General practice across the country has been struggling for years, reaching a critical situation with less funding, fewer doctors, and a shortage of staff to meet the growing needs of the Scottish population. This decline has been a result of various factors over the years.
In 2017, the Scottish Government recognised the challenges faced by general practice and promised to introduce a new contract starting in 2018, to be fully implemented within three years. At the time, the then Health Secretary Shona Robison MSP (now Deputy First Minister) acknowledged the growing workload and increasing risks faced by general practice. However, large parts of this contract have not been implemented. Additionally, when Health Boards were unable to spend the money allocated for employing additional pharmacists and other professionals, the funds had to be returned to the Scottish Government instead of being utilised to support local practices.
Scottish Government promised transitional payments to practices to offset the non-delivery of the contract but withdrew this funding, even after some practices had already utilised the money for additional cover. This has compounded the challenges faced by general practice, both locally and nationally.
Over half of the practices in Lothian have recently received substantial bills for their facilities from NHS Lothian, amounting to £1.6 million per year across the affected practices. Without additional funding, this is likely to result in reduced staffing, fewer appointments, and longer wait times for patients. Moreover, all practices in Lothian are impacted by the Scottish Government not funding an increase in compulsory pension contributions, a commitment already made by the English and Welsh Governments. This funding shortfall impacts the resources available to practices for administrative staff, nurses, and doctors.
Funding for practices is based on a national formula and does not reflect the number of patient visits. Practices receive the same amount whether a patient is seen once or a hundred times a year. In 2017, the Scottish Government acknowledged that this model was insufficient and promised a new funding approach, which has yet to be implemented. Consequently, funding increases have been substantially below inflation.
Patient contacts with practices have increased from 3-4 times per year to 6-7, due to factors such as an ageing population, more people with multiple illnesses, and more treatment options. The increase in waiting lists has also led to GP appointments being used for ongoing management while awaiting definitive procedures. Rising energy costs have further strained practice resources, as insufficient funding means these costs impact the services practices can provide.
Part of the government funding is earmarked for non-GP staff pay rises, which historically matched what was given to NHS staff. However, last year the Scottish Government broke this link, forcing practices to cover the shortfall or risk losing staff.
The number of GPs in Scotland is falling. The 2017 contract promised an increase of 800 GPs, but excluding doctors in training, the numbers are actually reducing. Since 2013, the GP whole-time equivalent (WTE) workforce has fallen by 5.35%, and the number of practices has decreased by 9%, while average list sizes have increased by 18% and the patient population by 7%. About 42% of practices in Scotland report at least one GP vacancy, and the number of GP partners has dropped by 14% between 2012 and 2022. Over the past 20 years, the ratio of GPs to hospital consultants has halved, reflecting a reduced share of the NHS budget spent on general practice.
Many practice buildings are too small and outdated, and the Scottish Government has cancelled all funding for new builds. This leaves many working out of unsuitable buildings. The withdrawal of sustainability loans, a scheme to reduce the risk for GPs who own their buildings, further exacerbates financial losses, impacting the services they can deliver.
Better IT systems would help improve efficiency, but current systems are cumbersome and unreliable, affecting patient care, increasing inefficiency, and damaging staff morale. Scotland is the only country in Britain still using paper prescriptions, which consumes a significant amount of clinical, administrative, and patient time.
Time to learn and develop systems is crucial for improvement, but support for this has been withdrawn by NHS24, and the Scottish Government has done little to reintroduce any reliable support.
The struggles of general practice in Scotland are multifaceted, involving funding issues, staffing shortages, outdated infrastructure, and inefficient systems. Addressing these challenges requires comprehensive support and intervention from the government to ensure practices can meet the growing needs of the population.
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