How general practice is paying for the cost-of-living crisis

Picking up the pieces

These challenges are evident across general practice. A survey published in September 2023 by the Royal College of General Practitioners found that 73% of GPs had seen an increase in the number of patients with problems linked to the cost-of-living crisis. Some 93% were also concerned that the rising numbers of such patients would limit their ability to provide quality care. The college called on the government to reform the funding formula to put more resources into deprived areas.

“We’ve known for a long time that there are more health problems in socioeconomically deprived areas, in particular more physical and mental health comorbidities,” says David Blane, a GP and senior clinical lecturer in general practice who works with the Deep End project in Scotland. The project is made up of GPs that practise in the 100 most deprived areas of Scotland. It recognises that rising levels of poverty lead to higher consultation rates, but points to research showing less time in GP consultations, less funding per need adjusted patient, and higher GP stress levels in deprived areas. “All of these things are a manifestation of the inverse care law,” Blane says.

“If you take a train across London from a deprived ward to a less deprived ward, there’s a 12 year life expectancy gap,” says Peter Matejic, chief analyst, insight and policy, at the Joseph Rowntree Foundation. The foundation’s report found that more people were going without essentials such as decent food and heating, and this was leading to rises in poor health. “All of the evidence suggests that poverty and poor health is a vicious cycle,” Matejic says.

Austerity and public sector cuts also mean those services that provide people with a place to go to meet others, such as libraries and community centres, are less available, if at all, to those who most need them. The few remaining local services, such as GP practices and schools, are therefore under greater pressure. This also contributes to workforce challenges in general practice where there are greater and more complex needs, but without the resources to meet them, leading to GP burnout. Between 2015 and 2020, deprived areas lost the equivalent of 1.4 more GPs per 10 000 population compared with richer areas.

Over-the-counter and social prescribing—but GPs can’t cure poverty

GPs can help families struggling to meet the cost of over-the-counter drugs by prescribing them to patients exempt from charges, suggests Azeem Majeed, professor of primary care and public health at Imperial College London. “If you’re a poor family, those over-the-counter medicines can cost quite a chunk of your weekly household income, just because you need some paracetamol,” he says. This is despite guidance published by NHS England to avoid prescribing paracetamol.4

Since 2022, primary care networks have a requirement to commission a “proactive” social prescribing service. Social prescribers are usually employed by GP practices or a community organisation working on behalf of the NHS. Social prescribers refer patients to services to help them with housing, employment, and other social determinants of their health needs, such as warm spaces and affordable energy schemes. They can also refer them to cheap or free health promotion activities, such as exercise classes or meet ups. These have a direct benefit to the people accessing them, but their ability to change the larger structural forces driving poverty and ill health are limited.5

Longer term there is also a challenge. Children who have been born and grow up in poverty are more vulnerable to poor health and worse life outcomes. The number of children growing up destitute has tripled in five years. “The early years are a key part of a child’s development; it is hard to make that back up over the rest of someone’s life,” Matejic says. That is not to say that it is impossible, he explains, but it requires concerted action. The Joseph Rowntree Foundation is calling on the next government to commit to an “essentials guarantee” to ensure that everyone can afford healthy food, heat, and housing.

“It is beyond the control of GPs to fix the welfare state and eradicate poverty. It goes back to the Marmot principles of reducing health inequalities6—such as investment in early years development, employment, and living standards,” says Blane. He says that means resource allocation according to need and using the influence of general practice both as an employer and as a trusted resource in communities to work across services and advocate for action on the social determinants of health.

General practice cannot “cure” poverty, GPs and social campaigners emphasise, it is determined by political choices about how to spend public money and run public services. “In the long term, we need more upstream policy reforms that are going to create better health outcomes for everyone,” Shah says.