Will the NHS survive without GPs?

That rhetorical questions like the recent one posed by some in the media are even asked shows how deeply ill-informed and distorted the discourse on healthcare has become in the UK. Any dispassionate observer would know that GPs are the bedrock of the NHS; and without GPs the NHS will collapse. Here are just a few home truths: GPs in England manage a wide array of acute and chronic health conditions through over 300 million patient consultations each year compared to 23 million A&E visits. [1] GPs issue about one billion prescriptions annually and have delivered two thirds of phase 1 covid-19 vaccinations. [2]

The public already know how hard their family doctors are working to care for them. Despite the challenges of the pandemic, soaring demand, a shrinking GP workforce and a workload that has often become unmanageable, GPs have one of the highest public satisfaction ratings of any public service in the UK. In a survey in July 2021, an overwhelming majority of patients (83%) rated their overall experience of GPs as good and 48.2% rated their experience as “very good.” [3] By contrast, in a comparable UK survey of adult hospital inpatients for overall experience in 2019, 48% of patients gave a score of 9 or 10 (good or very good). 

General Practitioners are highly skilled professionals who manage extremely complex medical conditions with limited access to resources, including high-tech diagnostics, available in secondary care. GPs not only treat medical conditions, but through their longitudinal and relationship-based care, also manage non-medical problems. One in five patients consults general practitioners for primarily social problems rather than medical. [4]

Much of the reputation of the NHS in international league tables (ranked number one health system out of 11 countries in 2017 and fourth in 2021) rests on the efficiency and excellence of its primary care. [5,6] A year’s worth of GP care per patient costs less than an A&E visit and less is spent on general practice than on hospital outpatients. GP practices were paid an average £155 per patient in 2019/2020, but the average cost of treatment in A&E, without the cost of ambulance or overnight admission, could be up to £400. Yet for the past two decades funding for hospitals has grown twice as fast as for general practice. [1] Further, between 2005/6 to 2017 the proportion of money spent in general practice fell from 9.6% to 8.1%. 

Recent surveys show two in three patients (67%) are satisfied with the appointment times available to them and 67% find it easy to get through to GPs. [3] General practice had to quickly adapt during the pandemic to provide safe care by fulfilling their public health role in protecting their patients and the community from covid-19. More patients now consult in primary care than the pre-pandemic with over half these appointments face to face. [7] There are however serious problems and challenges that patients face including access to GP services and the quality of their care.  

The public deserves honesty and courage from political leaders, commentators, and policymakers. Rather than skirting over facts by blaming GPs, who currently deliver over 31 million appointments per month in England, politicians need to be honest with the public on what kind of healthcare the population needs and what they are currently getting. 

The UK spends less per capita on healthcare than other comparable countries (0.27% of GPD compared to an OECD average of 0.51%). [8] The UK also has one of the lowest numbers of doctors in leading European countries relative to its population, behind Estonia, Slovenia, and Latvia (about 2.9 per 1,000 people, compared with an average of 3.5 doctors across the OECD). The OECD figure also includes hospital doctors which have grown. In England, between 2004 and 2021 the number of hospital consultants has risen by 83% (from 28,141 to 51,490). On the other hand, the number of permanent and locum qualified GPs in England has fallen with fewer GPs in December 2020 than the year before. The Nuffield Trust analysis shows the number of GPs relative to the size of the population has fallen in a sustained way for the first time since the 1960s with the shortage particularly marked in some English regions. 

Lack of an adequate GP workforce is only part of the problem. The recent media attacks on GPs highlights a total disregard for a workforce already at breaking point. A record number of GPs are seeking mental health counselling, and many are leaving the workforce by taking early retirement or working abroad. Therefore, the question that we must ask is: if the NHS collapses, who will notice it? Those with platforms to undermine the NHS will be unlikely to notice it. The elite has the means and resources to seek healthcare outside the NHS and even abroad, but for everyone else the collapse of the system will be catastrophic. 

The solution starts with putting a stop to attacks on GPs and the NHS by politicians and the permanently outraged sections of the media. Secondly, to achieve health outcomes comparable to other OECD countries, the NHS must tackle workforce shortages and the decline in quality of services. [9] The increasing health needs of an ageing population and the growing demand for better healthcare require more than alienating and undermining a workforce on whom the NHS depends. General practice could make better use of non-medical professionals such as social prescribers to reduce the workload and people could be sign-posted to services in the community without a GP referral. The administrative burden on primary care is also unsustainable and must be reduced; for example, by suspending CQC inspections. We also need a dialogue between the public, professionals, and politicians about what kind of primary care system they want in the UK; with plans then backed up with the appropriate level of investment. Health systems with a strong primary care infrastructure can achieve better health outcomes, improve patient experience, and reduce pressures elsewhere in the NHS. This should be the objective that we strive to achieve.

Mohammad Sharif Razai, NIHR In-Practice Fellow in Primary Care, St George’s University of London. Twitter: @mohammadrazai

Azeem Majeed, Professor of Primary Care & Public Health, Department of Primary Care & Public Health, Imperial College London @Azeem_Majeed

This article was first published in BMJ Opinion.

References:

1. NHS England. Primary Care. Available from: https://www.england.nhs.uk/five-year-forward-view/next-steps-on-the-nhs-five-year-forward-view/primary-care/ (accessed 19 September 2021) 
2. Patient Information. Where to get medication in an emergency. Available from: https://patient.info/news-and-features/where-to-get-medication-in-an-emergency (accessed 19 September 2021)
3. NHS England.  GP Patient Survey 2021. Available from: https://www.england.nhs.uk/statistics/2021/07/08/gp-patient-survey-2021/ (accessed 19 September 2021) 
4. Advice Services Alliance. The role of advice services in health outcomes: evidence review and mapping study. 2015. https://www.thelegaleducationfoundation.org/wp-content/uploads/2015/06/Role-of-Advice-Services-in-Health-Outcomes.pdf.
5. The Commonwealth Fund. Mirror, Mirro 2017. Available from: https://www.commonwealthfund.org/interactives/2017/july/mirror-mirror/ (accessed 19 September 2021)
6. The Commonwealth Fund. Mirror, Mirror 2021. Available from: https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly (accessed 19 September 2021)
7. Royal College of General Practitioners. College sets record straight on face-to-face GP appointments. August 2021. Available from: https://www.rcgp.org.uk/about-us/news/2021/august/college-sets-record-straight-on-face-to-face-gp-appointments.aspx (accessed 19 September 2021)
8. The Health Foundation. The UK spends less on capital in health care than other comparable countries. 2019. Available from: https://www.health.org.uk/news-and-comment/charts-and-infographics/the-uk-spends-less-on-capital-in-health-care-than-other-comp (accessed 19 September 2021)
9. Papanicolas I, Mossialos E, Gundersen A, Woskie L, Jha A K. Performance of UK National Health Service compared with other high income countries: observational study  BMJ  2019;  367 :l6326 doi:10.1136/bmj.l6326