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Independents' Day

GPs, it is time to face the elephant in the room

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I recently stated that I had hope about the future of general practice. But let me try and manage expectation, this is no silver bullet, no matrix blue pill movement and no road to Damascus revelation.

We are past the tipping point in general practice, a recruitment crisis, a retirement crisis, a patient expectation crisis, a morale crisis and practices are failing daily. Those of us old enough to remember will know we have been here before. In the mid 1990s, GP post lay empty, the magazines were full of the word ‘burnout’ and general practice was destined to fail due to the burden of out-of-hours work.

GPs were working one in four rotas for generations and this position was no longer tenable; general practice was a ghost town. Then the unthinkable happened, we came together as co-ops and started to share on call shifts. This happened almost overnight and the effect was transformative both to morale, recruitment and retention; there was renewal. Make no mistake a seismic change is about happen again. 

Here are some bitter truths

They say truth is like poetry, and everyone hates poetry, so here are some bitter truths. General practice will continue irrespective of what happens: even if there is no more money or GPs to recruit. The crisis we face is not about money it's about ‘work-life balance’. Working in a hospital currently is a lot more appealing to young doctors than a chaotic general practice. Offering more money will have a paradoxical effect; doctors will simply work less for the same money. To think otherwise is denial.

My solution is elephant in the room, a solution so blinding obvious it is crushing us against the wall. The only solution is scale. We need to merger together. Federations won't work as the bonds are too loose. Now many will simply stop reading, thinking: ‘I am off to cloud cuckoo land, on the back of a flying pig to see a screening of “La La land”. But read on.’

For scale means more cross cover, on-call systems, more consistency in clinical practice, more holiday cover, less administration, flexible working, financial security, diversification and that it's easier to attract and recruit staff. It means better life work balance.

Doctors will work in a well paid and well organised environment, they won't work in a highly paid but chaotic environment. If the working environment is better, then older doctors may decide to work longer. In the short term this could ease the workforce crisis.

I should be honest about the problems of a large practice. We currently manage nearly 40,000 patients. Patients don’t always like large practices because of reduced continuity, (but because of ubiquitous part-time working and out-of-hours organisations, traditional continuity is dead). Doctors also sacrifice some control and feel they are being ‘managed’. There is also a potential divide between the partner and the salaried doctors. Larger practices are not ‘super’, and no medical nirvana, but they are better than the current choke-hold most practices find themselves in.

Scale also gives you a voice. The BMA and the colleges have no vision and do not reflect the views of many working doctors. They have been unable to resist the largely pointless appraisal system, unable to rebut the CQC, unable to prevent the endless cycle of reorganisations, and unable to challenge NICE’s mindless guidelines. We are voiceless small units that have been divided and ruled to our detriment for decades.

If we allowed the current situation to continue then practices will fold, pass to the local health board, then corporations will step in as the only alternative. Doctors will have very limited control or input. This corporatisation is currently butchering the pharmacy and vet professions. We either elect to do something now or wait the inevitable.

Local practices are subject to historical petty jealousies and vanities, but we have more in common, than that which divides us. I would not presume to tell people how to merge, but merely say our practice has two themes: an administrative mantra (‘today’s work today’) and a clinical mantra (‘less medicine is better medicine’).

Brothers and sisters open your eyes see the reality elephant, don’t let your future be written by someone else. The only logical evolution of general practice is at scale. It’s time to change. 

Dr Des Spence is a GP in Maryhill, Glasgow, and a tutor at the University of Glasgow

This is the second of a two-part blog from Dr Spence as part of our ‘Great GP Debate’ season. Read the first here. If you would like to write a piece on how you see the future of general practice, then please email the Editor at


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Readers' comments (22)

  • No

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  • They say that history repeats itself, but is it right to take 1990s experience as a recipe for problems of today?

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  • Sorry Des, but you're wide of the mark this time. Scale is what I find in my kettle, not a solution to my problems. My neighbouring surgeries are, by their own admission, "teetering". Merging will not solve their problems, merely dilute them over more patients, buildings and staff. My profits would disappear into subsidising structural ineptitude. i will tread water until January 2019 when I can pull the pin. Nothing bad will happen quickly.

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  • We are in a fighting retreat, there is deficient numbers of new recruits coming to the front line.Most of us who haven't left are waiting for an opportune moment to leave the sinking ship.As already said working at scale does not solve the problems of a grossly underfunded health service.Someone has to grasp the nettle and tell the populace what can be afforded and not promise them anything and everything.That is the job of government,but politicians are cowardly and spineless and prefer underhand method to bring things to a head.Working at scale makes you a bigger target, not too big to fail.We are not the banks!

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  • 'Offering more money will have a paradoxical effect; doctors will simply work less for the same money. To think otherwise is denial.'

    Doctors might work less intensely but more GPs sessions would become available as those GPs who feel the marginal session is too much would consider doing it in a less intense environment.

    Put it the other way - if pay / income per session was cut would you expect there to be more or less GP sessions provided overall? Thus the converse is true.

    You can argue about the timescales and the elasticity of supply of GP time, but if you can prove increasing pay leads to a lower supply you will be up for a Nobel prize in economics, having discovered the mystical good that decreases as pay rises and increases as pay falls!
    The second law of thermodynamics can't be broken!

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  • Healthy Cynic

    Continuity is not dead.
    Some of us have clung on to the 'cornershop model' and as time goes on, we feel more and more vindicated in doing so.
    There are only 3 GPs in my practice that a patient ever sees, only one nurse and 2 HCA's. We are familiar faces. We know our patients. Continuity is king. Long live continuity.
    Working at scale is a solution to one problem, but generates more problems.

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  • Sorry Des. Enjoyed your last article, but the solution you suggest here destroys the very essence of General Practice that patients need.
    If we ever need an illustration that big is not necessarily good, we just need to look at the mess that this coropration driven world is fast becoming.

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  • The elephant in the room is the fact that a lot of what we traditionally do has no evidence to back it up. We need daytime triage. Not as tough as the out of hours. It's ridiculous to have a system wherby patients with trivial symptoms are able to see a health care professional as easily as someone with serious symptoms. Out of hours care is now rationed and is safe. We need the same in the day.

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  • my practice has no problems recruiting anybody. What is different about us? We have deliberately kept the list size low and therefore workload manageable. Yes you do not earn as much as next door, but it seems that young docs would rather have it that way. This is no answer to the national crisis - but we do nothing about that at this level

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  • It's very difficult to control your list size in some areas, they keep building houses! Patients will just be allocated if everyone does this.

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