It was Cory Doctorow, the author, who coined the term ‘enshittification’ when he used it to describe the evolution and, critically, the deterioration of tech platforms. In 2023 the American Dialect Society awarded it Word of the Year. It has proven adaptable to a range of contexts. This month Payne et al report on a multi-site 28-month case study of a dozen practices across the UK.1 The findings are bleak. The authors don’t use the word but the article details, with an unflinching eye and exemplary rigour, the enshittification of general practice in the UK.
The article covers many areas with which we are familiar and these have coalesced into a damning picture. We should always recall that austerity was a political choice, driven by the ideology of neoliberalism, enriching the richest, and it has driven us to extremes of inequality. Austerity has bitten hard, reducing resilience, and hollowing out social care and the welfare state. The erosion of public services has been stark. A report in January 2024 from the University College London Institute of Health Equity calculated that austerity has resulted in 1 million premature deaths in the UK.2 It’s staggering but all too apparent when one looks at the unrelenting strain on general practice and healthcare services.
The tension between protocolisation and personalised care for long-term conditions is keenly felt by individual GPs, as well as patients. One can make a case, in the UK, that we can trace some of this back to the 2004 contract, where family GPs willingly signed a surrender note. We can argue the merits or demerits of the Quality and Outcomes Framework (QOF) but, at that watershed, we ceded control and shackled ourselves to QOF box-ticking. Inevitably, successive governments ramped up requirements, eroding professional autonomy.
We all know about the workforce challenges. One of the impacts of the workforce crisis has been to further reshape the daily workload of the GP. Allied health professionals siphon off the ‘easy’ consultations, ratcheting up the pressure on GP workload. This is a complexity loop that deepens the crisis. Through this, we have to remind ourselves that health care and general practice is a complex system and even well-intentioned interventions create unpredictable shifts.
The Payne et al article offers a thorough exploration of the reality of modern general practice, including remote and digital triage. There are some benefits to these but it also suggests these have ‘introduced multiple new forms of inefficiency while compromising other domains of quality including accessibility, patient-centredness, and equity.’ One notable concern with new systems is the potential for reduced contact among colleagues and all the benefits for staff and patients this brings.
It goes on. The enshittification of general practice is a grim tale but it is not hopeless and it can be reversed. One fears that inaction will lead to disintegration. The authors have done us an enormous service and this is arguably one of the most important articles we have published in many years. It deserves the widest possible readership. We must know where we stand.
| Research this month explores areas where we can raise the quality of general practice, including articles on: personal continuity; communication between primary and secondary care about prognosis; additional workforce roles; and an exploration of antipsychotic management. The editorial by Woodall and colleagues on antipsychotics is a powerful call to action and flags a neglected area. Reeve, Allsopp, and Mulholland offer an important editorial that defines a GP, with an aim to reinvigorate and motivate GPs in difficult times. Clinicians should be helped with articles on earlier diagnosis of symptomatic lung cancer and the challenges around the use of fluoroquinolones. |
- © British Journal of General Practice 2025
