Helen Salisbury: It’s time to push back against the destruction of general practice

Sometimes I wonder if I’m doing general practice wrong. So many consultations not only take longer than the time allotted but also create more work to be done at the end of the day: letters to read, referrals to write, things to look up and pass back to the patient. This means that I rarely leave the surgery until the cleaning staff have been and gone.

But when I look at the various alternative models being touted,12 which promise an efficient service where doctors can concentrate on complex patients while “simple” cases are seen by other healthcare workers, it doesn’t look like an improvement.34 If my patient’s problem is straightforward I can see them quickly, usually building on an existing relationship. If it turns out to be more complicated than the presenting symptoms suggest, I have the training to detect that.

New members of the team (pharmacists, physiotherapists, and specialist nurses) bring their own expertise, which we welcome, but they don’t replace the GP colleagues we so clearly need. Indeed, one of the reasons given for expanding non-doctor roles in general practice is the shortage of GPs. However, there are now reports of GPs losing their jobs because practices can’t afford to employ them.5 There are also many more young doctors applying to the GP training scheme than there are places to train them: the ratio of applicants to places last year was 2.67:1, meaning that only 3935 of 10 514 GP hopefuls secured the opportunity to train. The number of training posts available was 5% lower than in 2022.6

The down-skilling of general practice is often euphemistically referred to as a “diversification of the workforce,” but it’s hard not to see it as a deliberate attempt to deprive patients of expert medical care. The motives may relate to cost, despite it being well documented that high quality general practice with built-in continuity saves money in the long run (as well as lives).7 Or perhaps it’s about control, as GPs are notoriously independent and averse to obeying orders.

The 2024-25 contract between NHS England and GPs—the third one that hasn’t been agreed but is about to be imposed—offers a 2% uplift to practice incomes, which is actually a cut if you take inflation into account.89 It’s hard not to interpret this as the government collectively thumbing its nose at GPs. Cost neutral ways in which more surgeries might stay afloat, such as the ability to use the money in the Additional Roles Reimbursement Scheme to pay for doctors and practice nurses, have been rejected by NHS England. The ready availability of resources to pay non-doctors while maintaining that there’s no money available to pay actual doctors clearly underscores the intention of the government and NHS England to down-skill general practice.

We should be wary of statements implying that there’s no alternative, and we should take with a large pinch of salt the suggestion that the solutions arrived at are inevitable because of shortages of doctors or money. A referendum of the BMA’s GP members is under way, giving us the opportunity to accept or reject this contract, although how we respond beyond that is still under discussion.10 Many of us believe that it’s well past time to push back against the destruction of general practice.