Disabling of general practice has driven NHS financial crisis, warns academic

The disabling of general practice's NHS gatekeeper function is the primary reason why the UK health service is increasingly unable to cope within its budget, a leading academic has warned.

Dr Helene Irvine
Dr Helene Irvine

Public health medicine consultant Dr Helene Irvine told the RCGP annual conference on Thursday that the gatekeeper function of general practice had been dismantled through deliberate disinvestment in the service over the past decade.

'The NHS is in serious trouble at the moment because of the disabling of general practice,' the NHS Greater Glasgow and Clyde academic warned. 'I believe it has been deliberate. I think they had to raid somebody’s budget and I think they picked general practice.'

Dr Irvine explained that she had begun looking at why Glasgow was spending £60m to £70m more than the NHS funding formula allocated it, working on the assumption that deprivation was the key factor.

NHS gatekeeper

But her research revealed 'overconsumption' of care by wealthy elderly people and rising use of unscheduled care by the poorest quintile of the population. 'The primary factor behind this is the loss of the gatekeeper function,' she explained.

She said that the 2004 GMS contract, with the introduction of the QOF, had changed the focus of GPs - forcing them to chase funding through specific targets at the expense of their NHS gatekeeper role - limiting their ability to manage patients before they end up in hospital.

The funding increase delivered to general practice through the contract had then been systematically withdrawn, at the same time as district nursing services that support the profession were cut back. More recently austerity had driven savage cuts to social care, another service that in tandem with general practice helps keep elderly patients out of hospital, she argued.

While GP funding had been cut in real terms, the NHS was spending more on hospital care and other community services, said Dr Irvine. The growth of community services outside general practice was contributing to fragmentation of care, she argued.

GP workforce

The consultant to GP ratio had flipped over the past two decades, she added - with GPs outnumbering consultants in the 1990s but consultants now outnumbering GPs significantly - a fact that reflected the decision to prioritise hospital funding and staff as key NHS targets were predominantly hospital based.

GP leaders have repeatedly warned that the share of NHS funding spent on general practice must rise after falling from around 11% a decade ago to less than 8% now. Dr Irvine said the share of funding spent on general practice was key. 'If you keep expanding the NHS and you don’t have a gatekeeper to protect the other bits of it, you have a runaway service.'

Dr Irvine also warned that the impact of disinvestment in general practice had been magnified by the sharp fall in numbers of GP partners since the 2004 GP contract took effect. 'We have propped numbers up with salaried and part-time GPs. But partners are the ones willing to work longer and harder and keep their business going.'

Ageing population is a key factor in driving pressure on general practice, she added, but governments have failed to notice the impact of a significant spike in births after the first world war. That cohort is now in its 90s, she said - and to have disabled general practice just at the time when such a large group of the population needs it has backfired.

She pointed to research that showed those patients were disproportionately represented in the rise in patients being admitted to hospital.

'It is multifactorial,' Dr Irvine said. 'The first thing is the change in contracts, then withdrawal of cash, improvement of A&E stimulates the change more, social care cuts then more, and the change in emphasis from general practice to community health services is also a factor.

'A major investment in general practice is required urgently or the entire NHS is at risk. People don’t respect general practice enough. We need more GPs and need to support them to do more to keep the affluent elderly out of hospital.'

Full coverage of RCGP annual conference

Photo: Pete Hill

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