Primary Care Requires New Lease of Life

While we’re constantly told that more money than ever is being spent on the NHS, the day-to-day reality for its patients and clinicians suggests this is delivering little, if any, effect, especially within the realm of primary care. 

The GP Contract, rolled out by the Scottish Government in 2018, promised a new dawn for general practice that would deliver real and meaningful improved patient outcomes. The reality has been far removed from that. Whilst general practitioners have largely kept to their side of the bargain, a raft of policies which underpinned the new contract remain, at best, partially implemented and, at worst, completely abandoned. 

One of the key destabilising factors for general practice which has significantly impacted on GP recruitment is premises-associated risk. The GP Contract included interest-free loans on the value of a GP surgery premises, designed to smooth the path of succession by allowing current and new practice partners to buy out retiring ones.  This measure has however been slow in delivery, leaving many practices incurring substantial costs to progress their applications with nothing to show for it.  The loan application process is also fragmented as Scotland’s 14 Health Boards each has its own criteria for implementing the policy.

Another key policy, which remains largely unimplemented, was that Health Boards would take over leases from GP practices which rent their premises from third party landlords. As a result, most practices within such premises are in limbo and facing significant dilapidations bills while hoping their landlords won’t take active steps to end their lease and force them to close.

Because the dilapidation costs ultimately become the responsibility of any GP partners who remain in place at the end of the lease, this is having a hugely detrimental impact for those practices needing to recruit new doctors. While the 2018 GP Contract committed to addressing the challenges of dilapidation liabilities through a combination of grants and loans, these have dried up leaving many practices high and dry.

The terms of the 2018 GP Contract were expected to stabilise general practice with Health Boards, recognising that funding of primary care was already on a knife edge, doing all they could to sustain practices.  Instead, we see Health Boards taking steps to force practices into paying occupation costs resulting in exponential increases without any additional funding to cover this. At least some Health Boards are effectively cannibalising primary care.  Within this emerging landscape it is unclear how such legislation will sustain general practice, raise morale amongst health service workers or deliver better patient outcomes.

The Scottish Government can, with some justification, point to the challenges of the Covid pandemic and its ongoing impact on the NHS as well as a lack of central government funding. These are undoubtedly major challenges which will require innovative solutions that go well beyond simply spending more money.

In the meantime, NHS primary care in Scotland faces an existential crisis. There are clear signs that our healthcare system is already in the process of collapsing. In December, BMA Scotland warned that the NHS will struggle to make it through another year without urgent reforms.

While politicians can point to ‘record sums’ being spent on the NHS along with legislation that claims to support GPs on the front line, this decline will only accelerate if they fail to properly support primary care and give it the secure foundation it requires to improve health and wellbeing outcomes in Scotland.

This article was originally published by The Scotsman on 24 February 2025.