Rather than doubling down on the partnership model with the government’s new ‘golden handshake’ to encourage GPs to become partners, the model should instead be phased out, writes Harry Quilter-Pinner
On the 5 July1948, the NHS was born. This new organisation joined up the nations’ private hospitals and local GPs into a single system, which was — and still is — free at the point of need. In securing its creation, the minister of state for health, Nye Bevan, utilised what has become the main tool for his successors in looking to secure reform across the NHS over the years. In his own words, he brought doctors (particularly GPs), and their trade union the BMA, on side by “stuffing their mouths with gold”.
Today, this same approach is still in use. Last week, the NHS announced its intention to address the workforce crisis in primary care, with (amongst other measures) the introduction of £20,000 “golden handshake” for GPs who sign up to be partners in their local practice. But, at IPPR, our research suggests that, whilst it may have worked in the 1948, it will not do so again today.
Of course, the government are right to recognise the scale of the workforce crisis in primary care — particularly amongst partners — but solving the problem will require a much more fundamental rethink than a “cash bung”.
This must begin with a recognition that, even as the nature of illness and patient expectations have changed, our model of care has remained (more-or-less) the same. Small practices of GPs support local patients with 5-minute appointments and referrals to specialists in hospital where necessary.
At the same time the management and regulatory requirements of running a GP practice have grown exponentially. The result is high stress and burnout amongst staff, desperate to do a good job in difficult circumstances, and poor access (and in some places quality) for patients in need of 21st century care.
Primary care at scale
The solution is “primary care at scale” — what we at IPPR call the “Neighbourhood NHS”. This would see GPs work in teams alongside a wider array of health professionals, including nurses, mental health specialists, pharmacists and link workers, in purpose build facilities, across larger populations.
This would allow GPs to spread their workload across a wider number of professionals, deliver care out of hours for working patients, and invest in diagnostics and treatment in the community, which can improve efficiency and outcomes for patients.
This is not a new idea. It is the vision that sits at the heart of the NHS long-term plan (and the Five Year Forward View before it). Notably, the NHS is in the process of introducing new groupings of GP practices, called Primary Care Networks, which will share resources (eg a wider staff team) and expand the patient care offer (eg longer opening hours).
This is undoubtedly a step in the right direction, but policy makers are still ignoring the elephant in the room. As a result of Bevan’s compromise back in 1948, most GPs are largely independent contractors.
This severely limits the extent of integration. Notably, whilst most practices are now part of a PCN and are collaborating on some level, a recent study found that less than 5 per cent of practices are ”working at scale for core general practice, with shared strategy and risk”. Put more simply: genuine integration and transformation are still the exception rather than the norm.
Without it, there is no doubt that patient care — in particular access — will continue to suffer. Likewise, the workforce crisis will also get worse; staff will be unable to stem the rising tide of demand within the confines of the current system.
This is why at IPPR we argue that rather than doubling down on the partnership model, the NHS should plan for a world without it. This may sound radical — local GP partners have been the “jewel in the crown” of the NHS since its inception — but it is already the direction of travel.
Even in the short time since the FiveYear Forward View was introduced, we have lost around 3,000 GP partners, with young GPs choosing instead to become salaried or to locum. By 2026, on current trends, they will be surpassed in number by salaried staff. This is unsurprising: looking after the needs of patients is more than enough to be getting on with without running a small (often struggling) businesses as well.
Instead of fighting the tides of change, the NHS must embrace a “New Deal” for primary care. This should start by giving GPs the “right to NHS employment” in new “neighbourhood care providers”.
These new organisations must be given access to capital funding to create purpose built new NHS facilities. And, over time, they should take on contracts for community, mental health and social care. Together these steps, unlike the NHS’ “golden handshake”, would begin to address the real causes of the GP workforce crisis.
After all, GPs aren’t in it for the money. What they need is jobs in organisations that give them a work-life balance and “time to care” for the patients they have trained to serve.