We all know what GPs used to look like. Mostly men with beards, they made house calls, wore tweed jackets and carried their patient notes around in battered Lloyd George envelopes.
Those days have largely disappeared. Home visits are now rare, many practices no longer have a single full-time partner, and patients are often more likely to speak to a nurse practitioner, paramedic or pharmacist before they see a doctor.
So what happened?
The NHS was never a state monopoly
When the NHS was established in 1948, hospitals and community services were nationalised and became part of the NHS. Family Health Services—GPs, dentists, pharmacists and opticians—did not. They remained private contractors providing NHS services.
GPs may have worked almost exclusively for the NHS, but they were never NHS employees. Most owned or jointly owned their practices as partnerships, much like solicitors or accountants.
You’ll often read claims that the NHS has been “privatised by stealth”. In reality, the NHS has always been a mixed economy of public and private provision. In fact, there has arguably been more stealth nationalisation than privatisation. At the birth of the NHS, around one-third of NHS spending went through these independent Family Health Services. Today that proportion is under a fifth.
The John Wayne contract
For decades GPs worked under the “John Wayne contract”: a GP’s gotta do what a GP’s gotta do. Their responsibilities were remarkably ill-defined. They were effectively responsible for their patients 24 hours a day, seven days a week.
That meant daytime surgeries, evening calls, night visits and weekend emergencies.
Larger practices shared the burden through rotas. Single-handed GPs often had no rota at all unless they paid a deputising service or joined a cooperative with neighbouring practices.
One GP I knew worked his own on-call rota while also working nights for both a commercial deputising service and a local GP cooperative. We called him “the thousand-yard stare”. The exhaustion showed on his face every morning.
Medicine became far more complicated
The romantic image of the old-fashioned family doctor overlooks an important fact.
For much of the twentieth century there was relatively little medicine could actually do. Antibiotics, cancer treatments, cardiac care, diabetes management and modern imaging were either in their infancy or simply didn’t exist. Much of a GP’s role was reassurance, comfort and recognising when somebody needed hospital treatment.
Over the next fifty years that changed beyond recognition.
Today’s GP has access to hundreds of medicines, sophisticated diagnostic tests, detailed clinical guidelines and an ever-expanding range of treatments. Patients rightly expect their GP to manage diabetes, heart disease, asthma, depression, arthritis, hypertension and dozens of other chronic conditions that once would simply have gone untreated.
The decisions became far more difficult.
Making life-or-death judgements at three o’clock in the morning, alone in somebody’s house, with limited equipment and incomplete records increasingly looked like an unsafe way to practise medicine.
Britain got older—and much sicker
Medicine wasn’t the only thing that changed. The population changed too.
When the NHS began, average life expectancy was around 66 years for men and 71 for women. Today it is around 79 and 83 respectively.
That success created an entirely different workload. Instead of treating short episodes of illness, GPs increasingly found themselves caring for people living for decades with multiple long-term conditions. A patient who might once have had a single medical problem could now have diabetes, heart failure, COPD, arthritis and kidney disease while taking a dozen different medicines.
Consultations became longer, more complicated and more dependent on good records and continuity of care. The workload didn’t simply increase—it became vastly more complex.
Recruitment became harder
General practice also depended heavily on overseas-trained doctors, particularly in deprived communities and single-handed practices where recruitment was difficult. Many doctors who arrived from India, Pakistan and elsewhere during the 1960s and 1970s experienced significant racism within hospital medicine. Running a GP practice often offered greater professional independence.
Ironically, many of these doctors ended up with the biggest patient lists, the heaviest out-of-hours commitments and the sickest populations. When inevitable mistakes occurred they were often judged harshly, particularly by newspapers and the public.
Recruitment became progressively more difficult.
The turning point: 2004
The real watershed came with the new General Medical Services contract introduced by the Blair government in 2004.
GPs could give up responsibility for providing 24-hour out-of-hours care in return for a reduction of around £6,000 in income. Responsibility transferred to Primary Care Trusts, which organised dedicated out-of-hours services.
The contract also fundamentally changed how practices were paid.
Instead of relying almost entirely on patient list size, practices earned income for meeting quality standards through the new Quality and Outcomes Framework (QOF).
GP incomes rose sharply. One GP I knew celebrated by buying a brand-new Jaguar packed with every available gadget. The increase proved controversial, particularly among hospital consultants whose traditional pay advantage narrowed considerably.
But viewed in context it probably saved general practice. Recruitment was becoming increasingly difficult, and without a more attractive career structure many practices simply would not have survived.
Private organisations entered the NHS to deliver general practice care under the new APMS contract, including multinational corporations such as United Healthcare and Virgin, as well as companies run by groups of GPs. These companies also started providing NHS walk-in centres, mobile screening units, occupational therapy and health visitors.
The end of routine home visits
Once Primary Care Trusts became responsible for out-of-hours care they also became responsible for the associated risks. NHS managers were inevitably more risk-averse than traditional family doctors.
Rather than driving around all night visiting patients at home, services increasingly operated from dedicated out-of-hours centres, often next to hospital emergency departments.
Home visits never disappeared entirely. They remain part of the NHS contract where there is genuine clinical need. But they have become exceptional rather than routine, with many now carried out by advanced paramedics, nurse practitioners or community teams rather than the patient’s own GP.
Running general practice differently
When I ran a Primary Care Trust we found ourselves dealing with another problem. Some practices simply could not recruit partners. Rather than allow one local practice to collapse, we took it over ourselves, employed salaried GPs and continued providing services directly.
We even opened an NHS dental practice to improve local access. That worked brilliantly—until Health Secretary John Reid mentioned our new NHS dental practice on the Today programme. By the time I reached work that morning there were patients queueing down the street.
We weren’t trying to nationalise general practice. We were simply responding to the reality that fewer and fewer doctors wanted to own businesses while more preferred salaried employment with predictable hours.
Demand was changing too
One of the most surprising things we discovered was that many practices actually had enough appointments.
The problem was that they had them at the wrong times.
Demand peaked on Mondays and Fridays. Unfortunately those were exactly the days many part-time GPs preferred not to work. Practices could simultaneously have spare appointments on quiet Wednesday afternoons while patients waited days to be seen on Monday mornings.
Capacity wasn’t always the problem. Organisation often was.
Covid changed perceptions
Covid accelerated trends that were already under way. GPs continued working, largely through telephone and online consultations, while many routine appointments disappeared.
Hospitals, meanwhile, remained under extraordinary pressure.
When restrictions ended, general practice faced enormous backlogs alongside the vaccination programme, from which many practices earned significant additional income. Fairly or unfairly, attitudes towards general practice hardened.
Many hospital doctors, NHS managers and politicians concluded that the traditional model of independent GP partnerships no longer reflected the needs of modern healthcare.
The long, slow nationalisation of general practice
Jeremy Corbyn’s Labour Party openly proposed ending independent contractor status and moving GPs into salaried NHS employment.
Many dismissed the proposal as ideological. Yet the direction of travel has continued under Keir Starmer.
The language is less ideological and more practical, but the destination is remarkably similar: larger multidisciplinary health centres, more salaried clinicians and a steadily reduced role for the traditional GP partnership.
Ironically, one of Wes Streeting’s most significant reforms may ultimately prove to be one of the largest programmes of NHS nationalisation since Aneurin Bevan—not of hospitals this time, but of primary care.
The end of an era
This doesn’t mean your local GP surgery will disappear tomorrow. Independent partnerships will remain part of the NHS for many years.
But the direction of travel is clear. The future belongs to larger organisations employing teams of doctors, nurses, pharmacists, paramedics and therapists working together, often as NHS employees.
Whether that is an improvement is a matter for debate.
What seems much harder to dispute is that the era of the bearded GP in a tweed jacket, making midnight house calls with a pocket full of Lloyd George envelopes, has already passed into history.