Peter Moore: The NHS is moving away from what works in general practice

It is a cliché to suggest that prevention is better than cure, but this idea has steered the NHS over the years.

We have a highly effective vaccination programme and screening for amongst other things, breast cancer, cervical cancer, bowel cancer and aortic aneurysms. Early diagnosis is vital but our cancer survival rates lag behind other developed nations. A and E departments are inundated, and some patients cannot be discharged despite no longer needing a hospital bed. 

Amazingly, there is one way to encourage early diagnosis, reduce premature mortality and cut the pressure on the A and E department but it is consistently ignored. There is overwhelming evidence from around the world that this can be helped by having a personal doctor. I remember my GP trainer telling me, “You don’t have ten minutes with the patient, you have thirty years in ten-minute slots”.  

Delegating work and reducing contact with a personal doctor, makes economic sense to an accountant or business manager but flies in the face of the evidence. Two systematic reviews have shown that having a personal GP leads to fewer hospital admissions, lower costs and even reduced mortality. There is also good objective evidence that phone consultations are less effective than face to face meetings. 

Having a personal GP leads to increased empathy by the GP. This in turn increases patient satisfaction, leads to fewer physical complications in diabetes and reduced mortality from all causes and yet all the changes over the last few years have pushed the NHS in the opposite direction. Seeing a different member of the team every time means that no one sees the whole picture.

Boris Johnson promised an increase of six thousand GPs from 28,000 to 34,000. The numbers fell by five hundred. In 2015 there were fifty-two GPs per 100,000 patients. Today there are forty-five. 

In 2019 GPs saw 13 million patients a month. GPs now see five hundred more. 

Why is there a shortage of doctors? When I was a student in 1975 just under a thousand doctors a year qualified. Today it is over 9,000. In 1975 there were 14,000 hospital consultants in the UK. Today there are 53,000.  The number of full-time equivalent GPs was just over 26,000. Today the number has hardly changed at 28,000 despite an increase in the UK population of over 13 million.  

There is also a problem encouraging doctors into general practice. In the 1980s and 1990s I was one of the course organisers for the GP training scheme. The Torbay Scheme was very popular. We used to get about a hundred application for four places. Many candidates were excellent. Appointing the right people was a challenge. Today some practices cannot get new partners.   

There are many reasons but it is partly the structure of the NHS. In 1948, when the NHS was founded GPs ran their own practices like a corner shop. GPs still own their surgeries which are run as a small business. This means that new partners have to buy in. This was not as horrific as it sounds because the NHS pay the doctors a rent for the use of the building.

The trick is to ensure that the rent coming in balances the cost of the loan. This also helps the NHS. The cost of GPs running their own practices is cheaper than the NHS building and running a clinic. The problem is that this system only works for doctors who plan to stay for thirty years.

As the first few years of any loan is only paying interest, leaving after two years is expensive. Most new doctors do not want to be committed for thirty years. They also have a large loan from university tuition fees as well as trying to get a mortgage. 

By closing community hospitals which used GPs there is nowhere to discharge a patient who no longer needs full hospital care but could not cope at home. This leads to the “bed blocking” when the district hospital cannot discharge a patient. 

I do not have a simple answer. For the NHS to buy out every GP, set up clinics and pay GPs a salary would be massively expensive. I expect someone at the Department of Health will come up with a new and revolutionary idea. Why doesn’t everyone have a personal doctor? I do not care who gets the credit, but it is time that we reinvented the GP.