There is a Chinese saying, “If we do not change direction, we shall arrive where we are heading”. As the NHS emerges from the multiple consequences and challenges of the pandemic, will we find ourselves on the right road?

The NHS will continue to deal with emergencies, large and small, to provide access to specialist investigations and treatments, to give children a good start in life and to help people die in comfort and with dignity, but an increasing challenge will be supporting and enabling people to live well with multimorbidity.

Multimorbidity is not a single entity and varies from the accumulation of physical problems with old age to the combinations of physical, psychological, and social problems in deprived areas which make longevity a distant prospect. But while people with multimorbidity are all different, their needs are the same –namely unconditional, personalised continuity of care, building the knowledge, confidence and ability to live well, to make good use of services, and to avoid or delay complications.

It is often said that about 15 per cent of consultant vacancies in NHS Scotland are unfilled, suggesting a crisis, but this needs to be viewed in context. In the last two decades the numbers of hospital consultants and specialists working in community health services have increased by about 50%, while the number of general practitioners has stayed more or less the same. The resulting imbalance of specialist and generalist services has had big consequences.

Specialist services are important, and often brilliant, but leave a lot for general practice to do in terms of patients who do not meet referral criteria, have difficulty in accessing services, are not made better by treatment, have conditions outside specialist interest and are discharged from specialist care.

With post-Covid syndrome, catching up with chronic disease management and the increasing health impacts of poverty and financial distress, workload in general practice has increased. Exhausted GPs are retiring early. The capacity of general practice (the “community sink” into which all sorts of problems have traditionally been poured) can no longer be taken for granted.

With nearly 90% of NHS patient contacts taking place in primary care, a reduction to 88% is imperceptible in the community but the impact in hospital, from 10% to 12% is huge. Understandably there are calls for increased A&E resources, but when a ship is listing to one side it is not the side nearest the water that needs extra weight.

The gatekeeping role of general practice is not confined to writing referral letters. Patients can attend A&E at any time but when the complications of their conditions have been prevented, when they are confident in their care and have ready and reliable access to a small team of health professionals whom they know and trust, they choose not to. The elegance of this aspect of gatekeeping is that there is no gate.

It is possible, of course, to live long and well without the help of doctors but in Scotland the 10% of patients with four-plus conditions account for nearly 50% of potentially preventable hospital admissions. Such patients are generally excluded from research and the evidence base but keep the NHS busy and are most in need of unconditional, personalised, continuity of care, building knowledge, confidence and agency.

A study of 700 consultations in general practice showed that affluent patients with multimorbidity had 25% more time with their doctor than deprived patients with similar levels of multimorbidity – a feature of NHS Scotland whereby everyone has equal access through the front door but not equal access to needs-based care. Despite premature mortality and multimorbidity increasing two-to-three-fold across the social spectrum, the distribution of GP manpower is virtually flat, especially in the more deprived half of the population.

The road we are on is paved with good intentions but has led us into three undesirable situations.

First, an archipelago of efficient, centrally-managed, specialist services in hospital and the community has fragmented care and increased the “treatment burden” of patients with multimorbidity ie. the work that patients do in accessing different services for different conditions.

Second, the weakened capacity of general practice exposes emergency services to patients whose preventable complications and crises have not been prevented.

Third, the gap between what GPs can do and could do for their patients with more time, better connections and better support is greatest in deprived areas.

Key features of the NHS at its onset were access, taking money out of the doctor-patient consultation and reducing the appeal, for those who could afford it, of private medicine. For individual families the best protection lay in all families being protected.

These features are still important, but healthcare has new challenges, especially in its contribution to improving population health. If healthcare is not at its best where it is needed most, inequalities in health will widen, as some groups benefit while others do not.

To paraphrase George Orwell, the argument that politics should be kept out of health care is itself a political statement, favouring those who benefit most from current arrangements.

Of its own accord the NHS does not travel in a straight direction but veers to the pull of special interests, including managerial, professional, and public. If politicians take their hands off the wheel, we shall arrive where we are heading.

Graham Watt is Emeritus Professor of General Practice and Primary Care at Glasgow University