Scotland's malfunctioning NHS could lead to a two-tier health system: one for the rich, another for the poor – Dr Andrew Buist

I think it’s fair to say the NHS is malfunctioning. Let’s avoid the word crisis for now but I am sure many would say we are already there.
GPs are being asked to look after too many patients (Picture: Christopher Furlong/Getty Images)GPs are being asked to look after too many patients (Picture: Christopher Furlong/Getty Images)
GPs are being asked to look after too many patients (Picture: Christopher Furlong/Getty Images)

Extensive waiting times for hospital services are really bad for general practice. Patients can simultaneously be in multiple virtual queues, and they don’t just wait, they suffer, they get worse and they go back to the only place they can: general practice.

Excessive workload for general practice was the number one pre-pandemic problem and it’s just got a lot worse. For those reading this who are not a GP, that’s why getting an appointment is harder than ever, capacity and demand are significantly out of sync.

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To highlight the difficulties, I wanted to focus on one single condition, one that’s been close to my recent personal experience: ADHD, an increasingly recognised disorder traditionally in the realm of psychiatry, a specialty which has suffered in recruitment terms as badly as general practice.

A desperate parent brings in their child – GPs recognise the pattern and the symptoms, but the offer of a specialist referral to be assessed in, perhaps, 18 months is professionally unacceptable, and families can see the system is letting them down. Some who have the funds, go private; most can’t.

An 18-month wait for a bright 16-year-old with probable ADHD can cause them to mess up their exams, ruin relationships and start addictive behaviours that damage prospects for life.

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To start ADHD treatment a GP needs two things: a confirmed diagnosis, and advice on therapy. Some GPs are even willing to help desperate parents by making the diagnosis and commencing therapy without specialist advice on the basis this is less harmful than doing nothing.

Putting aside our already excessive workload, it is of course a risk for a general practitioner to take on more specialist work in this malfunctioning NHS, even in a situation like this with the full support of well counselled patients as to why it’s necessary. But this is happening all the time now.

So, what’s to do about it? It’s not rocket science but then too often it’s just not happening. Firstly, we need to recognise we have a major problem. GPs, given the time, could do more, but they also need investment in their continuing professional development to maintain and develop their skills.We desperately need more GPs to deliver this: the current average of 1,600 patients per whole-time equivalent GP may have worked in the 1950s when appointments were five minutes, dozens of conditions we deal with now were unheard of, and when Scotland had thousands more hospital beds for a smaller, less expectant, population. But it’s totally inadequate today.Above all we need a public discussion on what kind of NHS we want now and going forwards, with all the trade-offs that may involve. We need to do this: our malfunctioning NHS is at great risk just now of universal care failing.

If that happens, those who can will make alternative arrangements and we will have a true two-tier system where the care you get in Scotland depends more and more on what you can afford. Continue down this path and we will have lost something very precious. It is that important.

Dr Andrew Buist is chair of the BMA’s Scottish GP Committee



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