25.04.2024

Dentistry: already largely an NHS-free zone

Lights going out

Dissatisfaction rates soar, surgeries close and new contracts are imposed on unwilling GPs - all part of the ongoing privatisation drive, writes James Linney

Spring has arrived, flowers are blooming and the winter’s darkness is now just a memory. Not too long ago this change in season would have seen some easing of the pressure in the NHS - a fall in respiratory infections would be evident in both a reduction of hospital admissions and demand for appointments with GPs. Wards and clinics would still be very busy, but the work would feel slightly more manageable for a time. But those days are now long gone: the current reality is that our healthcare system crisis simply deepens with each passing season and it is now perpetually ‘winter time’ in the NHS.

This crisis affects every aspect of care - accident and emergency (A&E) waiting times are longer than ever before, and similarly people are now waiting far longer for non-emergency hospital treatment, while there are staff shortages across the board. But the seriousness of the crisis is nowhere more clearly evident than in our GP surgeries and, with the enforcing of new contracts (see below), the future looks bleaker than ever.

The latest British Social Attitudes survey revealed that the public’s satisfaction for the NHS is not surprisingly lower than it has ever been.¹ Fewer than one in four (24% of people) were satisfied with the NHS, compared to 29% in 2020. Satisfaction with the NHS has been falling steadily with every year of Tory government: it seems like a lifetime ago now, but it was only 2010 when satisfaction levels were as high as 70%.

The main reason given for dissatisfaction is precisely the long waiting times for GP and hospital appointments (71%) and, despite what the Tory-friendly media would want us to believe, 84% of respondents stated that the main issue is the NHS’s major funding problems. This clearly confirms that the vast majority of the public hold the government responsible for the crisis, not the overstretched and overburdened staff.

As anyone who has tried to get a GP appointment recently will know, primary care is broken. Often people are spending hours on hold on the phone or having to call back day after day to secure an appointment - and these are the lucky ones. But even then there is no guarantee it will be any time soon - in February about 10% of people had to wait more than four weeks to see their GP.² There were a total of 30.5 million standard (non-Covid-19 vaccination) appointments³ - the equivalent of half the UK population. At the same time as people are struggling to get an appointment, primary care staff are burning themselves out simply by trying to get through each day.

There is clearly much more to the primary care crisis than the delay in appointments. In fact part of the problem is that NHS England, along with the government, has increasingly focused solely on improving GP access. Appointment numbers are now closely monitored and they are increasingly having to operate like an emergency department - being forced to deal with every problem on the day rather than being allowed the autonomy to more logically plan their own patients’ care.

GP surgeries are dealing with more appointments than ever - 50 million a year more compared to 2019, and this despite there being 1,862 fewer full-time fully qualified GPs since 2015. The arbitrary NHS England targets - whose point is only to try and make the government look good - are actually leading to a drastic fall in the quality of care, creating conveyor-belt healthcare, resulting in both harm to patients and a thoroughly disheartened workforce.

Contracts

April has seen the introduction of the Department of Health and 2024-25 national GP contract. This new contract is being forced on GP practices by NHS England - as with the previous one, which was imposed in 2019. GP practices have had no input into the terms: either they accept it or are forced to close.

The new contract sets out what targets surgeries need to meet, what services need to be offered and what funding the surgeries are entitled to. Surgeries have very little autonomy in how the money is spent and since the introduction of primary care networks (PCNs) they have had to share out increasingly sparse resources with other surgeries in their area. PCNs are the latest incarnation of the Tory NHS primary care reforms and, like those before them, they have been a vehicle for new layers of bureaucracy, defunding and the outsourcing of services to the private sector.

GP contracts also set out the yearly uplift in funding, which has been locked in at very low levels since 2019 despite surgeries having to deal with the Covid pandemic, and high inflation rates, producing increased costs of living and sky-rocketing bills for building upkeep, heating, etc. This defunding led to 57 surgeries being forced to permanently close last year, meaning that since 2013, 474 GP surgeries across the UK have closed without being replaced.⁴

Despite this decline the new contract provides for only a 1.9% increase in funding - which is woefully below what is needed and will without doubt lead to more cuts in staff and surgeries permanently turning their lights out. The proportion of NHS funding spent on primary care fell to 8.4% in 2023-24 - a smaller share than in any of the previous eight years. When patients cannot get to see their GP, they get sicker and end up having to attend A&E, where they are sometimes facing waiting times of 12 hours or more! It is well established that proper funding of primary care significantly reduces healthcare costs in the long run, because inpatient care is so much more expensive. The only sensible conclusion then is that the new GP contract represents wilful underfunding of primary care in a blatant attempt to undermine the NHS as a whole.

The British Medical Association (the largest union for doctors) has stated that at least an 8.7% uplift in funding will be necessary this coming financial year to make up for the deficit since 2019 - that is just for primary care to be able maintain the status quo and avoid more surgeries having to close their doors, being unable to pay for the staff they need.

BMA vote

Referring to the 1.9% uplift in this year’s contract, the chair of BMA’s GP Committee for England, Dr Katie Bramall-Stainer, rightly called such blatant defunding “an intentional, predetermined, strategic, non-evidence-based, ideological dismantling of NHS general practice”.⁵

Just before its imposition the BMA held a vote, asking its GP members whether they accept the new contract and, with a 61.2% turnout, a whopping 99.2% of the 19,000 GPs said ‘no’- no need for recount there! While this clearly reveals the growing anger primary-care doctors feel about their neglected industry, the vote does not change anything; the contract was still implemented and the government has so far ignored all calls by the BMA to rethink. The union’s next move - likely some time later in the summer - will be to propose to its members a vote on some form of industrial action. Although the BMA has not yet indicated what such industrial action will look like, it is unlikely it will be in the form of walkout strikes, as we have seen from nurses, junior doctors and hospital consultants. Unlike those disputes, this is not about GP pay, but about the funding for primary care as a whole, so it is likely the BMA will propose a vote on GPs abstaining from some elements of the contract, thus reducing services and limiting the number of patients a surgery sees each day.

These types of action will lack the impact of seeing GPs on the picket line, but framing the industrial action as about opposing the government’s defunding of primary care is certainly preferable to it being just about GP pay. This will also limit the impact of the rightwing media, when they inevitably try to claim that any industrial action is just about greedy doctors. Of course, for now this is all just speculation, but in the meantime patients and staff continue to suffer, as primary care limps on.

The continued defunding is just part of the Tories’ ideological attack on the NHS. Another is the persistent transfer of NHS services (and taxpayers’ money with it) into the hands of those grateful private healthcare providers. It is a fair conclusion that this combination of deliberate neglect and privatisation by stealth is a way of setting up the NHS for the knockout blow - doing away once and for all with the ‘free at point of care’ service.

This could initially follow the disastrous example of NHS dentistry services - with the introduction, say, of a standard fee for essential visits to your GP or emergency department rather than an immediate switch to an American-style, insurance-based health service. If this is the plan, then the Tories certainly are not going to unveil it any time soon: they have too much on their hands with the looming general election, which they are almost certainly going to lose anyway.

This means then that most likely by the end of the year the NHS will be in the hands of Sir Kier Starmer’s Labour Party. But, as I have previously stressed, this is not a situation to be celebrated by either staff or patients. Starmer and his shadow health secretary, Wes Streeting, have so far taken every opportunity to reassure private health companies that they have nothing to fear in the event of a Labour government and that the use of private health will, if anything, increase.

Last week, in his article in The Sun,⁶ Streeting wrote on how Labour would approach the task of ‘saving the NHS’ and cutting waiting lists - ominously warning that no additional funding will be provided without the “major surgery” of reform. He also promised that “middle-class lefties” were not going to stop Labour from allowing private health companies to cherry-pick further NHS services. Perversely he went on to say that not to allow private companies more access to the NHS just because he had “principles” would be a “betrayal” of working class people. Given that Streeting has received more than £175,000 from donors linked to private health firms,⁷ I would suggest he pawned his principles and betrayed the working class a long time ago.

No clearer indication is needed of the kind of Labour Party Starmer has incubated.