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The damaging decline of NHS general practice


GENERAL practice has been in accelerating decline for more than a decade, and no significant effort has been made to arrest the process. Not by any of the responsible arms of government who also foot the bill on behalf of the taxpayer, and least of all by the hierarchy of the GP profession who seem oblivious to the decay they are overseeing. 

Family practice was once a cornerstone of the welfare state and a source of reassurance and confidence for the public. I have been astonished by the complacency with which millions of people tolerate waiting for a month or more for a GP appointment and even then, possibly virtually. Unless, rather than seeing a doctor, they are offered an earlier appointment with a practice nurse, a pharmacist, a physiotherapist or a paramedic. Worst of all, in some practices by a Physician’s Assistant, who is not a doctor although patients may not be aware of this.

If a solicitor or an accountant treated clients in this way, their practice would fail, but GPs have a guaranteed income irrespective of performance. Of course, some GPs do their best to maintain standards but it is equally true that there is no incentive to provide a better service than some of their colleagues.

Where general practice thrives, for example in mainland Western Europe or Australia, GPs are paid on a fee-for-service basis. If they don’t see patients, they don’t get paid. In the UK, GPs are contracted to the NHS rather than employed by it. They enjoy security and freedoms which may not be in the best interest of patients.  

The death knell for general practice was rung in 2004 with a fatal decision negotiated between the British Medical Association and the then Labour government. GPs would work office hours only and have no responsibility for providing out-of-hours services to patients: not at night, at weekends or bank holidays.  In return, GPs would be expected to ‘improve access to medical services for patients’. Did that happen?  At the time, GP friends of mine could not believe the windfall benefits of the new contract. Surely this change amounted to an abdication of vocational responsibility? 

The pandemic was another fatal blow for patient services. In April 2020, NHS England enforced a ‘remote total triage’ model for general practice to protect their staff from the virus. All consultations would be virtual. There was nothing similar for A&E staff who bore the risks and workload consequences. Because virtual consultation was so convenient for GPs, it was continued after the pandemic and is now part of regular practice.

Virtual consultation may have a role in the review of patients previously seen face-to-face and examined, but has always been thought risky for initial diagnosis. That fear is now proven. A recent study published in the journal BMJ Quality and Safety described deaths, serious harm and missed or delayed diagnosis following virtual GP consultations. That data was collected in 2020-2023. We also know that there are some NHS GPs living abroad who practice only by remote consultation. Is this the service model, condoned by the General Medical Council, which patients deserve?

Part-time working by GPs is rife. Published in October 2022, a House of Commons report on the future of general practice confirmed that only 23.2 per cent of GPs worked full-time and 58.4 per cent worked three days per week or less. They do this because they can. This is the main reason, never discussed, why patients have difficulty accessing GP services, compounded by the fact that experienced GPs are leaving the profession early – surprisingly quoting workload and stress as the reasons. Newly qualified British graduates are reluctant to enter GP training unless their goal is to work part-time. Currently, 55 per cent of GP trainees are International Medical Graduates recruited from countries outside Europe mainly India, Pakistan and Nigeria. Is that what we want?

The complacency in government and among the general public to allow these eroding practices to continue unchallenged is staggering. Any future reform of the NHS must start with reform of general practice.

This is made more urgent by recent information. The UK is respected world-wide for its biotech industries, its excellence in research and its innovative treatment developments in cancer. Yet we have the worst cancer survival rate within the G7 countries and also compared with most countries in Western Europe.  Why is that?

It is an undeniable fact that early diagnosis of cancer is the most certain way of improving survival. The best surgery, radiotherapy and chemotherapy cannot regain the survival advantage lost by late diagnosis and the inevitable deterioration in prognosis. Data which is publicly available on the Medical Defence Union websites provides convincing evidence for our poor cancer survival.  In a range of cancers, about four in five of the complaints and claims for compensation for delay in diagnosis were against GPs. For example: breast and prostate cancer, and malignant melanoma (an aggressive skin cancer). Confirmation of this disturbing data can be found by searching online for ‘medical defence union delay in diagnosis of cancer’.  

I accept that GPs are generalists working at the front line, but they miss red-flag symptoms. Throughout the MDU articles, there are reasons given such as failure to provide continuity of care and patients being unable to see the same GP for repeat visits. This facility is particularly important in the early diagnosis of cancers that don’t present with specific symptoms, such as ovary and pancreas, again stressed in the MDU articles. The National Association of Sessional GPs now has about 8,000 active members who, by definition, cannot offer continuity of care.

The problems I have mentioned, namely virtual consultations, part-time working and failure to provide continuity of care, all contribute to the poor cancer survival in UK. This problem can no longer be ignored.

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J Meirion Thomas
J Meirion Thomas
J Meirion Thomas FRCP, FRCS, is a retired cancer surgeon.

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