NEARLY one in 10 GP practices in Scotland are now being run by health boards, rising to as many as one in four in some rural regions, according to figures obtained by the Herald on Sunday.

The rise of so-called '2C' practices, which are more expensive to operate and generally provide poorer continuity of care, has been described as a "disaster" by GP leaders who warn that the future of the NHS is at threat unless the trend can be reversed.

Figures obtained under freedom of information show that 76 GP surgeries out of a total of 910 in Scotland (8.4 per cent) have either become 2C practices or are heading in that direction after GP partners pulled out. This compares to 59 out of 943 (6.9%) in 2019.

The figure includes one of Scotland's largest practices, Inverurie Medical Practice in Grampian, which became the latest casualty of Scotland's GP shortage in March when its partners announced they would be handing back their contract to provide medical services from September this year after struggling to recruit new doctors.

READ MORE: Collapse of Inverurie GP surgery 'extremely worrying'

The data also shows significant regional variation, with 10% of GP surgeries in Grampian and 25% in the 'North Highland' (Caithness and Sutherland) region health board-run.

In Lothian and Tayside, more than 8% are 2C whereas in Greater Glasgow and Clyde only two specialist practices - for the homeless and patients with challenging behaviour - are run by the health board.

The traditional model for general practice is based on GP partners owning a practice which is contracted by the NHS to provide General Medical Services (GMS) - a core level of provision negotiated annually between the BMA trade union and government.

However, this independent contractor model has come under strain as Scotland's GP workforce has shrunk in real terms by an estimated 181 full-time GPs since 2013 and the number of GPs willing to take on the financial liabilities of a partnership has plummeted.

Between 2012 and 2022, the number of GP partners in Scotland fell by 515 as older GPs retired or quit to work as salaried or locum doctors instead, and younger medics shied away from becoming partners.

By 2022, just 72% of the GP workforce (excluding trainees) were partners, down from 85% in 2012.

The Herald: The percentage of the GP workforce who are partners ('performer') as an increasing number opt to be salaried or locums instead The percentage of the GP workforce who are partners ('performer') as an increasing number opt to be salaried or locums instead (Image: PHS)

This trend explains why more and more practices are collapsing, with health boards forced to step in.

In Grampian, 13 practices have handed back their contracts in the past five years and in the past year alone 13 out of the 15 practices in Aberdeen city centre have closed their lists to new patients in a bid to stem demand.

Dr Samantha Fenwick, an Aberdeen GP and medical director for the Grampian local medical committee (LMC), which represents the region's GPs, said: "There's a lot of potential Inveruries at the moment.

"We know of a lot of practices where, given one or two retirements or resignations, they could go under.

"The main factor for the recent ones has been recruitment - they're just not able to get new GPs."

Health boards have two options when a GP practice hands back its contract: they can take it over, or they can disperse patients to neighbouring surgeries.

Health board-run surgeries are costlier for a variety of reasons, including a heavier reliance on locums.

In some cases this has driven health boards to offload 2C practices onto larger, corporate-style medical chains which have been criticised for maximising profit by employing comparatively few GPs - making it harder for patients to see a doctor.

READ MORE: Scottish health boards forced to save GP surgeries from closure

In addition, research has repeatedly shown that continuity of care - where the same GP is responsible for a patient's care over years or decades - is associated with better health outcomes and fewer hospital admissions.

A shift to 2C practices, which tend to have higher doctor turnover, undermines this.

With NHS budgets under pressure, however, there are fears that health boards will become less and less able to take on practices and will increasingly expect other GP surgeries to absorb extra patients, potentially creating a "domino effect" as workload spirals - driving more partners to quit, and more practices to fold.

The Herald: The headcount for GPs has increased slightly, but the real-terms size of the workforce - after adjusting for part-time working - has shrunk since 2013The headcount for GPs has increased slightly, but the real-terms size of the workforce - after adjusting for part-time working - has shrunk since 2013 (Image: PHS)

The endpoint is more and more patients finding it impossible to get an appointment, or even register with, a GP and falling back on A&E instead.

"Inverurie was a warning because it's such a big practice and was a stable practice for a long time previously," said Fenwick.

"Moving forward, I think health boards will struggle to fund that [2C] model so there is a risk that the patients will be dispersed which, given the situation where practices are struggling, would be a disaster."

Exactly how much more 2C practices cost the taxpayer compared to standard GMS practices is difficult to quantify, but a recent analysis carried out by Dr Iain Morrison - chair of the Lothian LMC - put the figure for the region at estimated 48% more per patient.

Morrison, a GP in Midlothian, said: "The difficulty that a lot of 2Cs have is that they are practices which have been quickly established after a practice hands back its contract - the firefighting costs of that are exceptionally high.

"You're trying to entice the locum market into a practice they know is going to be exceptionally busy, so they have to pay the locums very high rates to attract them.

"That then means the locum market is inflated for everyone else so it can quickly spiral to disrupt the whole of the local GP market, and we're seeing that in Edinburgh."

The Herald: Dr Iain Morrison Dr Iain Morrison (Image: Lothian LMC)

Morrison added that practices in the capital which would have been "golden opportunities" 10-15 years ago were now struggling to attract any suitable applicants.

He said: "It's scandalous that in the city centre of Edinburgh we cannot attract enough doctors.

"We've got all the evidence we need that the independent contractor model delivers best value for patients and the taxpayer, and yet there's always money found in the firefighting situations rather than investing to save the independent contractor model and prevent this perpetual crisis.

"I really fear that we're headed for a two-tier system like dentistry. The patients who can afford it will go private, and those who can't will be stuck with a lesser service."

The Scottish Government insists that it is committed to delivering on a pledge of 800 extra GPs by the end of 2027/28, but Audit Scotland has warned that progress is "not on track".

READ MORE: 'It's falling apart' - GPs on their fears for the future of general practice

In addition, there is anger that money originally earmarked for general practice has been clawed back or "reprioritised", including £65 million from the Primary Care Improvement Fund.

The cash was intended to pay for multidisciplinary team (MDT) members in GP practices but had gone unspent, partly because there were too few pharmacists, physiotherapists, and advanced nurse practitioners available for hire.

The Scottish Government instructed health and social care partnerships (HSCPs) to use the funds elsewhere.

Meanwhile, a £15m sustainability payment for 2022/23 - intended to bolster practices through winter and Covid pressures - was cut to £10m, and in March GPs were told that 'transitional payments' to support practices continuing to provide services such as blood draws and ear syringing, which are supposed to have transferred to health boards, would end from April.

The Herald: Since 2012, the whole-time equivalent number of consultants in NHS Scotland has climbed by 32 per cent to around 6040 at a time when the WTE count for GPs has declinedSince 2012, the whole-time equivalent number of consultants in NHS Scotland has climbed by 32 per cent to around 6040 at a time when the WTE count for GPs has declined (Image: Turas)

Phil Wilson, an emeritus professor of primary care and rural health at Aberdeen University and vice chair of the Rural GP Association Scotland (RGPAS) said general practice has suffered from decades of disinvestment.

He said: "In real terms general practice has not received any uplift in its funding for 20 years, once you correct for inflation.

"In contrast, hospitals have had a massive injection of funding.

"So the number of full-time equivalent GPs has dropped over the last 20 years while hospital consultants have doubled."

The Herald: Professor Phil WilsonProfessor Phil Wilson (Image: Aberdeen University)

Wilson said the prioritisation of resources towards secondary care created a "vicious cycle" by destabilising general practice.

He said: "The more money governments pour into hospitals, paradoxically, the more pressure it puts on general practice.

"Every time they appoint a new consultant, it makes a GP's job harder because all kinds of new rules and regulations and guidance for referrals come into place.

"Now, all over the country you've got out-of-hours services collapsing because they can't get the GPs to cover shifts, so people are phoning 111 and being told to go to A&E.

"So we need the extra doctors in A&E because we don't have enough GPs, yet we know that it's far more expensive to fill a hospital emergency department with staff than it is to have a decent, experienced primary care service.

"The get out of jail free card that governments use over and over again is to say 'we've got loads more doctors and loads more nurses'. But they're all in the wrong place - they're in hospitals.

"General practice is the glue that holds the whole thing together, and if general practice collapses then we have to spend an absolute fortune on secondary care.

"Every penny you spend in primary care will save 10 pennies in hospital medicine.

"If the government said tomorrow 'right, from now we're not going to spend any more money on hospital medicine - any extra money we have we're going to spend on general practice', I think that would solve the problem.

"Because people would want to start working in general practice again - they would know it was a national priority."