General practice – and the whole NHS – is struggling badly

Across healthcare services we are not in a good place just now. To be honest it is only the increasing cost of living crisis, ‘partygate’ and the Ukraine situation which are dominating the headlines and at least to some extent keeping people from waking up to the fact that their NHS is really struggling.

Personally, I seem to be apologising to a lot of patients just now about the NHS and the limitations on the care they are receiving. In truth, I cannot remember another time like it in my 30 years as a GP. We’ve come through the pandemic and now the public understandably want their health service to be immediately back to how it was before.

Some of them are coming forward with problems they’ve held back during the pandemic such as arthritic joints and hernias – many will need elective surgery, but I cannot honestly tell the patient when that will be. That’s largely because our Health Board does not share that information with GPs or patients. It does seem a bit strange that they don’t do so, but I suspect they are quite anxious about it as according to Audit Scotland waiting times have risen significantly, with a 220% increase in those waiting longer than 6 weeks for diagnostic tests and a 155% increase in those waiting longer than 12 weeks for new outpatient appointment. Despite our constant calls, there is still a lack of real honesty and transparency about what the public could and should expect their health service to deliver and in what timescale.

Given all of this it is little surprise to hear that the number of patients in Scotland funding their own treatment has increased by 68 per cent since the pandemic. I would expect that trend to continue for the foreseeable future. Those patients with the means to do so are making calculations about their life expectancy and desire for quality years, which mean they can’t face the wait, so savings are being dug into. The net effect of this will be a two-tier system developing and the inevitable widening of health inequalities, something the Scottish Government (rightly in my view) has previously seen as a priority to reduce and tackle.

Reflecting on how we’ve got here is a massive challenge. It’s somebody’s fault, it’s nobody’s fault – I don’t know, there are just so many factors. We were not in a great place pre-pandemic, much of that can be attributed to years of poor NHS workforce planning. That means there are shortages in a number of key areas. The elective waits – with a 34% reduction in the number of scheduled operations in theatre system – relate to lack of bed capacity and significantly theatre staff are in short supply. So we have shortages not just of doctors but also the nurses, and we simply need to fix this bottleneck.

And right at the heart of this, and as a result, general practice too is struggling badly just now. Long waits for hospital care are causing back-pressure in the GP system, adding to our workload. Care pathways that have been unilaterally developed during the pandemic result in efficiencies for one area at the expense of another. This simply underlines the need for local interface groups to develop patient care journeys. These structures, which bring together primary care and secondary care need to be invested in and given time and priority to help make working across care in the community and hospitals as seamless as possible. Boards should have them in place, but they also need to ensure that secondary care doctors have the time they need to attend and contribute. The last thing we need in these tough circumstances is anything that puts barriers between different parts of the system. We know we need all sorts of things alongside this, like investment, proper workforce planning and an open and honest approach. But some of these are longer term – we need to make sure we fix what we can urgently too.

Looking specifically at primary care, we entered the pandemic short of GPs and that remains the case. The Scottish Governments commitment to recruit an extra 800 GPs by 2027 is a good one but training an extra 800 is not the same as getting them into practices where they are needed to improve access to our patients. It should not be a surprise that 800 extra GPs require 800 extra incomes. Without the funding to secure them in practices the pattern of a flatline in national numbers of WTE (whole time equivalent) GPs will remain a constant, with average list sizes per WTE GP will remain excessively high. The shift of workload to primary care associated with an aging population with increasing health care needs to a largely static GP workforce is one of the principal causes of burnout.

That’s why we urgently need to see real progress with SG on Phase 2 of the Scottish GP contract. Indeed, the case for this is stronger now than it was when it was agreed with the BMA in 2017. The central aim of this phase is all about boosting GP numbers while maintaining GP earnings. We need to deliver that, improving practice sustainability and targeting the extra GPs to areas of highest need. The government has however always caveated delivery of this to an unspecified affordability test, but the cost of delivering this increased GP workforce needs to be considered in the context of the cost of not doing it for the people of Scotland. And if the Scottish Government were to decide not to do this, my question is what is Plan B? The status quo is no longer an option. Progress is vital, for GPs, for tackling and reducing inequalities and for the very future of our health service.

Dr Andrew Buist is Chair of BMA Scotland’s GP committee

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