Is it time to make most GPs salaried NHS employees?

GPs are the lynchpin of primary care. Every year, Scots have more than 25 million appointments in general practice. This is on top of several million extra appointments across dentistry, community pharmacy, and out of hours.

Getting primary care right matters to everyone. And research published by the think-tank Policy Exchange has set out proposals to transform the model for the decades to come. In the report we look specifically at the NHS in England, although the vision outlined could apply equally in Scotland too.

Our main call is for smaller general practice surgeries to be incentivised to merge to form larger healthcare organisations. This could be with neighbouring practices or join up with their local hospitals. GPs would then become predominately salaried over the next decade – leading to the phase out of the independent contractor model which has persisted since the NHS was first created in 1948.

We argue that the remit of GPs has become too broad. In an era of resource constraint, growing demand from an ageing population, and difficulties in recruiting and retaining GPs, the “expert generalism” of General Practice must be deployed more effectively.

Our proposals would signal the end of GPs as the first port of call for healthcare issues. Other healthcare professionals, often with specialisms in areas such as physiotherapy or social prescribing, would pick up the slack.

The recommendations have caused plenty of controversy. Many current GP partners are proud of their status as small business owners, contracted by the NHS each year to deliver services on its behalf. Making them full-time NHS employees would mean a loss of autonomy, the theory goes, and with it the ability to innovate to design services in a way that best meets their patients. So why make this change? And to what extent could a new type of model apply in Scotland too?

The starting point needs to be the patient. Ask readers of this newspaper what they want from general practice care and similar things would come up. Speedy and convenient access, either remotely at home or, if physically, as close to home as possible.

Evening and weekend appointments should be available. Some, often those with complex needs, would value consistent contact with the same group of clinicians. For everyone, it is essential that different healthcare professionals have all their up-to-date information, covering their conditions, treatment, and medicines.

We need to design the system around these needs and work back from there. Patients don’t care about the historic divides that separate hospitals and GP surgeries. Many are unaware of the independent contractor status, and when asked, the vast majority (73 per cent of Scots according to a 2020 poll) think GPs and other colleagues in primary care should be salaried NHS staff.

Can the partnership model deliver against the things which matter to patients in 2022? It is difficult to determine exactly how the model is currently performing. There’s no data on performance or how the money gets spent. In Scotland more than a billion pounds a year is given to GPs, but they are effectively trusted to run the service to the best of their abilities with limited routes to accurately measure the value obtained.

This also creates issues when it comes to responsible sharing of data. When you ask patients, they want a single electronic patient record across all care services, which can be used for electronic test results, and correspondence. Yet whilst the care record itself is owned by the patient, GP practices have historically been the designated data controller and processor.

This means that each of the 1,000 GP practices in Scotland must decide whether that information is shared with other care providers.

Local arrangements might have worked well in the past, but this fragmented way of sharing and controlling data feels out of kilter with the 21st century – especially when as consumers we have grown accustomed to a high standard of digital experience in other parts of our lives.

The Scottish Government is already leading the conversation on how we can improve data sharing, with a proposal to move towards joint controllership. This should lay the foundations for proactive and appropriate sharing of information and Policy Exchange want to see joint controllership now rolled out across England too.

The workforce mix within general practice is another justification for change. Many current GPs in Scotland are contemplating retirement. Others, meanwhile, are opting for “portfolio” careers with greater flexibility over working hours and contracting. And fewer young GPs have the confidence to take on responsibility for running a business. This last point is a generational shift which reflects the liabilities of running a partnership.

One of the biggest is the financial risks of owning a practice building. If there is an issue with a leaking roof or a broken door, the partner is ultimately responsible. It would be unthinkable to imagine a consultant or surgeon at the local hospital having to spend their time on the phone to building contractors, so why should GPs still shoulder this responsibility?

Efforts are under way to reduce the premises risk, but this type of responsibility is preventing GPs from operating at the top of their licence; the latest survey data show that GPs spend less than 60% of their time on direct patient care.

We think that GPs should be freed from business administration, whilst ensuring that the best bits of being a partner – the ability to have a leadership position as part of a clinical team, to deal with complex care and to innovate in service delivery – are mimicked under a new model. Far from a threat to general practice, this new model would be more attractive and safeguard its future.

One of the biggest criticisms levelled at our plan has been around continuity of care. If you scale back the family doctor role, and bring allied healthcare professionals into the mix, how will you retain relationship-based medicine? We acknowledge that there is compelling evidence around the benefit for certain patients, such as those with dementia, receiving ongoing care.

But each GP is responsible for 2,000 people. Even if GP numbers were doubled, would it be realistic or even desirable for each doctor to know the names, family histories and backgrounds of 1,000 people simultaneously?

We should be aiming towards a different type of system; one which is intelligent enough to understand that different patients have different needs, and to plan those services to match.

Technology has a role here too – for example correcting historic imbalances in access to general practice between rural and urban areas in Scotland through greater use of video consultations.

We hope our research will spark a constructive debate on the future direction of general practice within primary care.

Policy Exchange is not the first organisation to have called for this change – in 2017 a Committee of Peers in the House of Lords chaired by Lord Narendra Patel, the renowned obstetrician, and former Chancellor of Dundee University, described the independent contractor model as”no longer fit for purpose”.

As we begin to emerge from the pandemic, the door is clearly open to radical solutions that can lead us to a more preventative system which puts the emphasis on good health. This is a moment to be bold.

Robert Ede is Head of Health and Social Care at the think tank Policy Exchange