Each region in the UK has a local medical committee (LMC), a statutory body that represents general practice in its area. The LMCs are independent of the British Medical Association (BMA) but act as its eyes and ears, advising the doctors’ union on the views and concerns of grassroots GPs and guiding it on policy. In May, the LMCs’ conference tasked the BMA with starting work on a “plan B”, a hybrid public-private model that would take general practice partly out of the NHS for the first time since 1948.
The phrase “becoming a dentist” was coined to describe this idea; Dentists have always provided both NHS and private care to their patients. There are two distinct reasons for GPs to want to follow suit. Some supporters argue that general practice is no longer financially viable under the NHS contract and that a hybrid model is the only way to survive. Others do not expect a “plan B” to ever be adopted, but hope the threat would force the government to rebalance NHS spending. The 8.3 percent of the overall budget going to primary care is the lowest ever, down from an all-time high of 11 percent in 2006, while practices are expected to meet record levels of demand.
To imagine what a hybrid service might look like, we only need to look at what is already happening. The number of doctors registering to practice outside the NHS, in whole or in part, has increased significantly since 2018, with around 400 a year now making the move. (There used to be only a few dozen a year.) They’re responding to two types of demand. One is for treatments not offered by the NHS, such as cosmetic procedures, weight-loss drugs for lower-risk patients or certain hormone therapies. The other, however, is about something that was once prevalent in health care but has been progressively eroded: continuity of care with a doctor you know and who knows you well, with the capacity and appointment time to address problems immediately and holistically.
The LMC conference coincided with the leak of the NHS’s revised ten-year workforce plan, which highlighted the need to vastly expand GP numbers if the aim of shifting care from hospitals to the community is ever to be realised. Governments of various stripes have been saying the same thing since 2015, yet the number of GPs has dwindled, even as demand from an aging, growing and more medically complex population has grown steadily. The problem isn’t training – we’ve never had so many qualified GPs – it’s retention. For years, the profession has warned the government that the job has become unsustainable, with doctors leaving wherever they can, and those continuing to reduce their time commitment to ease the punishing workload. The developing crisis has not only been ignored – it has also been accelerated by the contract reviews that have been routinely imposed by the government, despite near-unanimous rejection by the profession.
I do not believe that many GPs who move into private practice are motivated by providing services that the NHS does not provide. What they want is a manageable workday, and enough time and continuity of care to practice proper medicine again. The NHS no longer provides the conditions to do this in many parts of the country.
In the second term of Tony Blair’s government, a concerted campaign to improve the NHS began, part of which was adequately funding general practice. This led to a record 70 percent public satisfaction by 2010, the end of the new era of work, compared to 26 percent today. Blair’s belief was that when public services are good enough to rival the private sector, the middle classes will use them. But allow services to degrade critically and those with resources will abandon them. This perpetuates a cycle that cements two-tier provision, leaving the most disadvantaged in society with a full safety net service – exactly what has happened to NHS dentistry today. If the government wants to prevent the general practice of “making a dentist”, it needs to start working to maintain the profession in a radically different way.
(Further reading: Will AI replace doctors?)
