The GP problem: does NHS primary care need more planning or the market?

This Government does not have much time for GPs — and the feeling is mutual. Sajid Javid (above) has openly criticised general practitioners for refusing to return to face-to-face consultations, threatening to “name and shame” offending surgeries. Last month the Health Secretary pulled out of a speech to the Royal College of General Practitioners’ annual conference rather than face its members’ fury. Doctors feel that they have been made scapegoats for inadequate funding and accuse ministers of fuelling public hostility.

Now Javid is reported to be considering a proposal by a think tank to ban GPs from areas that already have more than adequate provision. The Social Market Foundation (SMF) points to wide disparities in the number of patients per GP between richer and poorer areas, sometimes even within the same town. According to figures compiled by the Liberal Democrats, the constituency of Blackpool North has 4,480 patients for each GP, while Blackpool South has just 1,900.  

For most of its 73-year history, the NHS prevented such inequalities by direct intervention. Until Tony Blair abolished it, the Medical Practices Committee had the power to turn down GPs who applied to work in areas that were “adequately doctored”. The committee was scrapped as part of a package of reforms that improved GP pay and conditions in the hope of tempting medical students to choose what had become an unfashionable branch of the profession. For the last two decades, the NHS has relied on market forces to regulate the distribution of practices, though bonuses of up to £20,000 may be offered to persuade GPs to move to “under-doctored” areas. The gap between the best and worst has grown and awareness of differences has become especially acute during the pandemic.  

As part of its levelling-up agenda, the Government has promised to increase the number of GPs by 6,000 in the next three years. In reality, numbers have actually fallen, as demographic pressures on surgeries rise, new treatments are expected and ministers demand that they deliver national policies such as the Covid vaccination programme on top of their usual duties. A return to a version of the Medical Practices Committee would be seen by GPs as a new attack on their status as independent doctors delivering a vital service to the community. It would be deeply unpopular and fiercely resisted.

The problem with GPs is a microcosm of the fundamental structural defects of the health service. The NHS was created in the postwar period when central planning, rationing and big government were in vogue. The Attlee government rejected the insurance system advocated by the Beveridge Report and instead opted to pay for the NHS from general taxation. Its founding principle — that health must be free at the point of use — remains popular and politically untouchable, but it has also inhibited reform by depriving the health service of the “invisible hand”, market’s self-regulating mechanism that keeps supply and demand in balance. Other comparable countries, with state regulated insurance systems, not only spend a higher proportion of GDP on health, but usually deliver a more consistent and higher level of care.

The failures of the NHS during the pandemic have shone an unforgiving light on the failure of successive governments to transform it into a modern health system that really would be “world-beating”. The injection of ever larger sums cannot disguise the fact that a taxpayer-funded health service will always be politicised and insensitive to the needs of patients. An opportunity to move towards a new, insurance-funded system was missed during the Coalition government a decade ago. Now, the post-pandemic decision to raise National Insurance to create a new hypothecated health and social care tax could over time evolve into a new, more flexible system funded by a insurance rather than taxation. But even to consider such a reform within the Government would instantly provoke a political storm. It won’t happen any time soon — and the NHS will fall ever further behind other health services.

In the meantime, the best way to improve primary care in the UK would be to boost the numbers being trained in our medical schools. Disparities between patients per GP are a crude and misleading measure of provision, because they take no account of other factors that may influence supply and demand. Most of us will require the services of our GP far more during the last few years of our lives than in all the rest of them put together. Even older people vary enormously in their state of health. So simply evening out the numbers between areas would not necessarily amount to “levelling up”. Not a central planning committee, but a decentralised, local system of administration will be able to determine where the gaps in provision really are.

Most GPs work in partnerships or are self-employed: their independence is a positive feature of the health service that should not be compromised to remedy a non-existent “market failure”. Instead, communities should be empowered to attract doctors to their districts. GPs are paid according to the number of patients they treat — a crude measure, but it should mean that areas that are “under-doctored” are more lucrative for practices than those where more doctors must compete for fewer patients. If that is not happening, patients are entitled to be told why. The vast, top-heavy bureaucracy of the NHS has done a poor job of ensuring that this part of the system actually functions as an “internal market”. Rather than reinstate central planning, we should use the market to make the NHS more responsive to localised needs of patients.

Few ministers understand how markets work better than Sajid Javid, a former Chancellor of the Exchequer and a successful investment banker earlier in his career. In the NHS he is grappling with a behemoth that now accounts for nearly half of all public spending — indeed, well over half if the cost of social care is included. GPs are the first line of defence against disease and the only part of the NHS that most of the public experiences first hand for most of their lives. It matters enormously that family doctors are well-paid and efficiently distributed.

But it would be a retrograde step to ban young doctors from practices in areas deemed to be “adequately doctored” by a remote committee that may have no local knowledge. Places that are more affluent may also have more elderly people with greater needs. There is in any case no obvious correlation between prosperity and GP provision: the five most “over-doctored” areas include Liverpool, The Wirral and East Staffordshire, as well as Oxfordshire and West Suffolk. The Health Secretary would be wise to consider the SMF paper for its analysis of the problem, but its solution is unlikely to please either doctors or patients.