If the government isn’t careful, GPs could go the way of dentists
Each region in the UK has a local medical committee (LMC), a statutory body that represents general practice in its area. LMCs are independent of the British Medical Association (BMA) but act as its eyes and ears, advising the doctors’ union on the views and concerns of grassroots GPs, and instructing it on policy. In May, the LMCs’ conference tasked the BMA to begin work on a “plan B”, a hybrid public-private model that would take general practice partially outside the NHS for the first time since 1948.
The phrase “doing a dentist” was coined to describe this idea; dental practitioners have always offered both NHS and private care to their patients. There are two distinct rationales for GPs wanting to follow suit. Some proponents argue that general practice is no longer financially viable under the NHS contract and that a hybrid model is the only way for it to survive. Others do not intend for a “plan B” ever to be enacted, but hope the threat would force government to rebalance NHS spending. The 8.3 per cent of the overall budget going to primary care is the lowest ever level, down from a historical high of 11 per cent in 2006, while practices are being expected to meet record levels of demand.
To imagine what a hybrid service might be like, one needs only look at what is already happening. The numbers of doctors registering to practise outside the NHS, either wholly or in part, has been rising sharply since 2018, with around 400 per year now making the move. (Previously there were just a few dozen annually.) They are responding to two types of demand. One is for treatments not provided by the NHS, such as aesthetic procedures, weight-loss drugs for lower risk patients, or certain hormone therapies. The other, though, is for something that used to be widespread in the health service but has been progressively eroded: continuity of care with a doctor you know and who knows you well, with the appointment capacity and time to address problems promptly and holistically.
The LMC conference coincided with the leak of the revised NHS ten-year workforce plan, which highlighted the need to greatly expand GP numbers if the goal of moving care from hospitals to the community is ever to be realised. Governments of different stripes have been saying the same thing since 2015, yet GP numbers have flatlined, even as demand from an ageing, enlarging and medically more complex population has been relentlessly growing. The problem isn’t training – we’ve never had so many GPs qualifying – it is retention. For years the profession has been warning government that the job has become unsustainable, with doctors walking away where they can, and those who remain scaling back their time commitment to mitigate the punishing workloads. The evolving crisis has not just been ignored – it has also been accelerated by contract revisions that have been routinely imposed by the government despite near-unanimous rejection by the profession.
I don’t believe many GPs moving into private practice are that motivated by offering services the NHS doesn’t provide. What they want is a manageable working day, and sufficient time and continuity of care to practise proper medicine again. The NHS no longer provides the conditions to do this in many parts of the country.
In the second term of Tony Blair’s government, a concerted campaign to improve the NHS began, one strand of which was funding general practice adequately. This led to a record 70 per cent public satisfaction by 2010, the end of the New Labour era, compared with 26 per cent today. Blair’s conviction was that when public services are good enough to rival the private sector, the middle classes will use them. But allow services to critically degrade and those with resources will abandon them. This perpetuates a cycle that cements two-tier provision, leaving society’s most disadvantaged with a rump safety-net service – exactly what has happened to NHS dentistry today. If the government wants to prevent general practice from “doing a dentist”, it needs to start working on retaining the profession in a radically different way.
[Further reading: Will AI replace doctors?]
