WEALTHIER patients should be charged a fixed fee for GP consultations "in a bid to reduce demand" on overstretched practices, a group of family doctors has said.
The suggestion has been put forward by the Grampian Local Medical Committee (LMC) as GPs from across Scotland prepare to hold their first in-person conference since the pandemic in Clydebank today.
It comes amid warnings that general practice in Scotland is at "breaking point" with figures from a workforce survey estimating that GP numbers have fallen in real terms from 3,613 in 2019 to 3,494 in 2022 at a time when the number of patients registered with practices has increased by 1.8 per cent.
The results of BMA Scotland's wellbeing survey, shared exclusively with the Herald ahead of today's conference, also found that 75 per cent of the GPs who responded are more likely to quit the profession, retire early or cut their hours over the coming year as a result of "excessive workload".
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Dr Andrew Buist chair of BMA’s Scottish GP Committee (SGPC) will today call for a national conversation on the future of the NHS, warning that without urgent changes "we risk sleepwalking into the death of general practice as we have known it".
Among the options tabled for debate are proposals from GPs at Grampian LMC which call on the Scottish Government and SGPC "to consider the introduction of limited co-payments, excluding patients who are unable to pay, as a way to reduce demand in general practice and not to subsidise current funding streams".
Co-payments are more commonly found in insurance-based healthcare systems where a patient is required to pay a certain amount, for example on each visit to a doctor.
Higher-earning patients in Ireland, where there is no NHS, pay €45 to €65 per GP consultation (£39-56) and there is some evidence that the model curtails unnecessary demand.
In the UK, where GP access is free universally, uptake of appointments tends to be disproportionately higher among more affluent patients - helping to exacerbate health inequalities.
The proposals are the latest to open the door to a two-tier NHS, with controversial leaked minutes revealing that some health board directors had suggested asking wealthier patients pay for operations to help subsidise the cash-strapped service.
First Minister Nicola Sturgeon has ruled out the move, with similar suggestions for general practice also likely to be vetoed by the Scottish Government.
However, there is growing anger among the profession that promised support staff have failed to materialise, with fears that spiralling energy costs will make some GP surgeries "financially unviable".
Only 18% of GPs who responded to BMA Scotland's wellbeing survey said they would recommend a career in general practice, down from 28% a year ago.
Dr Buist, a GP for 30 years, said he now counts himself among those reluctant to recommend general practice, saying that the "sheer volume of workload in excess of our capacity has made the job unbearable at times".
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He said GPs require "the backup of a full multi-disciplinary team", including pharmacists, physiotherapists, mental health workers, and nurse specialists, to reduce GP workload and enable doctors to spend more time with the most complex patients.
A key plank of the 2018 Scottish GP contract envisioned the creation of these multi-disciplinary teams (MDTs) embedded in or directly available to every practice in Scotland, but employed by the local health board.
However, nearly five years on deployment of MDTs has fallen short due to NHS-wide shortages of the required professionals.
Dr Buist said: “Without this change we risk sleepwalking into the death of general practice as we have known it.
"We can make general practice a great career choice again – at the heart of this must be making working as a GP not just bearable and manageable but actually getting the joy and satisfaction back into the job.
“Once again, we make the plea for a national conversation on the future of our NHS – honest and open communication involving the public, politicians from all parties, key stakeholders, clinicians and other healthcare workers.
"What should we expect from our NHS, how are we going to properly fund it and how can we deliver it?”
Ahead of today's conference, GPs at Lothian LMC said the independent contractor model - the cornerstone of general practice since the inception of the NHS - "is no longer fit for purpose".
They also warn of a "GP retention emergency", adding that the "mismatch between the GP workforce and present workload...poses a significant risk of harm to all".
It comes as figures this week showed that GP numbers, counted as whole-time equivalent (WTE), have fallen by 119 since 2019.
In 2017, the Scottish Government pledged to increase the number of GPs in Scotland by 800 by 2027, but only in terms of headcount - which does not take into account an increasing trend toward part-time working.
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Family doctors attending today's conference have called on the Scottish Government to provide clarity on "the number of patient facing sessions and whole-time equivalents for the mooted additional 800 GPs for Scotland".
GPs at Fife LMC also warn that "the rising cost of living and energy bills will make practices financially unviable" for the GP partners who own and run practices, with "potentially harmful consequences for patient care and further destabilisation of the NHS".
Meanwhile, Dumfries and Galloway LMC warned that the shift towards a health board-employed MDT model "incentivises the development of multi-site practices" whereby a small number of GPs are stretched across several surgeries belonging to the same GP group, with the bulk of staffing made up of allied health professions.
This "risks the demise of the longitudinal family practice in favour of transactional practice which is not in patients bests interests or the interests of the profession," they add.
GPs at Glasgow LMC also say that practices are facing "increasing demands following patients having undergone surgery in the private sector, both in the UK and abroad" who require subsequent care by the NHS, adding that it "deplores the lack of specialist follow up care that is being provided to those patients".
A Scottish Government spokeswoman said: “We are immensely grateful to GPs and GP Practice staff up and down the country who do an incredible job in a period of significant challenge. We are absolutely committed to ensuring that being a GP remains an attractive career choice with a manageable workload.
“Despite the pandemic, we have recruited 3,220 whole time equivalent healthcare professionals to provide support to GPs, underpinned by an investment commitment of over £500 million.
“We have a record number of GPs working in Scotland and are committed to 800 additional GPs by end 2027.”
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