Scotland’s Health Secretary calls it ‘very challenging’. Opposition MSPs say it’s a crisis[i]. What they agree on it that too few doctors are being attracted into General Practice to sustain local health services.

34 per cent of GPs in practice in Scotland in 2013 were aged over 50[ii]. There is a small but seemingly increasing number of GP practices that are being handed back to local NHS Boards as no new GPs can be persuaded to take them over.

Dr Alan McDevitt of the British Medical Association told the Scottish Parliament’s Health and Sport Committee[iii]:

“The BMA has been doing a GP practice survey every quarter for some time now. Our latest figures, which are from September [2016], show a 28.6 per cent vacancy rate in general practices around Scotland. It was the same rate in June. We have seen a substantial change in the number of posts that are still vacant after six months, from 42 last year to 80 this year, so we are getting clear evidence of a major recruitment problem.”

He added: “We also need over 50 per cent of junior doctors to choose to become GPs, and they are not doing that.”

But are the doctors who do choose community rather than hospital settings actually the wise ones – the ones choosing the more future-proof path?

Choosing a speciality for a junior doctor is something of a leap of faith that is based on current information rather than any certainty about what the job will be like in ten years, let alone thirty or forty. No doctor in the later stages of their career today will pretend that they could have foreseen how their jobs were going to change over their careers. New technologies and new medicines have increased capabilities dramatically, and with them the expectations of patients.

I would suggest that, in this respect, those who do not choose general practice might be taking a greater step into the unknown than their counterparts who do. Will oncologists, for instance, need the same breadth of skills in the coming years of precision medicines, where genetic testing of a tumour will dictate exactly which medicine the patient should take, with success rates that mean the services of surgeons and radiologists are rarely needed? Equally, how many specialists will see their patient population reduce through vaccines preventing people becoming ill, and eradication medicines curing previously chronic conditions?

Such changes may be a long way off but, across a career span, not impossible.

The Scottish Government is in no doubt. The priority is to recruit new GPs. The number of training places is to go up from 300 to 400 a year[iv], with training places in remote, rural and hard-to-staff areas incentivised with £20,000 bursaries[v].

Maintaining GP numbers is fundamental to delivering the government’s commitment to move care and treatment from hospital settings to those in communities, and people’s homes. As Shona Robison put it to the Health Committee[vi]:

“...general practice is at the very heart of our NHS. With over 90 per cent of healthcare being delivered in primary care and more than 24 million consultations in general practice every year, we must ensure that Scotland’s GPs get the support that they need in order to flourish.”

The creation of 31 integrated health and social care partnerships puts in place a structure to deliver the 2020 Vision – an approach that no opposition party opposes in principle. The ‘Vision’ is not just about shifting the balance of care to deliver it closer to home, but also to shift the balance of cost from hospitals to community. Indeed, the Scottish Government is committed to ‘transferring at least £250 million each year from the NHS to health and social care partnerships, to build the capacity and resilience of our social care services’.[vii]

Expect the painful process of centralisation of specialist services and closure of hospital wards and units to continue as, unless new money is found, the only way to meet the commitment to increase the current 7.6 per cent of NHS spending on General Practice to the 11 per cent promised by the First Minister this month[viii], will be to release money from the 92.4 per cent spent elsewhere.

The rhetoric, most recently at the SNP conference, suggests change will happen with or without applause from those in hospitals. And fewer specialist centres may make the competition for jobs in these specialist fields of medicine more intense.

So how does General Practice in Scotland become more attractive to those junior doctors who are currently considering it but are being put off?

Putting in more resources to primary and community settings will help; as will the promise of a broader role for GPs, perhaps being involved in a much wider range of services to patients.

Perhaps most important to many (current as well as) future GPs would be to be able to spend enough time with each patient, perhaps by ceding to other healthcare colleagues that which doesn’t have to be done by a doctor.

“It is probably true that about 25 per cent of the work that I do every day could be done by somebody else, and could possibly be done better,” Dr McDevitt told the Health Committee. “That is the scale that we are talking about and that might free up 30 per cent of my time to deal with complex care — the new agenda for care for patients — and to make the job more humane.”

Already this year, the role of pharmacists in primary care and community settings has come to the fore, with new money promised to help more work in primary care.

“This is not all about taking the workload off GPs;” Aileen Bryson from the Royal Pharmaceutical Society (RPS) told the Committee[ix]. “It is about filling the gaps in patient care to ensure that each of us around the table, and all the other professions who are not represented today, contribute in our unique way and in such a way that the patient actually gets the most benefit from the whole primary care team.”

Several professional bodies in Scotland are seeking to articulate their collective vision on this. The RPS issued a Joint Policy Statement on General Practice Based Pharmacists[x] with the Royal College of General Practitioners this month; while last month both organisations, alongside five others, published The future of primary care in Scotland: a view from the professions.[xi]

Dr Sian Tucker from the Royal College of General Practitioners described multidisciplinary working as 'brilliant’, but told the Committee[xii]:

“However many multidisciplinary teams we develop, we will not be able to replace GPs, nor should we want to do so. We will therefore have to grow our GP workforce even to stand still because, in addition to the GP workforce crisis, the changing demographics and the amount of care that is required are also drivers for the development of multidisciplinary teams.

“As part of the 2020 Vision, people want to be cared for at home or in a homely setting, and to do that we have to change our view, because currently everybody talks about hospitals – they are always in the press – and takes an acute view, so there is not a big view about primary care. For the national health service to be sustained, it will have to be about primary care.”

[i] Official Report Health and Sport Committee (27 September 2016): http://bit.ly/2doNBTC

[ii] Audit Scotland Prescribing in general practice in Scotland (2013) http://bit.ly/2eFMP5I  

[iii] Official Report Health and Sport Committee (27 September 2016): http://bit.ly/2doNBTC

[iv] Scottish Government Programme for Government (September 2016) http://www.gov.scot/programme2016

[v] Scottish Government News Release: http://bit.ly/2eOfPXy

[vi] Official Report Health and Sport Committee (27 September 2016): http://bit.ly/2doNBTC

[vii] Scottish Government Programme for Government (September 2016) http://www.gov.scot/programme2016

[viii] Scottish Government News Release: http://bit.ly/2dxy0BP

[ix] Official Report Health and Sport Committee (20 September 2016) http://bit.ly/2dFTolp

[x] RCGP RPS Statement http://bit.ly/2ek9pjr

[xi] View from the professionals http://bit.ly/2bVoR2O

[xii] Official Report Health and Sport Committee (20 September 2016) http://bit.ly/2dFTolp