The following statement was issued by Lothian LMC (LLMC) in September 2024.  LLMC is a body that represents General Practices within Lothian in discussions about funding and service delivery within NHS Lothian and nationally.  We (Lammermuir Medical Practice) have adapted the statement in parts to fit our local situation.

Why is your GP practice now unable to do everything they once were?

General Practice across the country has been struggling for years.  However it has now reached a critical situation with less money, fewer doctors and fewer staff to meet the growing needs of the Scottish population.

So how did we get here?

In 2017, the Scottish Government recognised the funding crisis within primary care and promised to introduce a new contract, starting in 2018 and to be fully implemented within 3 years.  At the time, the then Health Secretary Shona Robison MSP said “We equally recognised the fundamental challenges faced by general practice, not least growing workload and increasing risk”.

After long negotiations, a contract was agreed.  However, for the first time in the history of the NHS, large parts of this 2018 contract have not been implemented.

Even worse, when Health Boards have been unable to spend the money that they were given to deliver elements of the contract eg employing additional pharmacists or other professionals to support General Practice, the money has had to be returned to Scottish Government rather than being able to be spent supporting your local practice.

Scottish Government promised transitional payments to practices to recognise the non-delivery of this contract, but then withdrew that funding, even after some practices had already used the money for additional cover.

There have been many further challenges, both local and national, since then:

• Funding for practices comes through a national formula and does not reflect how many times patients are seen.  Practices are paid the same whether you are seen once or a hundred times per year.  In 2017, the Scottish Government recognised that this was no longer an adequate approach and promised to move towards a new funding model.  This has still not happened and funding uplifts have been substantially below inflation since then.

• The average patient used to contact their practice 3-4 times per year.  This has increased to 6-7.  The reasons for this are many and complex and include factors such as there being more elderly people, more people with illness (often multiple) and more treatment options.  The large growth in waiting lists has also had a significant impact, with GP appointments being taken up helping patients cope with their situation whilst awaiting definitive procedures.  A good example might be people who require more pain relief while they await joint replacement surgery.  Many GP appointments are used to discuss how patients can cope with these and other problems resulting from long delays to hospital assessment or treatment.

• Energy costs have risen greatly over the recent years.  Inadequate funding uplift has been provided by Government, meaning further loss to funding for patient services.

• Part of the funding which comes from government every year is earmarked for non-GP staff pay rises e.g. receptionists, nursing staff, practice managers.  This has always matched what was given to staff working elsewhere in the NHS.  But for the first time last year, the Scottish Government decided to break this link, leaving practices with a choice to fund the shortfall, risk losing staff or to reduce already tight staffing levels.

• Over half of the practices in Lothian have recently received huge bills for their facilities from NHS Lothian, over and above what they were already paying. This will amount to £1.6 million per year across the practices affected and, without any additional funding coming into practices, it is likely this will lead to reduced staffing, with fewer appointments and longer waits to be seen.   (This does not apply to Lammermuir Medical Practice, which has a different arrangement for facilities management.)

• The number of GPs in Scotland is falling.  As part of the 2017 contract the Scottish Government promised that numbers would rise by 800.  However when doctors in training are excluded from the figures, the numbers are actually reducing.  Since 2013, the GP WTE (whole time equivalent) workforce has fallen by 5.35% - a fall of 196.7 WTE GPs.  Over that same time period, the number of practices has fallen by 9%, average list sizes have increased by 18% and the total patient population has increased by 7%.  42% of practices in Scotland report at least one GP vacancy.  The number of GP partners has reduced by 14% between 2012 and 2022.  In the last 20 years the ratio of GPs to hospital consultants has halved, despite many things which used to be done in hospital now commonly being done in practice, and this reflects the falling share of the NHS budget spent in General Practice.

• In many areas, practice buildings are too small and are outdated.  Scottish Government has now cancelled all funding for new buildings, leaving many working out of buildings no longer fit for purpose . Scottish Government has also withdrawn sustainability loans, a scheme to reduce the risk for GPs who own their building.  This leads to financial loss which again impacts on the services they can deliver.   (Lammermuir Medical Practice, along with the Tyne and Orchard practices, were ‘next in line’ for a building upgrade prior to the cancellation of all new capital projects.  Our building is too small to accommodate any of the range of additional colleagues, eg physiotherapists or mental health specialists, we would like to have on site.  We are struggling to fit in all the doctors required to see the expanding local population.)

• With fewer staff and more work, better IT would help improve efficiency.  IT in General Practice is cumbersome and unreliable which often impacts on the care of our patients, increasing inefficiency and damaging staff morale.  We are the only country in Britain still using paper prescriptions – this alone takes a huge amount of clinical, administrative and patient time.

• In order to make systems better we need time to learn and develop.  Practices used to receive ten half days per year to work with our teams on making practices better for everyone.  The support for this was withdrawn by NHS24 and Scottish Government have done very little to reintroduce any form of reliable support.

Despite all of the above, your practice remains absolutely committed to provide the best service that it can.  However, we hope this summary provides some context to the difficult funding situation which it is faced with.

Update October 2024: the recent increase in Employer National Insurance contributions will have a huge impact on practice finances.  It is difficult to imagine what Government is thinking on this point.  With GP practices already struggling to provide a service and with national satisfaction levels at an all-time low, the employer NI increase will lead to more practice closures and an even more compromised service from those able to remain open.

At Lammermuir Medical Practice we have worked hard over recent years to adapt our service to these funding challenges and to continue to provide as good a service as we can.  We are fortunate to be located in East Lothian, where recruitment of GPs is easier than more remote regions of Scotland.

However we regularly receive concerned feedback from patients who have struggled to access an appointment or been disappointed that certain services are no longer available from the practice.

If you are not satisfied with the level of service that Lammermuir Medical Practice can provide, please consider looking beyond the practice and instead hold those with the power to improve matters to account: Scottish Government needs to do more to directly support General Practice, the bedrock of the NHS.  Please contact your MSP.  Their contact details can be found at Members of the Scottish Parliament (MSPs) | Scottish Parliament Website

Lothian LMC – adapted in part by Lammermuir Medical Practice to add local relevance