If there’s a phrase that sums up Iain Morrison’s mood at the moment, it could well be ‘cautious optimism’.

As chair of the BMA’s Scottish GPs committee, he and his team have negotiated what is possibly the most significant uplift to core general practice funding since the 2004 contract.

They have also won the commitment of the most recent Scottish Government to a rebalancing of care, with the aim of shifting a greater percentage of resource into the community, including primary care.

This, says Dr Morrison, is already beginning to have a positive impact on morale among GPs who last year came nearer than ever before to taking collective action over their working arrangements.

‘There were a lot of GPs who felt they had hit the trough,’ says Dr Morrison, a GP partner in Newbattle Medical Group, near Edinburgh. ‘Although we’re now looking up, there’s still quite a bit to climb to get ourselves out of this trough.

‘There’s a little bit more of a feelgood factor returning, but we’re under no false impression that we've still got an awful lot to do.'

So how did it get to that point? ‘In general practice we had a brief time of halcyon days from 2004 to 2008, when we’d secured the new general medical services deal, we had seen significant investment into core general practice, and the loss of out-of-hours, without the additional pressures on a non-functioning NHS. For a brief period I think the NHS and general practice was working quite well.

But since 2008 we’ve seen this continual erosion and denigration of general practice and a slow but deliberate transfer of workload into the community without any corresponding transfer of resource. Our share of the NHS budget has fallen from 11 per cent in 2008 to almost 6 per cent last year. So it’s no wonder that GPs have been left feeling exhausted and burned out, and with the moral injury of knowing that things could be done better.’

Every day, says Dr Morrison, GPs struggle to meet rising demand for patients – some of it caused because of problems in the wider health and social care system. ‘A lot of people on waiting lists [for secondary care treatment] are just bouncing back to us. We’re the holding pen for all that,’ he says.

‘It’s hugely frustrating because the profession is very proud of always trying to do our very best for patients, and when we can see with our own eyes that our patients are not getting the best of care, it’s hugely demoralising.’

Last year, SGPC entered formal dispute with the Scottish Government, saying that urgent action was needed to restore a £290m funding gap. BMA Scotland also launched a campaign urging patients to stand by their surgeries, highlighting the funding gap and the need for more GPs, and set out on a series of roadshows across the country.

At that point, a BMA Scotland survey on GP wellbeing found that almost half were struggling to cope and four in ten couldn’t meet patient demand for access.

The Scottish Government agreed to take part in negotiations, and in October, Scottish health secretary Neil Gray agreed a funding package worth more than half a billion pounds over the next three years, with a continuing annual funding boost of £249m. The funding – subject to budget agreements in the Scottish Parliament – is intended to boost staff numbers and capacity and improve access.

‘I’ve got a very good team that worked hard to get that deal over the line, and I feel very proud to be part of it,’ says Dr Morrison. ‘But under no circumstances do we think this is the solution – this is just the start of the solution. We see the next three years as very much restorative to general practice, because I do think we were on a cliff edge. And the profession backed us on that.’

After the election on 7 May, he would like to see the new Scottish government make an immediate commitment to the deal that has already been agreed. ‘It’s a binding agreement, and all parties in their manifestos have said they want to invest more in the community, so we don’t see it as under threat. But we want to see early talks on what happens next. This deal takes us up to [2028-29] with substantial investment, and at that point we want to kick on, and instead of having a restorative phase, we want to see an expansive phase.’

This would mean returning funding to the historic norm of 11 per cent of the overall health budget by the end of the next Parliament (and 15 per cent in the following parliament) and a substantial increase in the GP workforce, taking it to the equivalent of one WTE (whole-time-equivalent) GP for 1,000 of the Scottish population – an additional 1,800 GPs.

‘We’re moving forward with cautious optimism and actually focusing on how we make a career in general practice safe and sustainable and attractive to young doctors out there. It’s absolutely incumbent on us to do that.’

Final-year medical student Joe Payne was brought up in Lochgilphead, a small and picturesque town in Argyll and Bute, in the rural west of Scotland. He would love to do his training there, or in another Scottish remote and rural community – but instead, he’s being sent to Wales.

‘I was one of these people who wanted one of the less popular, very rural jobs around Scotland – in Fort William, or Wick, for example. I was very willing to do a job that a lot of people really don’t want to do, and serve a community that I’m from. But I’m not able to do that, unfortunately.’

Times are challenging for today’s medical students. Not only are they subject to the whims of the UK foundation year allocation programme – which essentially means they have only a limited say in where they will be based for two years after they graduate, but a lack of training places following foundation is creating (justified) worries about their career progression.

Not only that, a dramatic increase in the number of students in Scottish medical schools has meant lectures and placements have become crowded, with fewer learning opportunities, as a recent BMA Scotland report laid bare.

Add in the fact that he began medical school in the first year of the COVID-19 pandemic – and correspondingly didn’t even have his first hospital placement until the end of third year – and it’s clear that Mr Payne, who is also chair of the BMA Scottish medical students committee, and his peers have had a rough start to their medical careers.

‘Generally over the last six years [he intercalated] I’ve been putting in a pretty good shift, and that’s part and parcel of why I feel really disappointed with the allocation because I’ve worked really hard, and the allocation system is, in effect, random. Your rank is randomly allocated – preference-informed allocation. And short of having a child or, for example, becoming a carer for one of my parents if they were unwell, there’s no way for me to change that allocation.’

Historically, he says, only a handful of Scottish students who wanted to stay in Scotland were allocated elsewhere, but this year it’s far more. This was a shock, he says, because NHS Education for Scotland had actually increased the number of foundation programme places by 25 per cent in the last three years to accommodate at least part of the increase in students graduating from Scottish medical schools.

‘That kind of expansion can’t last forever,’ he adds. ‘We’ll get to the point where we simply can’t accommodate all the students who would want to stay here, even excluding those who want to move here from down south.’

Although Scotland-domiciled students don’t have to pay the fees for their medical degrees like those in (and from) the rest of the UK, most will still graduate with considerable debt. Financial challenge has been made even harder, says Mr Payne, by recent changes to travel reimbursement for medical students.

‘We have to travel quite a lot for our placements, particularly if we’re going to remote and rural areas. Funding has changed and this is leaving us even more out-of-pocket. And some of us already have part-time jobs because student finance simply doesn’t cover our living expenses, particularly in Glasgow, Edinburgh and St Andrews.’

Looking to the future, Mr Payne wants to make the best of his time in Wales – although he doesn’t speak Welsh, he has family there, and spent time there as a child. But he can’t even make concrete plans because he won’t know until June where he will actually be working because he is one of a small number who has been given a ‘placeholder’ job.

‘It’s not ideal given that Wales is such a large deanery. I could be in North Wales, Bangor or Pembrokeshire or Cardiff – there’s no way of telling. And as much as it’s helpful that Wales offers free accommodation for FY1, there’s a good chance I won’t be able to access that because of my late joining, and I’ll have to find a place to live with about six weeks’ notice.

‘But much as I’m sure it will be great working in Wales, ultimately I want to stay in Scotland and it’s the Scottish tax-payer who has invested in me – it seems kind of silly that I’m not able to stay.’

Mr Payne is trying to stay positive. ‘There are people who are in much worse situations than me. I’m 24, and I don’t have any dependents or a mortgage or anything like that. But folks I know who have gone to medical school later in life, who have houses and mortgages, have been told, for example, that they’re moving to Nottingham or Northern Ireland. They feel forced to take a year out and apply again instead of starting practice like they’ve been looking forward to. So it’s hard for me to feel too sorry for myself.

Having said that, he is looking with some dismay at his future job prospects at the end of the foundation programme. Currently he plans to apply for specialty training in anaesthetics, which is very competitive. ‘It’s unfortunate, but it’s become a bit of a joke, where we all talk about when we’re going to be unemployed after FY2, or when we’re going to Australia or New Zealand because that’s where the jobs are.

‘Unfortunately when you’re in a position where you’ve got 1,600 medical students coming through every year, and only 750 CC1 and ST1 training posts available at the end of it, it’s discouraging for those of us who want to work here.

‘We’re training to be doctors, we’re training to provide an essential service for Scotland and the rest of the UK. And we are needed – waiting lists are still very long, and people are waiting hours and hours in A&E. To think we’re struggling for jobs in that context seems crazy.’

Glenlivet Medical Practice is in Speyside in the north of Scotland, not far from the border where Grampian meets Highland. As the name suggests, it’s slap bang in the middle of malt whisky country; the surrounding area is hoaching with distilleries as well as lochs, rivers and mountains.

With just 560 patients, it’s a dispensing practice which forms part of a group with surgeries in nearby Grantown-on-Spey and Aberlour – nearby in rural Scotland terms, that is – it’s a good half hour in the car from Grantown and a bit less to Aberlour.

The nearest acute hospital is the small Dr Gray’s in Elgin – only about 40 miles, but at least an hour on narrow rural roads (weather permitting), and it has limited services. The larger Raigmore Hospital in Inverness means a round trip of around three hours and public transport options are extremely restricted.

Al Miles is a GP partner with the group and today he’s just finishing off morning surgery at the Glenlivet practice – a small, but modern and well-maintained building on the Glenlivet Estate.

The group took over the practice, he explains, when the previous single-handed GP was retiring. This is a common scenario in rural areas of Scotland, where it can be nigh on impossible to attract GPs to fill vacancies, and too often the local health board ends up running them, with variable results. For example, it can harm continuity of care.

‘At the point that NHS Grampian put the contract out for tender, we knew the community hospital in Grantown was going to close, so we thought if we took the contract on, we’d be able to avoid any redundancies and allow us to keep all our staff.’

Each contract is separate, and the practice ensures continuity of staffing at each site so that patients see the same doctors, says Dr Miles. ‘We’re quite doctor-heavy – Grantown’s the only site that uses advanced nurse practitioners – so we run a fairly traditional model in terms of practice nurses and GPs, and that seems to go down well with patients.’

Continuity of care is good for GPs and staff as well as for patients, he says.

‘It’s really enjoyable and there’s a good evidence base behind continuity being very good for patients in terms of patient outcomes, patient satisfaction, and lower use of healthcare services. Patients are less likely to need to be referred for secondary care tests or outpatient appointments just because you’ve got a better knowledge of them and a good relationship to talk openly about what the patient really wants.’

He would like to see a greater focus on continuity of care for all patients in the next parliament and beyond. ‘I think continuity has suffered over the last ten years, with demand going up while funding for general practice hasn’t kept pace with demand – in fact, as a relative proportion of healthcare spending in Scotland, general practice funding has almost halved [since 2008] so that’s made continuity very challenging to deliver.

'You see it with patients – they don’t know their doctors as well, they’re more likely to put in complaints and have unreasonable expectations. It’s not as enjoyable for doctors either. So GPs and patients both want to get back to continuity, but to achieve that, you’ve got to have sufficient capacity in the system.’

He believes rural areas in particular suffered as a result of the 2018 Scottish GMS contract, which aimed to introduce more multi-disciplinary working across general practice, with additional services funded and run by health boards – such as physios and mental health practitioners working from GP practices.

‘Rural areas in Scotland very quickly saw it wasn’t going to be deliverable because it was under-funded and over-ambitious and they couldn’t fully implement it. There also weren’t the staff available for the MDT, so the positive impact that had been anticipated for GP workload just wasn’t materialising at all. A lot of GPs got quite frustrated with what they saw as not very efficient use of funding and they felt they could have used it much more effectively through the independent contractor model to provide patient services.

‘There are a lot of good things about MDTs, but there’s definitely some significant drawbacks with it being a health board-run service with the inevitable inefficiencies that come with that. So we were aware that demand kept rising, and we didn’t have the workforce or funding to meet that demand, so GPs were working faster and harder and at risk of burning out.’

He believes the new deal agreed last year with the Scottish government, which delivers more funding directly to general practice, will help. He is less convinced (to put it mildly) about the Scottish Government’s recent decision to introduce walk-in centres to try to improve access to GPs. This is part of SNP policy, and has already started, backed by significant investment.

‘The frustrating thing is that there is already so much evidence that walk-in centres don’t work,’ says Dr Miles, who has already shared his feelings on the subject in this blog. ‘They widen health inequalities and they don’t reduce demand on GPs or accident and emergencies.’

He is equally scathing about Scottish Labour’s proposal to insist that Scottish medical, dental and nursing students who are funded to train in Scotland must work for at least five years in Scotland’s NHS or social care or pay back their tuition and bursaries. ‘It just doesn’t work with the way jobs are currently allocated – my daughter is an FY1 and was lucky because she managed to get a job in Edinburgh and Fife, but friends of hers who applied for Scotland got sent to England. Plus, there’s the FY2 cliff edge for jobs [because of a lack of places for speciality training].

Dr Miles clearly loves rural general practice – he’s actually working just a few miles (as the crow flies) from where he was brought up. But he hopes that the new Scottish government will take action to protect and expand general practice in rural areas and as a whole. ‘You can only have a well-functioning public health care system if you have a really robust primary care and general practice,’ he says simply.

‘We’ve neglected that over the last 20 years and that leads to a very unaffordable model of healthcare. If you can't keep your population well, and you're focused on treatment and hospital treatment that's incredibly expensive, then demand for that will only go up, because if the population isn't being kept healthy, they're going to develop more ailments that require that kind of treatment. So we need that investment into general practice, primary care and public health as well.’

As a GP in one of the most deprived areas of Scotland Nóra Murray-Cavanagh witnesses the effects of health inequalities every day. And she wants this to change.

‘Health inequalities are inexcusably present,’ she says. ‘We’ve known too long about the existence and the effect and the impact of health inequalities on our population and we simply need to do better. And while the NHS is being used as a political football, that’s not going to happen.’

Dr Murray-Cavanagh was talking to The Doctor magazine just before the BMA Scotland’s hustings ahead of the Scottish Parliament election on 7 May. Representatives of the six main political parties in Scotland took part, including the health secretary Neil Gray for the SNP – which polls suggest will remain the dominant party after the election.

Not surprisingly, almost all panellists named tackling health inequalities as one of their main concerns. But given that governments of various hues – whether Westminster or Holyrood – have been saying similar for years, while healthy life expectancy is only getting worse, voters could be forgiven for not holding their breath.

Dr Murray-Cavanagh wears several hats. She’s a GP at Wester Hailes Medical Centre in Edinburgh, part of the Deep End initiative, which involves practices serving the 100 most deprived areas of Scotland. She is also GP lead health inequalities in the public health team at NHS Lothian and deputy chair of the BMA Scottish council. But whichever hat she is wearing, it’s clear that tackling inequalities and injustice is her passion. 

‘Our patients live fewer years,’ she says. ‘They live more of their years in ill-health. They’re less able to participate in healthful activities. We’ve got higher smoking rates, poorer diets, poor educational attainment, higher substance misuse, poorer social cohesion. There’s an intergenerational poverty and trauma cycle – it gets right into your very DNA.’

She wants the incoming Scottish government to look at health inequalities as part of a wider context, recognising that every policy area has a role to play.

‘People’s lives are so precarious. A patient might say: “I can’t come and see you today because I have to see my housing officer. I can’t prioritise my blood pressure, (which is going to be an issue for kidney brain and heart health over decades), because today I need somewhere to live.”’

Patients present with illnesses much earlier – sometimes by decades – than they would in a more affluent area, she adds, and they also die earlier. ‘Every three months we have a death review meeting in the practice, because it’s important to think about what we’re doing right and what could be better. I’ve been working here for almost 15 years, and I’ve kept a little tally of deaths in people under 65 and over 65. Mostly it’s under-65s, which is horrific in 2026 in a purportedly wealthy country.’

Again, it’s wider than actual health services. ‘You have to think about how equipped people are to do the lifestyle stuff that might help keep them healthy,’ she says. ‘My patients coming to see me won’t have had the money to pay for private physio first. Maybe they’re smoking – it’s maybe their last and only pleasure and they’re not supported by their family to give up. So you have to look at what people are carrying: what’s the weight of the genetics? What’s the weight of the environment?’

As Scotland’s capital city, Edinburgh is a place of contrasts. On the one hand, around a quarter of children attend private schools, and the city’s beauty and history contribute to high house prices and millions of visits from tourists. It’s a hub for culture and the finance sector, and its universities have an impressive reputation.

Yet in schemes (estates) like Wester Hailes, it’s a very different picture. ‘Edinburgh is very polar,’ says Dr Murray-Cavanagh. ‘It has something like six out of 10 of the most affluent practices in the country, but Wester Hailes is very firmly in the Deep End. All the things we know about the inverse care law in general practice can be seen here. We know that patients in the Deep End are more fatalistic, they are less able to prioritise their health, their health literacy and health enablement is poorer. But also, when they do get in the door, there are fewer GPs at the Deep End where the care is really needed.’

A more nuanced approach is needed, she says, so that general practice improves for everyone, without leaving any areas behind.

Wester Hailes is ‘a really optimistic place’, she adds, with impressive wider community initiatives, often run by the voluntary sector. She cites The Health Agency, third sector partners who provide food security, physical activity and mental health security in the community, Starcatchers, which works with young families, and Whale Arts, a community-led arts project, which, among many other activities, offers a mental health programme.

‘Patients who would come to see me regularly get on to a programme at Whale and they’re able to reduce the amount they rely on general practice. We don’t identify these things as health interventions, but oh my goodness, aren’t they?’

Dr Murray-Cavanagh wants a step change. ‘If we cast our net more widely, and think about, for example, how does Denmark do it, and just step out of party political narratives, and say we fundamentally believe that healthcare is a human right, and we’re all of us going to collaborate because we’re a smart and compassionate country.

‘There needs to be an urgency about it, and it’s about the whole piece. It’s not just the things that sit comfortably within what we have historically defined as health, but it’s about what does a healthy life look like? What is a healthful existence? We need to talk about why libraries are important, why public transport is important, and a really good education for everybody. And obviously we need great general practice and other health and social care services. We want everyone to be able to thrive – and at the moment, that’s just not happening.’

• Read our other pre-election coverage – secondary care doctors on the intense challenges they face and an interview with BMA Scottish council chair Iain Morrison