This article appears as part of the Inside the NHS newsletter.

Among the many things hanging in the balance as the nation goes to the polls is the future of general practice.

Across the UK, practices are closing and patients are finding it harder than ever to get appointments.

How did we get here – and how do we fix it?

Partnership model

New data this week revealed a major milestone in the decline of general practice as the number of fully-qualified GPs working in NHS England who are GP partners has dipped below 50% for the first time in the history of the NHS.

By headcount, as of May 2024, just 18,781 GPs in England were partners – the doctors responsible for owning and running a practice – out of a total of 37,575 GPs (excluding specialist trainees).

Scotland has been following a similar downward trajectory, although we have not yet crossed that particular Rubicon.

By headcount, between 2012 and 2023, the percentage of the fully-qualified GPs in Scotland who were partners fell from 84.9% to an all-time low of 71.4%.

In Scotland, as in England, more and more GPs are opting to work on a salaried basis instead, or as locums.

Many younger doctors are avoiding partnerships altogether while older GPs are retiring or quitting partnerships in favour of working as salaried or locum GPs without the financial and administrative burden of keeping a practice afloat.

As a result – on both sides of the border – practices are disappearing.

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More than 1000 GP surgeries have closed in England over the past decade, while Scotland has lost a commensurate 97 practices.

Some have been taken over and merged into neighbouring GP partnerships, some are now '2C' practices run directly by the health board (a much costlier option for taxpayers), and some are just gone.

Meanwhile, the GP workforce – in real terms – has shrunk.

This is partly because GP partners are much more likely than their salaried and locum colleagues to work full-time. Counted as whole-time equivalent (WTE), Scotland's GP workforce has declined by 5.4%, from 3,675.1 in 2013 to 3,478.4 in 2023.

At the same time, patient demand is up: there are 7.1% more people registered with a GP practice in Scotland now than a decade ago, and the number of those patients who are aged over 65 has ballooned by 19.3%.

If you've ever wondered why it's harder than it used to be to see a GP, this is why.

But why has it happened?

Scotland's GP workforce has declined by 5.4% from 2013 to 2023 (Image: Derek McArthur)

Funding

If the polls are accurate, Wes Streeting will be health secretary in a newly-elected UK Labour government by the end of the week.

Given that health is devolved, he will be solely responsible for what happens to the NHS in England.

Nonetheless, policymakers and medics north of the border will be watching with interest to see what happens.

Mr Streeting recently conceded that general practice "is on the brink of collapse" and that "unless we fix the front door to the NHS in general practice, we’re not going to get the rest of the system working".

He has promised to pilot Neighbourhood Health Centres – hubs bringing together GPs, physiotherapists, nurses, care workers and health visitors under one roof with evening and weekend opening hours – along with more controversial financial incentives (GP practices that provide better continuity of care would receive higher funding).

This is part of an over-arching promise to divert "billions of pounds" from hospitals to primary care (exactly how much is unclear).

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In England, as in Scotland, general practice has been getting a smaller and smaller slice of the health budget pie (roughly 8% now compared to 11% 20 years ago) – and most experts blame this for the exodus of GP partners.

If the cost, stress, and liabilities of being a GP partner outweigh the benefits, fewer and fewer doctors will take it on. At some point, the whole system unravels.  

Of course, the Scottish Government could choose to allocate a larger share of its health budget to general practice and primary care – but if Westminster do it first, it will be harder to find excuses not to.