Intended for healthcare professionals

Views And Reviews Primary Colour

Helen Salisbury: No room for growth at general practices

BMJ 2021; 374 doi: (Published 06 July 2021) Cite this as: BMJ 2021;374:n1691
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

There aren’t enough GPs to meet patient demand, and we’ve been invited to plug the gaps with other health professionals funded though the Additional Roles Reimbursement Scheme (ARRS). The plan is that by 2024 an extra 26 000 staff—including physiotherapists, pharmacists, paramedics, social prescribers, and dietitians—will work in general practice teams, offering a better service to patients and (if all goes to plan) lightening the load for GPs.

So far around 9000 of these allied health professionals are in post, but it remains unclear whether the 2024 target will be reached. Lack of suitably trained personnel is an issue—we really can’t solve staffing problems in the NHS by poaching people from other services—but one of the major constraints is physical space.

When I first joined, our practice occupied a dilapidated building that was far too small for our needs. It had only two consulting rooms for doctors, so to manage any work that wasn’t directly patient facing, GPs had to jostle for space in the admin office so that someone else could use their room for consulting. Eventually, to make room for foundation doctor training, we had to convert one of the toilets. Once the porcelain was removed there was just enough room for two chairs, although patients had to be taken to a couch elsewhere in the building if they needed to be examined.

After many years of planning and wrangling, we finally moved into a purpose built surgery in 2012. My delight in the luxury of adequate space, level floors, and cleanable surfaces still hasn’t worn off, and I’m conscious of my good fortune. Many practices are not in this position: list sizes and demand for GP services have grown, and premises have not kept pace. Eight in 10 practices are in purpose built premises, but needs and standards have changed over the years, and what was once state of the art may no longer be fit for purpose.1

When we moved, we anticipated expansion and deliberately created more rooms than we initially needed. Even so, mapping staff to rooms is getting harder: it’s a complicated logistical exercise, requiring constant juggling as it takes place alongside a steady stream of pleas to accommodate more services and new learners.

The ARRS won’t fulfil its potential without paying a lot more attention to the GP estate and committing the necessary resources to expand it. NHS England seems to recognise the problem, but its response has been less than satisfactory. A recent communication included the advice that primary care networks should “reconfigure current estate to reflect patient need.”2 Leaving aside the assumptions built into this statement about the relations between individual practices (which control premises) and the networks, this advice is insulting in its naivety. It’s highly unlikely that practices already struggling with the intractable problem of a lack of space will benefit from the proposed patient flow and workspace redesign tools. If it was that simple, we’d have done it already.