England’s GP shortage points to need for new primary healthcare model

When Joanne Hodson sought help from her family doctor for perimenopausal symptoms, exacerbated by emotional distress following the death of her mother, the response left her stunned. The nurse manager from Greater Manchester was offered a telephone conversation — in a month’s time.

Only after suggesting to the receptionist that she might be suicidal did she receive prompter attention, although still remotely. Hodson, who counts herself as “very assertive” but has had to fight to get the care she has needed, lamented the loss of the continuity so long seen as a strength of the cradle-to-grave British system. “I haven’t seen my own named GP for over two years,” she said.

The much loved general practitioner, first port of call for those seeking help from the UK’s taxpayer-funded universal health system, is a national trope. But burgeoning demand from a population needing ever more complex care, with fewer doctors to deliver it, means the model is coming under strain as never before.

While politicians and doctors are at loggerheads over the lack of face-to-face appointments after many surgeries largely switched to seeing patients virtually during the pandemic, some GPs believe the focus on the doctor as the fount of all care and knowledge is no longer sustainable and the model needs to be reformed.

While many health systems are facing pressures from ageing populations, the nature of primary care in the UK poses particular challenges. According to Nigel Edwards, chief executive of the Nuffield Trust think-tank, while every comparable European nation has a form of primary care, the job description for family doctors in the UK tends to include “a wider range of services, including minor medical procedures, paediatrics and more of the management of chronic and long-term diseases, such as diabetes”. While in France or Germany, for example, “you would expect more of these kinds of services to be dealt with by specialists”. 

Faced with an overwhelming workload, some medical practices are looking at ways to reduce patient demand through “social prescribing”. On a crisp autumn day in Woodley, near Stockport in Greater Manchester, a group of over 70s are meeting for their weekly stroll through picturesque lanes followed by a cup of tea in a nearby café.

Derrick Brammall, a retired engineer of almost 90 who underwent a quadruple bypass at 63 and never misses the gathering, cheerfully shares his prescription for longevity: “Keep your weight down, a good diet, exercise and a clean mind.”

Mark Gallagher, a local GP, said he has seen a measurable reduction in demand for conventional healthcare from some of those he has referred to the walking group and other similar activities. “We can actually see that many people are happier,” he added.

But while such social prescribing is one successful approach to improving patient health while sparing resources, more radical changes may be needed if general practice is to satisfy a 21st century population.

The NHS’s long term plan, published almost three years ago, emphasised the role wider primary care teams, including nurses, physiotherapists and “physician associates” can play in caring for patients. Beccy Baird, a primary care expert at the King’s Fund, a think-tank, said she had recently spoken to “a practice in Gateshead where they’ve got a GP vacancy and decided . . . [instead] to recruit a frailty nurse and two community link workers ‘because these people are better than a GP for our population’”.

Such examples remain unusual however. Staff shortages and the time needed to integrate the roles into hard-pressed practices mean the approach has been slow to take root.

Dr Harpreet Sood, a 36-year-old who practices in Kennington, south London, is part of a new generation of leaders who believe medical and technological advances can be harnessed to make primary care more responsive to its users, and ease the pressure on GPs. The current model of between 7,000 and 8,000 physical GP practices is outdated, he argues.

Instead, he believes more resources should be devoted to community labs, giving patients rapid access to blood and other diagnostic tests so they arrive to see their GP already armoured with the vital information on which a diagnosis can be based rather than being “pinballed around” between surgery and hospital before their conditions can be identified and treated. “We’ve seen so many advancements in diagnostics, and labs and radiology, why are we not embracing that in terms of how we offer a primary care service?” he asked.

Sood pointed to countries that are creating new primary care systems, such as the US and India. With no legacy structures to contend with, “the GP isn’t the first resort . . . the GP is only there for more tricky situations rather than having to see everyone and triage everyone”, he said.

The approach is exemplified by Boston-based Iora Health, part of One Medical, another US healthcare provider. It has tripled the resources it has devoted to primary care, using technology to monitor people in their own homes, along with a system of “coaches” who help patients stick to treatment plans while supporting them to improve their lifestyle.

Moving away from a “reactive and transactional” model centred on visits to the primary care physician has led to “roughly a 40 per cent drop in hospitalisation . . . as well as about a 10-20 per cent drop in total spending on healthcare even when you take into account the increased primary care spend”, according to Rushika Fernandopulle, Iora’s chief innovation officer.

In Sheffield, GP Ollie Hart has established a coaching company with a fellow GP to work with surgeries around the country. He says he has had some “incredible success stories” since he began deploying the approach, estimating that about 20 or 30 patients in his own practice have either cured their diabetes or, at a minimum, become more motivated to manage their own health.

“It is possible to shift the system but it does require a new rhetoric, a new narrative to go with it,” he said. “And that’s what we’re really missing at the moment. People are still hankering after the old model of general practice and it’s just falling over.”