Is general practice about to face its biggest shake-up in the history of the NHS?

A further £6 billion should be used to gradually “buy out the GP-owned estate” - that is, doctors’ surgery premises.

READ MORE: Key aims of Scottish GP contract 'will not be met' by April 2021 deadline

It might have seemed like pie in the sky, except that Health Secretary Sajid Javid had penned the foreword to the paper in which he welcomed the proposals as “credible” and “pragmatic”.

It also came just weeks after reports that Mr Javid was planning a review of primary care and a probably-not-coincidental visit by government officials to Wolverhampton NHS trust where GPs are already sub-contracting functions such as payroll and the employment of practice nurses and receptionists back to the trust.

This Spanish-style "vertical integration" model is supposed to allow GPs more time for patient care and there is some evidence that it is associated with a “modest, but statistically significant” reduction in unplanned hospital admissions.

Sajid Javid, the UK Health Secretary in charge of general practice in England, said the proposals were "pragmatic" and "credible"

Given that health is devolved, any overhaul of the independent contractor model which has underpinned general practice (as well as dentistry, pharmacy, and optometry) since the NHS was founded in 1948 will apply to England-only - at least for now.

But it would be difficult to ignore such a seismic change on our doorstep, or to imagine that it might not influence thinking here.

READ MORE: Health chiefs 'suppressed' report revealing profiteering by GPs in deprived areas 

In both countries, the workforce is struggling to keep up with demand.

By headcount, Scotland gained just 302 GPs between 2011 and 2021 - an increase of 6%, to 5,195, at the same time as the number of patients aged over-65 registered with GPs ballooned by 21%.

Worse still, in real terms, the GP workforce is actually shrinking: between 2013 and 2019, Scotland lost the equivalent of 62 full-time GPs amid a growth in part-time working.

Female GPs (who are most likely to be working part-time) now make up 61% of family doctors compared to 52% a decade ago, and maternity leave is the number one reason for staff absence.

Male/Female GPs by headcount, 2011 to 2021 (Source: Public Health Scotland)

At the same time, male GPs in their 20s and 30s are also much more likely to work part-time compared to male GPs aged 45 to 54.

Given that nearly one in three GPs is over 50, this should trigger alarm bells for what a post-pandemic exodus of early retirements could bring.

GPs by headcount up to 2021 (top) and GPs by 'whole-time equivalent' (above) up to 2019, the last year for which estimates are available (Source: Public Health Scotland)

There is also a clear decline in younger GPs becoming partners - the doctors who own and run GP practices.

In Scotland, GP partners now make up just 64% of the profession compared to 77% a decade ago, while salaried GPs - employed by a practice but without a financial stake in it - make up nearly a quarter of the workforce compared to one in 10 in 2011.

Without enough doctors willing to buy into partnerships and take on the liability for premises, the independent contractor model will unravel.

READ MORE: Experts calls on Scottish Government to end system where taxpayer-funded GPs can keep earnings secret 

For decades the advantage was autonomy: family doctors were free to run their own practices with limited NHS interference.

Overall, it was also consistently associated with better value for money for the public purse compared to the costs when health boards are required to take over the running of practices (for example, because all the partners have left or retired).

Over time, however, as funding flowed disproportionately to hospitals, trainee medics were increasingly attracted into consultant careers with a starting salary of £87,500 and none of the overheads involved in, effectively, owning a business.

The average net annual income for a GP partner is around £100,000, but comes with “considerable variation”.

A GP partner in remote or rural Scotland banks much less on average than their urban counterpart, while GP partners can also maximise their earnings by employing fewer support staff or working ‘single-handed’ - without any other partners - even if that means a poorer service for patients.The percentage of GPs who are partners ('performers') has been declining as younger GPs increasingly opt to be salaried practice employees instead (Source: Public Health Scotland)

This potential for ‘profiteering’ is inherent in the independent contractor model; it has even been blamed for decades of disinvestment in general practice (the suggestion being that ministers were reluctant commit funds which might end up in GPs’ pockets rather than spent on patient care).

Scotland’s 2018 GP contract set out to address some of these problems, guaranteeing full-time GP partners a minimum income of £80,630; a gradual takeover of premises by the NHS; and a ‘multidisciplinary team’ of pharmacists, physiotherapists, and mental health workers embedded in every practice to give GPs more time for complex patients.

The latter has been slowed by NHS-wide shortages of healthcare professionals, and progression to the more controversial ‘Phase Two’ of the contract - supposed to get underway in 2020/21 - was stalled by the pandemic.

Dr Andrew Buist, leader of BMA Scotland, has insisted the trade union and Government remain committed to the independent contractor model in Scotland

Phase Two is important because it promised to pave the way to a new consultant-style “income scale” for GPs and see practices directly reimbursed for staffing and premises expenses.

Ministers presented this as a means of reducing financial risk; cynics saw it as finally tackling the “profiteering” minority; and many doctors feared it signalled a shift away from the independent contractor model to a “salaried service by stealth”.

READ MORE: Travel vaccines row as NHS Glasgow hands £700k contract to private GP clinic with only two branches

It was to be based on income and expenses data which had to be submitted by all practices by the end of January 2020, enabling the Government to see for the first time exactly how GPs were spending taxpayers’ money.

Then Covid came along and Government analysts were diverted into picking apart Covid statistics instead.

Discussions on a new plan and timeline for Phase Two have recently resumed between the Scottish Government and BMA.

To proceed, however, a majority of GPs will have to vote in favour - and that is far from certain.

But, on both sides of the border, the future shape of general practice may be on the brink of a watershed.