Scotland's GP plan is failing to deliver while real-terms funding falls, finds watchdog

Scotland’s Government has failed to deliver on several of its 2018 commitments to support GP practices, the country’s watchdog has found in a damning new report.

Audit Scotland highlighted that the proportion of NHS spending on general practice dropped from 7% to 6.5% between 2017/18 and 2023/24, while direct spending on GP practices decreased in real terms by 6% between 2021/22 and 2023/24.

The 2018 GMS contract was the first time a Scotland-specific contract had been negotiated with the BMA, and it set out a number of ambitions intended to bolster GP sustainability, address recruitment challenges, and free up GP time.

But Audit Scotland’s new report concluded that several commitments to be completed by 2021 have not been fully implemented, and that the Government ‘has not been transparent enough’ about its progress since 2018.

The Scottish Government’s commitment to increase the number of GPs working in Scotland by at least 800 by 2027 is unlikely to be met, the watchdog found, with the number rising by only 135 between 2017 and 2024.

On funding, the Government had committed in 2018 to reform the GP contract to include ‘direct reimbursement of staff and premises expenses’, but this has not yet been agreed with the BMA’s Scottish GP Committee.

The watchdog’s report said: ‘[The Scottish Government] does not have a full understanding about the current expenses of running a general practice or how much GPs earn.

‘It could therefore not provide assurance that this model is affordable. But it has not set out what it would do if this model is deemed unaffordable.

‘This lack of strategic and financial planning has created uncertainty for GPs about how they will be funded in future.’

The report said that despite the ‘substantial challenges’ in achieving direct reimbursement of expenses, this reform would ‘support the long-term sustainability of general practices’, and that without it ‘GPs are at risk of bearing the financial burden of increasing costs’.

Other watchdog findings

The Scottish Government had committed to transferring the responsibility for providing six priority services from GP practices to NHS boards, and expand the use of MDTs to reduce workloads;
- This has only partly been completed and the Government has not set out when it will fully implement these commitments.
QOF was replaced with ‘GP clusters’ as a means of improving quality of care;
- But they ‘are not yet working as intended’, and the Government has ‘not done enough to create the conditions for clusters to succeed’
The Government committed to provide interest-free sustainability loans for GPs who own their own premises, with the intention that NHS boards would own premises entirely by 2043;
- But the Government has ‘not been transparent about the investment in sustainability loans’ and also made a ‘misleading announcement’ about their uptake’.
- The Scottish Government also does not have ‘sufficient oversight of whether GP premises are fit for purpose’.

Source: Audit Scotland

In order to correct these failings and delays, Audit Scotland urged the Government to publish a ‘clear delivery plan’ for general practice by the end of this year.

This plan should include a ‘medium-term funding trajectory’ for the profession, as well as better support for tackling health inequalities.

Audit Scotland also called on the Government to set out plans for moving towards a model where GPs are no longer expected to provide their own premises within one year.

The BMA said the report ‘demonstrates in forensic detail’ why so many practices are ‘struggling to meet demand’ and why GPs are left ‘angry and demoralised’.

Scottish GPC chair Dr Iain Morrison continued: ‘The failure to invest in General Practice and plan effectively to recruit GPs is taking its inevitable toll.

‘After seven years, the 2018 GP contract has failed to create anywhere near the services and capacity promised to the profession by the Scottish Government.’

He called on the Government to ‘urgently address the shocking situation’ GP practices are in by investing ‘directly’ into them, and also to increase general practice’s share of the NHS budget to 15%.

The RCGP said Audit Scotland’s report ‘lays bare the increased pressure that GPs and their teams have worked tirelessly to absorb’.

Scotland chair of the college Dr Chris Provan said: ‘The divergence of workload and resource simply cannot continue, and we welcome the report’s various recommendations for better financial decision making, workforce planning, and data gathering in general practice.’

The Scottish Government thanked the watchdog for its report, and noted that ‘many of its recommendations are already in progress’.

Health secretary Neil Gray said they are ‘committed to working with the BMA to support general practice’ and to meet their promise to deliver 800 more GPs by 2027.

‘The First Minster and I have been clear that we know too many people have had issues with seeing their GP and we have set out a plan to improve access, with a greater proportion of new NHS funding going to primary and community care so that GPs and services in the community have the resources to play a greater role in our health system,’ he added.

In December, Scotland’s GP leaders outlined a list of demands for the Government to meet in order to avoid industrial action, including GPs receiving 15% of the NHS budget as well as long-term contract reforms.

The First Minister announced earlier this year that the Government will allocate an extra £10.5m to general practice as part of a shift to more community-based care.

But some doctor leaders said the plan lacked detail on how the Government is planning to shift more care and funding into primary care services in the long term.