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The shifting switches

The shifting switches

Editor Jaimie Kaffash says the Government needs to stop asking the impossible of GPs and decide what type of service it wants from general practice

There is a great gif I saw on Twitter that applies to general practice in the UK. It shows three switches, labelled ‘good’, ‘cheap’ and ‘fast’. You can easily switch two on – but try to switch on all three, and one automatically turns off.

As our analysis today shows, this could quite easily apply to access, with the buttons changed to ‘face-to-face appointments’, ‘short waiting times’ and ‘seeing a GP’. The problem is, the media – and therefore the Government and NHS England – insist that GP practices should be able to provide all three (as well as being good and fast and cheap). 

The headlines we saw in November when the league tables on GP appointments in England were released were demoralising. It was clear the media were determined to spin them as negative, even before they were released. Objectively, the figures were positive – GP practices saw a record number of patients in October, and 71% of appointments were face to face. Yet practices were named and shamed for apparently failing to see patients in person, especially in local news. 

I’m sure those at the top of Government and the NHS know it is impossible to offer face-to-face appointments at the same time as short waiting lists and the option to see a GP if the patient wishes. Yet they are happy to fuel such unrealistic expectations. 

As I said in my December editorial, this year offers a chance for a reset, with negotiations for a major new contract in England, threats of collective action in Scotland, huge numbers of practice closures in Northern Ireland and in Wales. 

Such a reset will need more realism from GP leaders. They won’t extract more funding from the UK Treasury. If UK ministers are not willing to find money to prevent nurse and ambulance strikes, they won’t do so for GPs – especially as they are probably gone at the next election. And of course no increase in GP workforce numbers will even touch the sides of the current crisis. So there needs to be a strong message from GP leaders across the UK:  governments and NHS leaders need to decide which switches to turn off. And the contract, in England at least, offers a chance to do this. 

Does the Government want a comprehensive service, where the work done by GPs is loosely defined and patients can continue to use services as they see fit? Fine, but then don’t expect a quick service (a notion that could be enshrined in the contract) and you might also want to find a way to deal with urgent, on-the-day care.

Or do they want a service that gives patients the choice of face-to-face consultations, and the right to see a GP if they so wish? Also fine, but again, don’t expect a quick service, and start to think about contractually defining exactly what GPs need to provide in terms of care. More importantly, give GPs sound contractual mechanisms to refuse anything outside this. 

Or how about reducing those waiting lists, with a quick service? Once more, fine, but a lot of consultations will be remote, I’m afraid, and you might again need to define what GPs are providing (again, with contractual mechanisms for GPs to refuse further work).

The Government has made clear that it is happy to allow general practice to deteriorate, and the current service is what they are left with (and it is only barely functioning due to GPs going above and beyond). Now, it is up to ministers to make the hard choices. 

This column originally appeared in the January 2023 issue of Pulse

Jaimie Kaffash is editor of Pulse. Follow him on Twitter @jkaffash or email him at



Please note, only GPs are permitted to add comments to articles

Sam Macphie 12 January, 2023 12:14 am

Yes, what a government. Also, last weekend Mr Integrity PM, Rashy Sanuk, gathered public service bodies including NHSE,
Amanda Preachard, Steve Barclaybanker, together for a grand photo opportunity and more talking shop antics. Plus, true to his so-called ‘integrity’ PM said, in the chamber at Westmister, he sees private doctors and he is registered with a NHS GP, but this
registration could be just since last weekend, and for the benefit of the media, the optics and the population; however I reckon his oppo, Keir Starman, and many of the populace and media, see right through this PM of great integrity, Mr Sanuk, and are not impressed by this PM of great Photo Opportunity. Meanwhile, 300 to 500 extra deaths per week, due to long waits in ambulances, outside A and E, that’s an extra 25,000 patients killed per year: do the math, so-called ‘Mr Integrity’.

Christopher Ho 13 January, 2023 12:12 pm

Thank goodness you’ve finally realised what many economists and rationalists have known for decades. see Friedman, Sowell, Ben Shapiro, etc :). Any health service can only fulfil 2 out of the main 3 outcomes: Affordability, Universality, and Quality. Your 3 switches. Welcome, to the red pill. Our situation is further compounded by our open door immigration policy. “You can have open borders, or a welfare state, but you can’t have both”.

Now, you make the mistake of looking to the government, and to ministers for the “solution”/”hard choices”. Their only concern is to maintain power, not your interests. But what do you really want? Personally, I would like the health service to be affordable, and of high quality, and would like to stop being forced to fund “universal, cradle-to-grave, healthcare”, being redistributed via an irresponsible 3rd party (the state), to not just fellow citizens, but everyone else in the world too.

Paul Burgess 14 January, 2023 10:46 am

Are you referring to ‘health tourism’? I doubt that is a significant part of the problems of the NHS

Christopher Ho 19 January, 2023 3:35 pm

Depends on how you would define “health tourism”, Paul. If you limit it to temporary visitors, then no. If you include healthcare being offered to immigrants (1 mil last yr alone, by the way) who become resident here then….

fareed bhatti 20 January, 2023 7:05 pm

I think there are many many ex-pats that come back to have their knees done and annual chronic disease reviews with piles of pxs taken back to sunny Spain and Portugal each year. They will cost a bloody sight too.
What about the immigrants that are helping run this effing sinking ship and paying taxes. The NHS is very happy to import ‘immigrants’ by shitloads to fill up GP vacancies or run nursing recruitment drives in Philippines and then start moaning too !
Yes, its all the immigrants fault. Would you also like to tell us which colour immigrants dont you like as well. Might make things a lot clearer too.

John Evans 24 January, 2023 10:05 am

EU immigrants paid more in tax than they consumed.
Similar specific job roles that need immigration eg healthcare workers, agriculture.
Less clear picture with non-EU immigration

Illegal immigration cost is around 1-2 billion each year – real life support as well as border/maritime policing. A lot although unlikely to make a meaningful impact upon benefits/health/social care.

I suspect that countries don’t want to sort out refugee processes as the numbers who may qualify overseas would be huge. We disregard those vulnerable trapped and try to dissuade those trying to enter illegally.

However, as often happens any discussion on immigration tends to lead to accusations / implied racism.

It should be a discussion regarding the potential impact on uk poor balanced against contributing to the collective support of vulnerable overseas (albeit an ideal riddled with compromise / moral conflict).