Has COVID changed opinions on nationalising general practice?

The pandemic has led the UK health secretary into a debate about whether GPs should be directly employed by the NHS. Azeem Majeed argues that this is an opportunity to correct a flawed model, but Simon Hodes says that partnerships are still the best model for primary care

CREDIT: This is an edited version of an article that originally appeared on The BMJ

Azeem Majeed, professor of primary care and public health

The intense micro-management of general practices by NHS England since the start of the COVID-19 pandemic has shattered the illusion that NHS GPs are truly ‘independent’. For example, during the pandemic, NHS practices often received weekly updates from NHS England on how they should provide primary care services. The opening hours and working arrangements of general practices are also highly regulated by NHS England and GPs are not independent contractors in the way that professionals working in other fields, or indeed primary care physicians working overseas, would recognise.

GPs are not even able to offer private medical services to their patients in the same way as NHS trusts or dentists. In effect, they have all of the disadvantages of being self-employed contractors and none of the benefits of being NHS employees.

A decade of underinvestment

For more than a decade primary care in England has suffered from under-investment and a lack of key staff such as GPs and practice nurses. In contrast, the NHS hospital sector – although not without its own problems – has seen its funding and medical staffing increase at a much quicker rate than NHS primary care, yet more NHS work continues to be shifted to primary care without being followed by a commensurate increase in funding and staffing. Attempts by NHS England to prevent this, such as introducing the NHS hospital contract, have failed.

Clearly, NHS England is not going to invest adequately in the current independent contractor model of general practice, so being a GP partner is increasingly unattractive for younger GPs. It’s therefore time to look seriously at the alternative – GPs becoming salaried employees of the NHS.

Of course, being employed by the NHS is not a panacea. Many NHS staff employed by NHS trusts suffer from stress and overwork, just like those working in primary care, but they’re not personally responsible for the ownership of their employing organisations, and their income doesn’t depend on how well their organisation performs financially. Their working hours are also better-regulated than those of self-employed GPs.

If GPs had employment contracts similar to those of NHS consultants they could then have job plans with time allocated for activities such as quality improvement, NHS management, teaching, training and research; currently, these activities are often done on top of their regular working hours.

Working in organisations that employ large numbers of GPs would also create opportunities for a better career structure – for example, it may be possible to create posts for GPs who specialise in areas such as the care of elderly people, or child health, as well as for GPs who take on clinical leadership, quality improvement and NHS management roles in addition to a clinical role.

Finally, GPs becoming NHS employees would make NHS England directly responsible for delivery of primary care services, just as it already is for specialist services, and it would be the responsibility of NHS England – not GPs – to ensure that patients have timely access to a comprehensive range of high-quality primary care services and the infrastructure needed to deliver this care.

An increasing proportion of NHS GPs are already salaried, so the future for GPs looks to be heading in this direction. The question for GPs is, ‘Do they want to be employed by the NHS, with similar terms of employment to consultants, or do they want to be employed by private companies and ‘mega-partnerships’, with the inevitable variability in terms of the employment they will offer?’

Simon Hodes, GP partner

Since the NHS was founded in 1948 GP partners have been classed as self-employed practitioners. To this day, GP partnerships function as small-to-medium sized businesses contracted by NHS commissioners to provide care in a geographical or population area. Although England’s health secretary, Sajid Javid, recently mooted ‘nationalising’ general practice, that same week the BMA announced plans for a ‘new deal’ for general practice based on the independent model.

Each general practice can organise itself to provide services to the NHS in the most efficient and flexible way possible in its local area. Partnerships offer accountability, responsibility and exceptional value for money; this has been highlighted during the pandemic, as GPs have responded rapidly at a local level to help protect their communities. GPs remain at the heart of health promotion and prevention strategies, tackling health inequalities and providing mass vaccination – all key determinants of health.

All of this for around £3 per week per patient, paid to the practice.

In recent years policy has pushed England’s general practices into ‘primary care networks’ serving 30,000-50,000 patients, with a clinical director at the helm – potentially reducing the need for so many partners in the constituent practices. Large group general practices (or ‘super practices’) are run by small numbers of managing partners or by private companies. There has been much disquiet about US companies buying up chains of NHS general practices.

Continuity of care is best provided by stable GP teams – which are traditionally led by partnerships. Continuity has a strong evidence-base for reduced morbidity and mortality, improved patient satisfaction, reduced referrals, safer prescribing and lower admission rates. It also leads to improved efficiency, as well as higher satisfaction for both patients and healthcare professionals.

Changing landscapes

Although the majority of GPs remain as partners, it’s true that the percentage is falling. Over the past 20 years we’ve seen a major shift away from newly qualified GPs seeking lifelong partnerships, to a generation of GPs seeking salaried, locum, or portfolio work. There are many reasons for this, including concerns about uncapped hours and responsibility, building liabilities and a narrowing gap in earnings between partners and non-partners. Historically, an income was attracted for each partner to each practice, but this was scrapped under contract changes – and many would argue that this triggered the demise of partnerships as we know them.

GP teams are working ever harder – expanding in size and workforce – with increasing reliance on allied healthcare professionals, any of whom could, potentially, become partners to support a dwindling workforce while caring for an ageing, growing population living for longer with more complex health needs and long-term conditions. GPs remain the ultimate generalist specialists and, perhaps, this needs to be recognised in consultant status. 

While the number of GPs is falling, the number of patients per GP in the UK is rising rapidly. The government’s 2019 GP Partnership Review concluded, ‘We need a clear vision for the future and the role that general practice and partnerships will play in that’. The NHS Confederation commented that, ‘our members report support for the current model in terms of its basis in serving local populations of registered patients which facilitates continuity of care’.

Updated independent partnership model

GP teams deal with around 90% of all NHS patient contacts – for less than 10% of the overall NHS budget. As the NHS Five Year Forward View says, ‘If general practice fails, the NHS fails’.

It’s understandable that a new generation of GPs don’t relish the responsibility, workload and financial commitment required in owning and running a practice, including estate planning and organising staffing but, ultimately, the autonomy this brings – and the ability to plan your own destiny, prepare your working environment and shape your workforce and strategy – is what attracts many GPs to partnership and continues to provide so much long-lasting job satisfaction.

Policy-makers cannot sleepwalk into the GP crisis any longer; they must invest in the best model of care delivery. For now, that is almost certainly still best-provided through an updated independent partnership model.