James Hibberd is a salaried GP at the Miller Practice in Islington. He is also the primary care research lead for Noclor and the Islington GP Federation
With recent polling putting Labour significantly ahead it seems likely that they will form our next government. It is sensible, therefore, to pay close attention to Labour policy suggestions for the NHS. Wes Streeting has been clear that there will be a need for reform, especially in primary care. In a recent speech at the King’s fund (21st April 2023) he laid out his vision for a ‘neighbourhood health service’ with the aim to move care away from hospitals and into the community. Whilst undoubtedly a good idea as the King’s Fund press release stated after the speech, ‘there has been a clear consensus for more than 30 years…that moving care from hospital to communities is the right thing to do. The challenge is making this actually happen’. There are multiple reasons that this mission has repeatedly failed. Not least among these is fact that primary care gets only 8% of the NHS budget. At a deeper level, I believe, there has also been a lack of focus on what general practice does best, long term relationships and continuity.
It is widely recognised that continuity of relationship between GP and patient improves mortality rates and the satisfaction both of patients and GPs.
It is widely recognised that continuity of relationship between GP and patient improves mortality rates and the satisfaction both of patients and GPs. Whilst continuity is rarely measured it is possible to do so and it should be this that is one of the main metrics by which success in general practice is measured.
Currently continuity in primary care is maintained largely via the partnership model. Despite a steady decline over the last two decades in the number of GP partners and a corresponding increase in the number of salaried doctors, partners still make up over half of the GP workforce (53.3%) and are disproportionally represented as full time equivalent (61%) – this means many partners work more than full time. The reduction in GPs taking up partnership roles seems set to continue with 35% of trainees intending to be a GP partner at 10 years post qualification (down from 45% in 2016). Alongside this is an increase in less than full time working especially among the younger end of the workforce.
Despite a steady decline over the last two decades in the number of GP partners and a corresponding increase in the number of salaried doctors, partners still make up over half of the GP workforce…
Mr. Streeting in his speech accurately identified the need to explore ‘how to make the future of general practice sustainable…when more and more GPs are choosing to take the salaried route and partnerships are forced to close’. Whilst he, thankfully, distanced himself from his earlier rhetoric that he was ‘minded to phase out the whole system of GP partners altogether’, it isn’t clear what he sees as the solution.
If Labour are serious about the ‘Neighbourhood Health Service’ they need to focus on how to maintain continuity in general practice. The traditional partnership model may be struggling but a simple switch to an often less than full time salaried workforce is not the answer. A way to enthuse GPs into longer-term roles needs to be found. One solution may be to incentivise locally run social enterprise companies. These have been set up successfully on both small and large scales throughout the UK. They have the benefit of both avoiding the ‘murky’ finance of partnership that Mr. Streeting is not keen on but also allows GPs to take salaried clinical and senior leadership roles within their organisations without the financial risk that comes with traditional partnership.
The decline in partnerships threatens the long-term relationships between patients and their GPs on which the NHS relies. Salaried GPs and locums are less likely to stay in one practice for prolonged periods of time than traditional GP partners. Moving more care into the community is sensible and essential but it’s purpose should be to improve rather than dilute continuity. It is on this aspect of primary care that Labour should focus when thinking about reform.