The SNP promised 800 extra GPs. Five years on, we have 61

Fast-forward to the present - the halfway point - and how far have we actually come in reaching that goal?

The answer is pretty dismal: according to Public Health Scotland’s own statistics on headcount, updated earlier this week, the general practice workforce in Scotland increased by just 61 GPs between 2017 and 2022.

To achieve the target, we would have to find an extra 739 GPs between now and 2027.

No one in the profession believes that is a realistic possibility, despite now-Health Secretary Humza Yousaf insisting that the Government remains committed to it.

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Worse still, counted in real terms the GP workforce has actually shrunk over the past five years, from an estimated 3,575 in 2017 to 3,494 in 2022 - a decline equivalent to losing 81 full-time doctors.

This partly reflects a steady climb in the proportion of female GPs, who now account for 62 per cent of the GP workforce (compared to 57% in 2017) and who are also more likely to work part-time. Maternity leave was also the biggest source of GP absence

GP numbers have increased slightly by headcount, but in real-terms the size of the workforce has shrunk once part-time working is adjusted for (Image: PHS)

This is why counting GPs on a “whole-time equivalent” basis - where one GP equals eight clinical sessions per week - shows a shrinking workforce. A “session” is defined as a four-hour period of patient appointments.

At the same time, younger GPs are less likely to be working full-time than those aged 50 to 59.

Younger GPs are also less likely to be GP partners (the GPs who own and run practices) and GP partners tend to work more sessions per week than salaried GPs (those employed by a practice, but without a financial stake in it).

As of March this year, 72% of the GP workforce in Scotland (by headcount) were partners, down from 77% in 2012.

Little wonder then that, back in August 2019, Audit Scotland warned that reaching the 800 extra GPs target would be “challenging”, noting: “The increase in the proportion of GPs who are salaried rather than partners, and the pattern of younger GPs increasingly working part-time, is likely to mean that for every GP that retires more than one will need to be trained and recruited to replace them.”

Put simply, GPs are quitting or retiring faster than they can be replaced.

These trends combined signal a looming crisis not only for general practice, but for the NHS as a whole.

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If an ever-smaller percentage of GPs are willing to take on the burden of owning practices then a gradual slide away from the independent contractor model towards a salaried service becomes inevitable.

Over the years there has been a suggestion that successive governments have disinvested in general practice precisely because the existing model opens the door to potential profiteering - whereby GP partners can opt to limit their practice expenses in order to boost their own take-home pay.

Overall, however, the independent contractor model delivers much better value-for-money for taxpayers compared to practices which have to be taken over an run by health boards - something that is likely to become increasingly common as partner numbers dwindle and spiralling overheads (from energy costs to rent for premises) see practices implode.

GPs are dealing with a growing number of patients whose health is deteriorating while they wait for inpatient (top) and outpatient (above) care (Image: PHS)

GP partners are angry, for example, that the UK-wide 4.5 per cent pay award for doctors will not apply to them.

While they are contractually obliged to give the salaried GPs employed in their practice a 4.5% uplift, few - if any - practices will be able to afford to award similar increases to the GP partners.

Normally, Government calculates funding increases to cover practices’ non-staff running costs (lighting, heating etc) based on CPI inflation. It is this pot of money which practices then put towards partner pay rises.

This year, however, the hike was just 4.5%, which - given the soaring costs of gas and electricity - will leave little for partner pay.

How much GP partners will see their earnings increase by will vary from practice to practice depending on their costs, but estimates for England suggest that the average uplift will be just 2%.

With scenarios like this, why would younger GPs want to be partners?

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It also comes at a time when morale has been eroded by rising workload, with patient numbers up and complex health problems exacerbated by everything from the cost-of-living crisis to huge backlogs for hospital treatment.

In November, BMA Scotland recommended that its members should limit patient consultations to a maximum of 25 per day - fewer if patients required complex care.

This was met by scepticism from many GPs who said such as threshold was impossible to apply given current demand. In some cases, practices are carrying out around 70% more consultations per week than they were in 2019.

Inevitably such a move - if applied universally - would also spark criticism from some patient groups, politicians and sections of the media at a time when GPs have been (unfairly) accused of “refusing to see patients face to face”.

Patient numbers have been climbing steadily since September 2020. The number of people registered with a GP exceeds the population due to people who have since left Scotland - such as students - failing to de-register (Image: PHS)

Recent data from England indicates that roughly two thirds of GP appointments now are done face-to-face compared to around 80% pre-pandemic - hardly a massive slump considering that telephone appointments will be more convenient for many patients.

There is no national data for Scotland, but the picture is likely to be similar.

Whether it is feasible or not, limiting patient contacts to 25 per day could have a dual-benefit of reducing stress and improving GP retention, while also providing safer care for patients. Exhausted doctors are more likely to make mistakes or miss red flag symptoms.

On the other hand, reducing GP appointments could also have the effect of spurring frustrated patients to turn to A&E departments instead, which are already bursting at the seams.

There are no easy answers, but unless GP numbers can genuinely - and substantially increase - general practice as we know it will not survive.