018 (all P <0.001) (Supplementary Table S8).
Overall, more practices were involved in the training and education of undergraduate students in 2023 than 2018 (74% versus 59%, P <0.001). In 2023, 72% were involved in training (non-medical) healthcare professionals, compared with 55% in 2018 (P <0.001) (Supplementary Figure S3).
Improving the care of patients with complex needs
Fewer GPs reported giving longer consultations for complex patients in 2023 than in 2018 (39.8% versus 52.2%, respectively; P <0.001). Only 5% of GPs thought the new contract was improving the care of older patients with multimorbidity, and only 4% felt it was improving the care of multimorbid patients in deprived areas (data not shown)..
Discussion
Summary
Scottish GPs’ working lives, career intentions, and views on cluster working in 2023 showed little change since 2018. Job satisfaction and negative job attributes did not change, and, although both positive job attributes (P = 0.011) and job pressure (P = 0.004) increased, the differences were very small (effect sizes <0.2) and thus unlikely to be meaningful. However, worryingly, more GPs were planning to reduce their hours and leave direct patient care in 2023 than in 2018.
Views on clusters were largely unchanged but there were small improvements in understanding of QI. More than half of the GPs reported that access to MDT staff was insufficient to reduce their workload in all staff categories except vaccinations. Inaddition, fewer GPs reported offering longer consultations to complex patients in 2023 than in 2018. Significantly, more practices in 2023 were trying to recruit GPs (P<0.01), and GPs reported worsening NHS services, higher workload, and lower practice sustainability (P<0.001). Only 1 in 20 GPs believed the new contract has improved care for patients with complex needs.
Strengths and limitations
A key strength of this study is having comparable and broadly representative national data examining GP views across the first 5 years of the new Scottish GP contract. The 2023 response rate was lower than in 2018 (30% versus 56%), but the characteristics of responding GPs was virtually identical in both years, even in sub-group analysis by age and gender. Analysis of GPs who responded to both surveys generally supported our conclusions (see supplementary Tables S9 and S10).
The limited impact of the new GP contract should be considered in the context of the disruption caused by the Covid-19 pandemic.
Comparison with existing literature
The present study’s finding that job pressure has increased is mirrored by the 2021 English GP Worklife survey,26with other data from England showing a higher number of appointments being provided in 2023 than any year since 2018, despite a fall in the number of fully trained full-time equivalent GPs.28,29 In contrast to the present study’s finding that overall job satisfaction in Scotland did not changed from 2018 to 2023, scores on the same measure in the English GP Worklife survey fell significantly between 2019 and 2021.26 English data show a continued trend of GPs reducing their working hours, and increasing numbers planning to leave direct patient care,26,30 in keeping with the present study’s findings. The authors plan to compare the Scottish 2023 survey with the next English GP Worklife survey (2023–2024) when data become available.
The findings on MDT staff echo those of a recent Public Health Scotland survey of GPs, which reported insufficient access to MDT staff (particularly urgent care staff), and a lack of reduction in GP workload with no release of time for complex patients, and similar concerns about disadvantages.31 Similar findings have been reported in England in the Additional Roles Reimbursement Scheme.32
Implications for research and practice
There is widespread recognition that general practice faces an unprecedented crisis, across the UK and in other high-income countries. This survey of Scottish GPs provides further evidence that the key aims of the 2018 GP contract have not been realised and, despite the rapid increase in the MDT workforce, the majority of GPs reported no decrease in workload. This has implications for ongoing negotiations for phase two of the GP contract in Scotland, highlighting the need to take more robust measures to reduce GP workload and improve workforce sustainability. It may be that the key to reducing GP workload does not lie in the expansion of the MDT but in the expansion of the GP workforce itself. In 2017 the Scottish Government pledged an additional 800 GPs within a decade,33 but since then GP whole-time equivalent numbers have fallen not risen.30 New approaches are required to increase GP recruitment and retention. Further longitudinal research is required on routine consultation data to confirm the findings of the survey.
In conclusion, although there have been minor improvements in some aspects of GP working life in Scotland since the new contract in 2018, most aspects have remained the same or worsened. GPs — including younger GPs — are responding by planning to reduce their hours or leave direct patient care, which is a worrying picture given the problems of GP recruitment and retention.
Notes
Funding
This study was funded through a research grant from the Economic and Social Research Council (reference: ES/T014164/1).
Ethical approval
Ethical approval was obtained from the Wales REC 6 research ethics committee (reference: 21/WA/0078), and research and development approval from participating Scottish Health Boards.
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
Acknowledgements
We would like to thank our Patient and Public Involvement group: Colin Angus (Chair), Morag Cullen, Mary Hemphill, Anne Marie Kennedy, who gave valuable feedback throughout the research programme. Special thanks to our Patient and Public Involvement Coordinator: Jayne Richards We would like to thank all the GPs who contributed to the survey.
