All posts by Iain Hotchkies

The demise of NHS General Practice?

I can support the aim of the NHS as it was initially envisaged. Pretty much as I can (in theory) support the aim of almost any socialised system. We ALL pay to keep the system running, and we USE it according to NEED (not WANT – but that’s another story). And it SHOULD function as long as costs are spread and the work is spread and the use is spread.

If any one part of the system becomes overloaded (or more than one part) then the system will start to FAIL. Unless the load is spread more evenly then the system will BREAK.

NHS general practice is failing. The breaking point cannot be that far off. Some believe this might be a good thing, so that something better (idealists) or cheaper (Tories) can be erected in its place.

Derelict hospital
Photograph by Chris Lloyd (CC BY-NC-SA 4.0 licence).

Why is this?

My opinion is that the failure can be traced back to the introduction of the “purchaser provider split”. Here’s the definition of this from the website:

“The purchaser-provider split in the NHS in England is intended to enable competition between providers, decreasing costs and increasing quality and innovation.”

Instead of the NHS (GPs, hospitals, community services, etc) all being one big ‘thing’, everything was divided up, parcelled out, costed (ho, ho!), and so on. Services were “commissioned”.

Different “providers” were encouraged. “Commissioners” could look at all the providers and choose the “best”. In practice this would either be the cheapest or the most politically desirable, rarely the “best”.

Once the NHS had been divided up into countless different parts, and the bottom line became cost, it soon became apparent to those with their eye on this bottom line that they had a golden goose right in front of them.

The GP contract

Nearly everyone in work is paid to perform a certain function. This might be folding tab A into slot B 100 times an hour. It might be seeing 15 patients in a clinic and operating for up to 5 hours per session. Or waiting on the 8 tables in your section of the restaurant.

The essence of paid work is that you’re paid to do a job.

The GP contract is not like this. A GP practice gets a set fee (usually between £80 and £100) per patient per year and for this they have to do pretty much ANYTHING ANYONE wants them to do.

They have to see patients when they’re ill (or when they BELIEVE themselves to be ill).

(And not just ill, but if they want to discuss an article they read about ME or total body candida, if they want a form signed for jumping out of a runaway train, or to get their anti-malaria tablets for their trip to Laos, etc etc etc)

They have to respond to calls and letters and emails and faxes from midwives, district nurses, counsellors (who’ve done the course), podiatrists and basically any one of 100 different types of “healthcare professionals” now populating the NHS who’ve all been taught that EVERYTHING now goes through the GP.

I could go on, but I won’t. The point is that GPs are not paid per episode, or per letter, or per phone call, or per illness, or per anything other than than set-fee, all-you-can-eat fee.

And this did not go unnoticed.

Hence the massive movement of patient care AWAY from almost everyone else TO the GP.

Which makes sense if all you care about is the bottom line (which, in the case of the NHS, is not high quality patient care but CASH) but it makes no sense at all if you’re a GP.

Why? It isn’t what you trained for. It isn’t why you became a GP. It isn’t what you’re good at. It isn’t in the best interests of your patients, your bank balance, or your health (mental and physical).

I could provide a dozen examples but that would be labouring the point. Suffice it to say that in nearly every hospital specialty, patients who were once followed up (if not long-term, then certainly for half a dozen clinic visits or so) are seen once and kicked out back to the GP.

And this is not a good idea.

Why? The clue is in the name. GPs are “generalists”. I know a little about a lot but I know a lot about very little. (I know a lot about the Gabriel-era of the progressive rock band Genesis but that’s of little use to my patients)

Ten years ago, you could see that hospital doctors often were not comfortable with this “new” way of working but this is not the case in 2015. It’s been accepted by everyone that this is the way to provide secondary care.

If – heaven forbid – a patient is admitted, they must be discharged as fast as possible, with no follow-up, with the GP to “chase” all outstanding tests, and to manage the patient, whatever their condition, whatever the number of their chronic conditions, however many drugs they’re on, however serious their status is.

If (oh, and this is SUCH a signifier of poor performance these days) a GP refers a patient to a specialist, they must be seen ONCE only and discharged with no follow-up.

Only GPs can prescribe anything. Only GPs can issue sick notes. etc etc etc

This is NOT the fault of hospital doctors. It is the “fault” of politicians, NHS managers, think tanks, the BMA, the RCGP and CCGs.

The GP contract is unilateral. GPs cannot change it. Only the government can change it.

Thus GPs are doing the only thing they can: voting with their feet. Older GPs are retiring as soon as it’s financially viable. Younger GPs are emigrating, or reducing their hours to the point where their sanity can be preserved.

So, what’s the solution?

I don’t think there’s ONE solution.

Some redressing of the balance would help. But the only way I can see that happening is a new conract for GPs and that would have to entail a much greater emphasis on item of service payments.

Co-payment is a political non-starter. That’s just a fact.

I would favour a radical overhaul, bringing primary, secondary and community care all under the same umbrella, and getting rid of (for-profit) private providers. But I’m aware this isn’t a popular option.

If SOMETHING isn’t done SOON, UK general practice WILL FAIL.