Why does inequity matter? Something to do with the British sense of fair play, I suppose. Look at two imaginary but realistic areas. The first is an inner-city deprived area, with a population of 20,000, and has 14 full-time equivalent GPs. The average list size is 1,428 patients, which is theoretically “over-doctored”. The second area is an affluent, leafy suburb with a population of again 20,000 served by 8 FTE GPs. The average list size is 2,500 patients, which is apparently “under-doctored”.

 

The reverse is true. The first area needs more GPs; it is not over-staffed. And the second area is not genuinely under-doctored. In the first area, patients are likely to have difficulty getting appointments to see their GP, whose workload is probably underestimated. In the second area the GPs look after a larger population but have a larger income and often seem to manage. The paradox is apparent.

 

An ideal list size of 1,000 is now being talked about by the medical profession. The actual average list size per full-time GP in areas in England is about 2,200 in March 2026. The timeline for achieving this ideal is uncertain, as general practitioners are retiring or leaving the profession at a rate that exceeds the production of new GPs needed to accommodate the increasing population.

 

There remains a national shortage of GPs, and there needs to be a means of discouraging GPs to work in over-doctored areas, while encouraging them to work in under-doctored areas. A national system designed to achieve an equitable distribution of GPs in England is still not anywhere to be seen. DHSC has confirmed in recent guidance on policy for managing applications to join the England performers list, including GPs, that this function will continue to be managed nationally and will be the responsibility of DHC. Conspicuous by its absence is any mention that GPs are not being told where they can or cannot work. SEDGE would overcome that problem.

 

The story begins in 1946, with the National Health Service Act of that year. Section 34 created the Medical Practices Committee for England and Wales (MPC), which held its first meeting on 15 July 1948, and then met almost every week until 2001 when abolished by the Health and Social Care Act 2000.

 

The MPC was given the duty of ensuring that every area of England had an adequate number of GPs, which was interpreted by the MPC and the Ministry of Health to ensure an equitable distribution of GPs. The MPC could reject applications to join the local medical list if it assessed the area already had more than enough doctors. The MPC was empowered to refuse such applications on grounds of adequacy with the GP having the right to appeal against the MPC’s decision to the Minister.

 

This power of ‘negative direction’ as it was called, did not permit the MPC to push GPs to work in an under-doctored area. But there were inducements: GPs could find under-doctored areas and be given incentives to go there, in a process administered by the MPC, agreed with the Ministry. These Designated Area Allowances were also applied in the New Towns, where rapid population growth had not yet justified the presence of GPs.

 

To enable it to function, the MPC made an initial assessment of the adequacy, in terms of average list size, of about 1,250 areas in areas in England, with the help of the then NHS Executive Councils. Areas where the average number of patients per GP was below 1,700 were classified as ‘Restricted’, meaning newcomers could hardly ever go there. Areas with average patient lists of between 1,700 and 2,200 were called ‘Intermediate’, meaning some application would be agreed, other would not. Those areas with average lists of over 2,200 were classified as ‘Open’ and the MPC could not refuse an application that was valid. Those that were severely under-doctored, with average lists greater than 2,500 were called ‘Designated’, and extra payments were made to GPs to work in these.

 

The NHS Executive Councils, in conjunction with their Local Medical Committees, handled GPs applications, recommending acceptance or refusal by the MPC. A few tweaks, adding rurality, temporary residents, deprivation, and percentage of elderly patients to the assessment of adequacy helped the MPC to come to decisions. That did not, however, include adding an artificial number of extra patients for elderly and deprivation until very much later.

 

In 1966, came the New Contract for Family Doctors in England, designed to overcome the problems in primary care. One aspect was to use the MPC to ensure that the influx of new GPs from overseas worked where they were most needed by deflecting them from over-doctored areas, thereby encouraging them to go to under-doctored areas. Kenneth Day, a long-serving MPC member, effectively led the process in Birmingham.

 

In 1986, an important milestone was reached by the MPC. The last area classified as Designated, with average list of over 2,500 was Spennymoor in Co Durham, which was finally reclassified as Open, meaning it was no longer severely under-doctored. There have been no areas in England classified in this way ever since. And areas classified as Open became increasingly rare over the years until the MPC was abolished.

 

In 1996, the MPC became more aware that it should do something about some deprived areas where the average list size appeared to merit a Restricted classification. That was because the deprivation payments applied, although recognised by the MPC as important, were not added to the area or practice lists. The MPC set about remedying this discrepancy by introducing ALFRED, a contrived acronym for adjusted lists for really equitable distribution. Along with members of the MPC, I claim credit for this innovation. In the late 1990s, after I had moved on, the MPC devised a similar scheme for counting elderly patients, which was long overdue.

 

By this time, however, the Department of Health seemed determined to do away with the MPC, for reasons that never became apparent, at least to me. In the Health and Care Act 2000 the MPC was abolished, with effect from early 2001, I think. That might not have mattered too much were it not for the fact that the Department saw absolutely no need for anything to replace the MPC, and has remained adamantly opposed to the very idea, as far as I can see. There is therefore no form of control over where GPs work, apart from some attempts by the Department of Health and Social Care to introduce financial incentives to work in selected areas.

 

Areas in this context are now called Primary Care Networks. PCNs are soon to be translated into Neighbourhoods’. There will probably be about 1,250 Neighbourhoods in England, coincidently about the same number of the MPC’s original areas.

 

In 2026, a national shortage of GPs is widely accepted to be the case. The average list size is 2,200 or thereabouts. But that disguises the fact that there are parts of the country where the average list size is below 1,400 contrasting with others where the average list size is 2,700 or even more.

 

Paradoxically, some fully qualified GPs cannot find a job, and don’t know where to look for under-doctored areas. There have been many who recognize the dire situation, and propose amendments to Bills debated in the House of Lords. Creating an arm’s length body, such as a Special Health Authority would be easy, would help to solve the problem, and would be cost neutral. I suggest the SEDGE agency, an acronym for System for Equitable Distribution of GPs in England.

 

SEDGE could be set up as a Special Health Authority, a relatively straightforward process. Neighbourhoods, rather than single GPs, would submit applications, which would then be routed through ICBs. Staff of SEDGE could be a Clerk and two Deputies. Membership would comprise two nominations each from the RCGP and the BMA’s GPC. The Chair would also be GP, though a layperson might be attracted by an advertisement. There would be no need for meetings: emails to and from the Clerk would suffice, and business could be conducted rapidly. If only 4 members responded, and they were equally split, the Chair would have a casting vote on whether to agree or refuse an application to increase or reduce the number of GPs on the local Medical List

 

Footnote: I was Secretary of the MPC from April 1981 and from June 1995 to October 1999. From May 1971 to February 2004, I worked in DHSS/DH, holding 13 positions across 4 grades as a jobbing administrator or ‘jack of all trades’. Since retirement, but only after a decent period, I’ve argued, without success, that a new mechanism is needed for the equitable distribution of GPs in England. This is my third attempt.

 

John G Gooderham

March 2026