A GP's view of the NHS, from outside and in

Where I started

I trained in medicine in New Zealand, at Auckland School of Medicine. I qualified in 1990 and spent the following six years as a junior doctor and GP in New Zealand, and Australia. In 1998 I arrived in London, initially as Senior Coordinating Doctor at International SOS, the global medical-assistance and repatriation service. For four years my working day involved coordinating care for patients across dozens of healthcare systems: US, French, German, Swiss, Japanese, Singaporean, Hong Kong, Australian, South African, Scandinavian, African, Middle Eastern, and many more. Calls came in at three in the morning about patients in Kyrgyzstan or Cape Town or Sao Paulo or Reykjavik, and the job was to get them the right care in the right place as quickly as possible.

I then entered UK GP training, passed the MRCGP in 2004, became a partner at Wandsworth Medical Centre in 2006 and its managing partner for ten years, and served on the Wandsworth Clinical Commissioning Group as a Board Member and Clinical Lead for nine years between 2007 and 2016. Alongside the NHS work, I have founded and run private clinics in London for most of that period. London Travel Clinic (2010 to 2018), London Doctors Clinic (2014 to 2022), London Medical Laboratory (2019 to 2024), and now LoveMyLife.

That background means I have seen UK healthcare from the outside (as a trainee and as a cross-border coordinator) and from the inside (as a GP, a partner, and a commissioner). I have also had the unusual experience of watching it from the private-sector side while remaining rooted in NHS primary care.

What the NHS does that I have not seen done better anywhere else

There are specific things the NHS does that I have not seen any other health system do at the same scale, at the same cost, with the same consistency.

### Universal access to approved effective treatments, free at the point of care

When the National Institute for Health and Care Excellence (NICE) approves a new medicine through a technology appraisal, the NHS in England is legally required to make it available, to every eligible patient, within 90 days (30 days for fast-track approvals). There is no insurance-coverage negotiation. There is no ability-to-pay gate. There is no postcode lottery, although local commissioning differences do produce some variation in practice.

In the International SOS years I dealt with patients in several major health systems being told they could not have a new cancer drug because their insurance plan did not cover it, or because their employer had moved to a cheaper formulary, or because they were between jobs, or because the drug was not on their country's reimbursement list. None of that happens in the NHS. A recently approved gene therapy is available to the cystic fibrosis patient in Blackpool on the same basis as to the cystic fibrosis patient in Kensington.

This is, to me, the most striking structural achievement of the NHS, and the one that is most invisible to UK patients who have only ever known it. It is not a minor feature of the system. It is the system.

### Universal coverage at a lower share of GDP than most peers

The UK spends 11.1 per cent of gross domestic product on healthcare, less than most G7 peers. About 81 per cent of that is publicly financed, higher than the OECD average of around 60 per cent. Life expectancy is broadly in line with comparable high-income countries.

The combination is unusual internationally. Universal coverage, including very expensive treatments, on a mid-table share of GDP, with patient-side costs close to zero across almost the whole population. That is not a common outcome. Most countries that achieve universal coverage do it at higher GDP share (France, Germany, Sweden, Netherlands) or tolerate significant patient out-of-pocket costs (Switzerland, the US mixed model). The UK has found a specific equilibrium.

It has come with trade-offs. It always does. But the equilibrium is a real one, and from my position having worked in other systems, I remain of the view that it is worth defending.

### Clinical generalism as a specific discipline

UK general practice is one of the most developed generalist medical disciplines in the world. The three-year specialty training, the MRCGP examination, the shared-care infrastructure, the longitudinal patient-record tradition, the continuing-medical-education framework, and the QOF-defined chronic-disease management programmes together produce a clinical discipline that does not exist to the same depth in many direct-access systems.

I have referred patients between specialists in half a dozen countries over the years. The moment I most often missed a UK GP was when I needed a clinician to hold multiple threads of a complex case together in one consultation, with a clinical record that spanned decades, and a professional identity built around doing exactly that. In systems where every clinical contact is a specialist contact, that work often falls between specialties and falls on the patient.

What the NHS does not do, and why I run private clinics too

Having said all that, I have chosen, repeatedly, to work on the private side of the UK healthcare economy alongside my NHS work. That is a deliberate choice and it is worth being honest about why.

The NHS is not, and has never been, designed to deliver what private healthcare delivers best. The design was set in 1948 around universal access, clinical prioritisation, and fiscal control. It was not set around individual patient convenience, around short waits for elective specialist care for every patient, around longer consultations, around choice of channel, or around the commercial-service experience that patients in other sectors of the modern economy have come to expect.

Those gaps are not failures. They are design choices. A tax-funded universal system cannot realistically optimise for individual convenience and population-level universal access at the same time on a fixed budget. The trade-off has to fall somewhere, and the British answer since 1948 has been to let it fall on convenience.

What I have observed over more than twenty years is that the gap is real, it is getting more visible as patient expectations shift, and a growing proportion of the British public wants a route that addresses it. Private GP services, private consultations, private diagnostics, and private elective surgery all exist for exactly that reason.

I do not think private care produces different clinical outcomes to NHS care. In most cases the same doctors deliver both. What private care offers, reliably, is a different service experience: faster access, longer appointments, channel choice, predictability, and continuity of provider. Some patients value those things enough to pay for them.

The case for a properly developed private primary-care sector

One structural feature of UK healthcare that I think is worth noting is the asymmetry between the private secondary sector and the private primary sector, covered in more detail in the dedicated article on the topic. For seventy-seven years the UK has had a substantial parallel private hospital sector, staffed largely by NHS consultants, used by about 8 per cent of the population, coexisting with the NHS without undermining it. Private primary care has only scaled meaningfully in the last fifteen years.

I suspect that history is going to look at this asymmetry as a temporary feature of a particular period. A properly developed private primary-care sector, at the scale of the private hospital sector, would give patients whose priority is convenience a route that does not depend on the NHS accommodating that want. It would leave NHS general practice free to do the work it was designed for: universal, list-based, continuity-of-care primary medicine for the whole registered population.

This is not an anti-NHS argument. It is a pragmatic argument about a system that is already being used at scale by the minority of the population that can afford it, and that might usefully be developed further as a relief valve. The private secondary-care sector has done that job for nearly eight decades, with the same consultants working across both sides, and no one seriously argues it has harmed the NHS.

The case is not ideological. It is practical.

What I would tell a patient

I am asked regularly, by patients and friends and colleagues, what route I would use in the UK for a given situation. My answers have remained broadly stable over the last two decades.

• Register with an NHS GP. Everyone. Always. It is the foundation of your medical record, your access to NICE-approved treatment, your link to the rest of the NHS, your screening and vaccination call-and-recall, and your long-term clinical continuity. I am not aware of any circumstance where not being registered with an NHS GP produces a better outcome than being registered.

• Use the NHS for complex, chronic, critical, and urgent care. The NHS has the infrastructure, the expertise, the integration, and the funding. Private hospitals deliver excellent planned elective work but do not have the critical-care infrastructure for the genuinely complex end of medicine.

• Use private care for defined, convenience-priority, one-off needs. A one-off specialist consultation for a defined question. A travel vaccination before a trip. A medical or a report. A longer generalist consultation when the NHS ten-minute slot cannot fit the case. A faster diagnostic scan when the NHS wait is the bottleneck. Hand the letter back to your NHS GP afterwards.

• Do not assume private is better clinically. It is not. It is different in service experience and in access, not in clinical quality.

• Be sceptical of anyone, private or NHS, who claims unique superiority. Clinical medicine does not work that way. Any clinician who tells you they are in a different clinical class from the alternative is trying to sell you something.

This is the advice I have given my own family, and it remains my honest answer.

What I hope this series does

UK healthcare is an extraordinary system. It is not perfect. No universal system anywhere is perfect. The trade-offs are real and the challenges are real, and the people who work inside the NHS see that most clearly.

The NHS also gets a remarkable amount right. A lot of it is invisible to the patients who use it, because the free-at-point-of-use architecture means the financial machinery never touches them. That invisibility is one of its great strengths, and one of its public-understanding weaknesses.

If this series helps a handful of readers understand how the system is structured, why it feels the way it does, how to use it well, and how the private sector sits alongside, it will have done its job. I am a genuine fan of the NHS, despite (and in some ways because of) having spent my career partly outside it. I hope that comes through.

About the author

Dr Seth Rankin is a London GP and the founder of LoveMyLife. He qualified in medicine in New Zealand in 1990, passed the MRCGP through the London Deanery in 2004, and has worked across NHS and private practice in London for more than two decades.

Read more about Dr Seth Rankin.

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