Although he has still to reveal the details five months after flagging it up in the Times, health secretary Sajid Javid is still pushing a radical proposal to transform the primary care landscape – by turning every GP partner into a salaried NHS employee by 2030.

Since The Lowdown first analysed the proposal and possible motives behind its introduction, the momentum behind Javid’s plan has picked up. The publication in March of a report from the right-leaning Policy Exchange thinktank was praised by Javid as a “pragmatic contribution to the debate on the future NHS”. It  said that GPs should become predominantly salaried within large-scale providers. Just two weeks ago, he told the audience at the NHS Confederation’s Expo conference that, “I will be setting out my plan shortly.” 

However, some aspects of Javid’s salaried GP proposal may prove troublesome, judging by a statement from one commercial participant involved in two pilot programmes. 

Despite the health secretary’s enthusiasm for commercially developed, app-based NHS services access to these services looks unlikely to become widely available for some time. The CEO of Babylon Health told investors last month his company was “very cautious” about expanding further in the UK while it continued to lose money on every NHS patient it sees. It already offers digital access to NHS patients in pilot programmes in London and Birmingham (via its GP at Hand service), and in Wolverhampton (in a five-year deal with the local NHS Trust).

GPs blamed

Meanwhile, one or two elements of the media are still promoting the notion that GPs operating under the partnership model are the root cause of serious problems within the NHS. This month the Care Quality Commission told Pulse that the Mail on Sunday and Mail Online had each misrepresented the results of a minor survey the CQC had commissioned, jointly with just one hospital trust, to suggest that nationally almost 5 million visits to hospital A&E departments were directly attributable to “a lack of access to GPs”. NHS Confederation primary care director Ruth Rankine recently outlined the impact of this type of negative coverage, saying, “Health leaders want to see an end to the constant barrage of criticism faced by GPs and those working in primary care from some parts of the media and political sphere, something which is further demoralising an exhausted workforce.

Fundamental issues

Inequitable funding and recruitment failures – rather than any perceived shortcomings of the partnership model – remain crucial factors behind poor GP access in deprived areas. At the end of May, new analysis from the Nuffield Trust revealed a major factor in the difficulties some patients have getting an appointment to see their GP: widespread disparities in GPs’ patient lists. Its research found that in some regions individual GPs were responsible for more than 2,500 patients each, while in other regions doctors only had to care for half that number. The reverse side of the coin showed that areas such as Portsmouth and Hull had around 40 GPs per 100,000 inhabitants, while the Wirral and Liverpool had double that tally of doctors.

Calls for practices in deprived areas to receive a greater share of funding are therefore growing. NHS England head of primary care Dr Nikki Kanani told the audience at the same NHS Confederation Expo conference that Javid attended, “We still have fewer members of primary care working in more deprived communities, which means [patients there] get poorer care, and those practices get less money.” Currently, for every 10 per cent increase in a practice’s ‘multiple deprivation score’, payments only go up by 0.06 per cent.

Poor workforce planning is central to the current shortages of GPs, and was one of the key points of a campaign launched in March by the BMA and the General Practitioners Defence Fund, with the backing of Health and Social Care Committee (HSCC) chair Jeremy Hunt. “I think the government has got its head in the sand when it comes to workforce pressures in the NHS,” Hunt told the BMJ. “The workforce crisis is the biggest issue facing the NHS. We can forget fixing the backlog unless we urgently come up with a plan to train enough doctors for the future and, crucially, retain the ones we’ve got.”

With the latest survey, published last month, from the RCGP showing nearly 19,000 GPs and trainees are set to leave the profession over the next five years, it’s clear that the mismatch – one that existed long before the pandemic, despite claims to the contrary from the health secretary – between falling GP numbers and rising demand for patient care is set to grow. 

The results of the RCGP survey prompted NHS Confederation primary care director Ruth Rankine to say, “There are now 1,600 fewer GPs in post than in 2015 and alarmingly this survey shows that those numbers could yet rise further. At the same time, according to the latest NHS performance statistics primary care staff are carrying out 50 per cent more activity than they were at the same point two years ago. In 2019 the Government pledged to increase GP numbers by 6,000, unfortunately it is now clear this target is not going to met.”

The figures Rankin highlights underline the continuing governmental failures over the past 12 years to address the issue of GP numbers. Just consider the following: 

– Recruitment from abroad has long been used to boost NHS numbers, and the trainee GP sector is no exception. But just last week Pulse revealed that only 124 doctors recruited via NHS England’s international programme are still practising here – only 155 GPs had actually been recruited under the programme between 2018 and 2021, against a target of 2,000, and 31 had already left the programme during the same period. Brexit has perhaps justifiably been cited as one reason for these low numbers, with BMA spokesperson Dr Kieran Sharrock explaining, “You’ve got to remember that this all coincided with a period when the UK voted to leave the EU. The doctors who were being recruited were being recruited from across the EU and it created significant uncertainty for them.”

– And adding to that sense of uncertainty must surely be the risk of deportation. Earlier this month RCGP professional development vice chair Dr Margaret Ikpoh told the HSCC inquiry into the future of general practice that new doctors are “literally going from celebrating the fact that they’ve become a GP to receiving letters threatening them with deportation”. In April it was revealed that up to 1,000 overseas GPs were at risk despite completing their training because of complex immigration rules stopping them from extending their visas. Tellingly, the Doctors’ Association UK notes that a Bill to give indefinite leave to remain to all staff working for the NHS has repeatedly been “kicked into the long grass”.

The wrong focus?

However, by focusing on the salaried model for GPs, Javid appears to be dodging all the difficult questions relating to recruitment and funding, and is instead pushing a proposal within a sector that has already gone some way to embracing it – a much easier challenge. After all, a letter in the BMJ in March, reacting to Javid’s proposal, floated the notion that this model would make GPs more malleable – as the correspondent explained, “The salaried model is automatically assumed to be the lowest common denominator, where GPs are dictated to by others.”

In May, a Pulse survey of GPs found that 41 per cent of respondents would consider becoming a salaried GP, and that half of the GP workforce already consisted of salaried and locum GPs. And according to GPonline earlier this month, senior GPs are now warning that Javid’s proposals “have already exacerbated reluctance among GPs to take on partnership roles, with interest in partnerships ‘collapsing like a Jenga stack’”.

So even though in May the BMA’s GP committee voted to reject “NHS England’s approach in replacing general practice with a one-size model all-salaried service”, other elements within primary care may not be so resistant to Javid’s ‘nationalising’ initiative. Of more concern, perhaps, is the possibility – as noted by one GP – that once practices are under the control of hospital trusts, private health providers could eventually step in to privatise them.

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