'It's falling apart': GPs on the future of general practice

He says his surgery overall is probably carrying out around 50 to 70 per cent more consultations with patients now than before the pandemic, yet appointments "disappear in the blink of an eye".

He said: "There's no capacity to meet demand. I wouldn't swap being a GP - but it's falling apart."

The medic, who runs the GP Survival Scotland Facebook group - a online forum for family doctors with 1,100 members - is one of many who fears for the future of general practice.

Most GPs have an exit plan, he said.

"Putting it bluntly, the majority of people I know have formulated a Plan B or C which will usually be retiring, emigrating, cutting their hours, or finding another post outside of general practice.

"It's becoming increasingly tenuous because the number of people with a Plan B is significant. A friend of mine quit his partnership a year ago to move to Canada. He has more time with patients, more money, and zero problems with recruitment."

By contrast, Mcintosh said he knows of one rural surgery in Scotland which has been advertising for a GP partner for two years without a single applicant.

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In recent weeks, BMA Scotland has warned that the profession is at a "tipping point" with a shrinking workforce and soaring demand.

Statistics published last week show that - by headcount - the GP workforce in Scotland has grown by just 2.2 per cent since 2012 at the same time as the number of registered patients has increased by 6%, including a 20% spike in the number of patients over 65 who require the most care.

In real terms, however, the situation is even bleaker: the number of GPs counted as whole-time equivalent is estimated to have plunged by around 241 (6.5%) since 2013 as more doctors - especially younger and female GPs - work part-time.

This also reflects a struggle to regain work-life balance, however, as many GPs working three days a week still rack up 36-plus hours once admin - from ordering blood tests to writing letters - is included.

At the same time, the proportion of GPs who are partners has dropped from 77% in 2012 to 62% now as many more opt for careers as salaried GPs, unencumbered by the responsibility of owning and running a practice.

Dr Andy Mcintosh (Image: Collect)

Mcintosh is among them. A GP for 10 years, he has done stints as a salaried GP as well as locuming - but has no desire to take on a partnership.

"If you spoke to most of us we'd say the partnership model is still what we need - but I'm not sure what can be done to make partnerships more attractive," said Mcintosh.

"What I do now enables me to be home when I need to be home - it allows me to control my hours, my workload.

"When you have a vacancy it falls to the existing partners to take on that workload as well as all the nuts and bolts of paying the bills.

"Seeing the general state of things, I don't think it's an attractive option for a lot of people."

The decline of the partnership model has implications for patients and the taxpayer. As partners leave or retire, practices which are unable to recruit replacement partners eventually fold.

The proportion of the GP workforce who are partners ('performer' - dark blue) is shrinking, with serious implications for how general practice will be funded and organised in future (Image: PHS)

At this point, patients might be might be transferred to neighbouring surgeries - resulting in many more patients competing for the same number of GP appointments - or the practice will be taken over by health boards, which is much more expensive than the independent contractor model and tends to provide less continuity of care for patients since practices are entirely staffed by salaried and locum GPs.

The Scottish Government insists it is on track to increase GP numbers by 800 by 2027, compared to the 2017 headcount, but Mcintosh believes any gain will be swallowed up by existing vacancies and an exodus of senior GPs.

Nearly one in three GPs (30%) in Scotland are over 50, with punitive pension taxes also incentivising many to retire early.

READ MORE: What happened to the promised 800 extra GPs?

Mcintosh fears that patients will find it harder and harder to see a GP, with doctors becoming a "spider in the web" increasingly reliant on other allied health professionals in the practice - such as nurses and physiotherapists - to manage patients.

He said: "The only way I see it going is where we do more and more triaging and filtering of patients to cope with demand, so it's going to become more than just a one-line 'can you tell me why you want to be seen?' thing from reception.

"Prioritisation will become more of a necessity. I don't think any of us really want to be the spider in the web - sitting in meetings having 16 different people reporting to us about Mrs Bloggs. We want to be seeing Mrs Bloggs. But realistically, that's not how things are going.

"I genuinely hope I'm wrong, but I don't see where the GPs are coming from."

In Edinburgh, Iain Morrison believes paying to see a GP will become more and more common.

Thousands more patients facing lengthy waits for hip and knee replacements have already been turning to the private sector, but independent hospitals are increasingly looking to set up GP clinics as well in a move that could make access to NHS appointments even tougher.

READ MORE: Wealthier patients 'should pay for GP appointments' to curb demand, says doctors group

"We're already seeing significant growth of that within Edinburgh," said Morrison, a GP partner in Dalkeith and chair of the Lothian Local Medical Committee (LMC), which represents the region's GPs.

He added: "Private healthcare companies have been making significant recruitment drives in the Edinburgh area.

"There were always some private GP services, because it's an affluent area, but it's ceding off the lack of capacity in standard practices and the more that grows, the more it will recruit away from the NHS, and the more the NHS will struggle to provide a service that the doctors and patients are pleased with, so it becomes a vicious cycle.

"Patients who are unhappy will go private - if they can - and the private sector will recruit more and more doctors from the same pool, so we will see the indirect creation of a two-tier system.

"You're already seeing it with elective surgery, and outpatient specialties, but once it happens in general practice then it will be very difficult to maintain the NHS as we know it."

Dr Iain Morrison (Image: Lothian LMC)

Morrison said a dwindling number of GP partners in the capital is leaving many practices in a precarious situation.

He said: "There is a focus of closures in the south-east of the city which is having a knock-on impact for the remaining open practices - it's a bit of a pack of cards really.

"We're now getting patients allocated to practices significantly outside their area which is very inconvenient for those patients and makes it very difficult to offer them a full service, like home visits.

"There will be inevitable consolidation of practices.

"In Lothian they're doing everything to avoid '2C' [heath board run] practices, but until we get the workload concerns addressed we will continue to struggle to recruit.

"There's a junior doctor in my practice who's very keen to become a GP, but of all his friends who've just qualified he's one of only two who are staying in the UK. They're all off to Australia and New Zealand.

"I did that myself and I came back - but I just fear the way things are now, if you have that mobility, fewer and fewer will return."

READ MORE: Rural GPs vote to reject new Scottish GP contract 

Remote and rural areas, where GP practices are more often "single-handed" - owned and run by one partner - are particularly vulnerable.

In Wick, Caithness, Ewen Pearson is one of the youngest GPs in the region at 46.

He took over his practice from his father, but struggles even to find locum cover for holidays.

As partners have left or retired, neighbouring practices have merged or been taken over by NHS Highland - with some patients opting to register with Pearson instead.

"My list size has gone from 2,200 to 2,380 in the past six months alone," said Pearson, whose practice also has a physiotherapist and a nurse.

"We were performing better in terms of patient satisfaction, so I can understand why patients move over, but it creates this snowball effect because we become busier and access becomes harder, and the patients who move tend to be the ones who have chronic health problems.

"They come over and they need more help and attention, but that just means there's less to go round.

"There's nobody in their 30s coming up to take over partnerships, and I don't blame them.

"It's grim really. It's like the Highland clearances again."

The number of GP practices in Scotland is falling as surgeries close or merge, leading to larger practice lists on average (Image: PHS)

BMA Scotland recently advised its GP members to limit themselves to a "safe threshold" of 25 patient appointments per day, but Pearson said if he stuck to that his patients would be "waiting three or four weeks" to see him.

"That's just a poor service, and then it feeds into people getting sicker," he said.

An Aberdeen University study this week warned that patients listed for hip replacement surgeries in Highland in July could face waits of seven years in a worst-case scenario unless surgical rates increase.

Pearson is already seeing the impact first-hand.

He said: "We're seeing patients wait more than 18 months - even to two years - for hip replacements and knee replacements who end up on morphine basically - addictive, high dose painkillers.

"One lady had her operation cancelled four times. She got her operation done but then she was stuck on morphine and it took a long time to wean her off it.

"Ten years ago that just wouldn't have been happening."

Dr Ewen Pearson (Image: Collect)

As for his own future, unless Westminster eradicates the pension charges which are penalising senior doctors, Pearson says he will be forced to quit his partnership within a few years.

"People are having to pay to work - it's crazy," said Pearson.

"And the only way to mitigate those bills is to cut your hours or your sessions which, as a single-handed GP, means I'd have to resign and do fewer hours as a locum."