Restore the balance between general practice and hospital care – Professor Philip Wilson
The massive increase in expenditure on the NHS in Scotland since 2012 (27% in real terms) has been accompanied by a fall in life expectancy. Population aging does not explain the size of the increase in funding over time. The NHS is not working well, and money is being wasted.
NHS spending is mainly directed towards hospital care, and it has increased dramatically. In contrast, expenditure in general practice has remained static (at best), so there has been a relative decline in expenditure on general practice, where over 90% of patient contacts take place and which is subject to the same demographic pressures as the NHS as a whole. General practice spending as a proportion of the overall NHS budget was 9.8% in 2008, 7.8% in 2013 and 6.25% in 2021.
It is important to distinguish the terms ‘general practice’ and ‘primary care’, although the terms are often conflated by politicians. Most general practices in Scotland are still run by ‘independent contractor’ GP partners who provide a broad-ranging set of services through their contracts with Health Boards. Practices in the UK hold comprehensive, lifelong medical records for everyone registered with them and so hold the key to a holistic picture of patients’ health. In recent years, many practices been unable to recruit new partners and so have handed their contracts, and the keys to their surgeries, back to the Health Boards. This has dramatically increased costs to the health service because Boards, in general, do not run community-based services well. Not only are these Health-Board run practices expensive, often employing highly paid short-term locum staff, but publicly available data on patient experience show that their patients are much less satisfied with their services – probably because, as the surveys show, they are much less likely to provide personal continuity of care. There is a large body of evidence that continuity of care is associated with better outcomes for patients. Perhaps equally importantly, independent contractors, unlike NHS employees, are able to speak out publicly in advocating for their patients and to hold the NHS to account when things go wrong.
‘Primary care’ consists of all the other community services provided and managed by NHS Boards – district nursing, health visiting, physiotherapy etc., plus the pharmacists, dentists and optometrists who are also generally independent contractors.
Since 2004, there has been a progressive disempowerment and atomisation of general practice. Out-of-hours services, antenatal care and preventive child health services were transferred to Health Boards in 2004, while immunisation and hospital-recommended tests were lost in 2018 – and many more aspects of general practice are going to be run by Boards in the near future. As with immunisation, this will almost certainly be at much greater cost, much more inconvenience to patients and will deliver poorer outcomes. General practitioners are losing their power to coordinate services for their patients – and adequate funding for GP services would have prevented this.
There are several explanations for the failure of general practice funding to keep up with overall NHS expenditure and it brings serious consequences for the smooth running of the health service. First, politicians and the media constantly demand increasing numbers of nurses and doctors in hospitals, increased installation of cutting edge technology (‘scanners’ seem to be a particularly attractive suggestion) as the solution to the dire state of the NHS. It is very rare to hear similar demands for expenditure on primary care, and this situation has become a self-fulfilling prophecy. Second, doctors’ organisations (particularly the BMA) are much more likely to make loud and effective demands for funding of hospitals rather than primary care. This is in part because there are now twice as many hospital doctors as there are GPs, compared to roughly equal numbers 30 years ago, and their voices are louder. Third, hospital medical staffing has become bloated through an inexorable tendency towards super-specialisation. When I began my career as a GP in the late 1980s, every hospital had at least one general physician and a general surgeon. These tended to be the most senior members of their professional groups and they were an invaluable resource to the GP in sorting out the best way to deal with more complex cases. These generalists have now all but disappeared apart from a handful in our few rural general hospitals, while many hospital departments have seen a doubling or tripling of consultant numbers while waiting lists continue to increase. One result of increasing hospital specialisation is that increasing numbers of referrals are rejected, leading to more work for the GP and inconvenience (at best) for the patient. Paradoxically, every new consultant post leads to increasing work for their GP colleagues and to a general increase in referral activity. Fourth, general practice has become a less attractive career choice for young doctors – it was not uncommon there to be a hundred applicants for GP partnerships in the 1990s, and now it is more common for there to be none at all. It has become increasingly difficult for GPs to act as effective advocates in the NHS and to practice holistic care.
One important consequence of super-specialisation is a potentially disproportionate focus on individual pathologies, and a holistic approach is easily lost. One consequence is that far too many patients are subjected to futile and hugely expensive treatments at the end of life, which might extend their lives by a week or two but often decreases the quality of those lives. A previous Chief Medical Officer, Catherine Calderwood, made the astute observation that most doctors would themselves choose to have less treatment than they feel obliged to recommend to patients.
What are the potential solutions for this situation where we are pouring more and more money into a health service which is delivering less and less effective and compassionate care?
First, we need to stop increasing the funding for hospital care and ensure that future developments deliver more efficiency. This should involve a rolling back of the tendency towards increasingly specialised silos which do not communicate well with each other. Second, we need to transfer funds from the hospital sector to general practice and other community care services such as district nursing and health visiting. Third, we need to celebrate and support generalism, both in general practice itself and in hospitals. It is easy to fall into the trap of thinking that specialists always deliver better care than generalists – this may be true for individual technical procedures but it is too easy to forget the person behind the pathology being treated. Fourth, we need to renew a commitment to independence and continuity of care in general practice. This will require a re-jigging of contracts in favour of partnership rather than locum or salaried work which currently pays better. Finally, we need to take a long, hard look at how to assess when medical treatments are futile and to be more honest with patients. Much NHS expenditure takes place in the last few months of life and resources might be better used in keeping people healthy in the first place.
Philip Wilson is a retired GP and Professor emeritus of primary care and rural health, University of Aberdeen
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