I have posted this thread on Twitter this morning:
I criticised Labour, Keir Starmer and Wes Streeting for their comments on GPs and their financing this weekend as I consider them irresponsible. That needs explanation in more detail, taking into account what needs to be done in this area. So, another thread on GPs, the NHS and Labour....
I am critical of Labour for discussing GPs and the way they're paid negatively (and how else is 'murky' to be interpreted?) when this might a) increase tension, with already angry patients putting GPs at risk, and b) when Labour has no alternative to offer as yet.
I find it hard to forgive people who put others at risk unnecessarily, and this I think Labour has done. But I also dislike politicians who say there are problems and have no idea how to solve them - which is exactly what Starmer himself said was wrong with politics last week.
So, what is the issue with GP funding? First, let's be clear that it is not murky: it is governed by a contract which is government determined. So the allegation that there is something dodgy in it is just wrong.
Second, for sure GPs are deemed to be self-employed under this contract, which is in tax terms anachronistic, but that is no more unusual than the special tax status given to MPs and ministers of religion, so let's not get too excited about this as an issue.
Third, GPs being self employed does not stop them being an integral part of the NHS: about 90% of all patient contacts in the NHS are via GP surgeries so let's not pretend, as Starmer seems to be doing, that they are a private sector tack on: they are integral to the NHS.
Actually, they are more than that: GPs are the risk sink that makes the NHS as a whole work, in my opinion, because the whole role of the GP is to appraise medical risk and live with the consequences. We can't ignore that they are implicitly paid for taking that risk.
Fourth, let's look at how GP services can be paid for. There are in essence three models. One is to pay on a capitation basis. So, GPs are paid a fixed sum for each patient, whether they ever see them or not.
The inevitable result is threefold. GPs have an incentive to have big patient lists. They have an incentive to do as little as possible for patients. And GP practices of this sort are really attractive to private buyers. All in all, not perfect.
The next alternative is to pay for services performed. Again there are perverse incentives such as doing too much for some patients that is not really needed at the expense of what might actually be required by those who are really sick.
And after that, if some things attract higher payments than others then mysteriously more cases of what is well paid for will be found: that's just the way things are bound to happen.
So neither of these models of contracted care is perfect. The other alternative is wholly salaried GP service. Part of what we already have is of this sort: most GP practices have some salaried GPs rather than profit-sharing partners on their staff.
But, there are big problems with a fully salaried service too, because then there is no one who is contracted to provide a GP service come what may, which is what we have right now. Under the current contract GPs have to accept crazy workloads because the contract says they must.
Put all GPs on salaries though and whilst GPs may not work to rule, they may well say that more than 30 patient contacts a day is unsafe (as it might be) and they will almost certainly say they are not coming in on days when they aren't paid to do admin, as most partners do now.
In other words, under this model the buck for supplying GP contacts passes from the GPs back to their employer, which will be an NHS authority, who will have to provide enough GPs, and provide sickness cover, maternity cover and all the other things GPs themselves organise now.
That model may well require many more GPs than now. The service might be better (maybe) and GPs will not be so burned out, and may make fewer mistakes (maybe) but it is also likely to be more costly (almost certainly).
And will there still be perverse incentives? That's entirely possible depending upon how the salaried contract is negotiated - and it cannot be open-ended. This risk has to be understood before suggesting any such service.
In reality then there is no good model of supplying GP services from an economic perspective. I know I have significantly summarised things here but each model is flawed in some way, which is my whole point.
Of course, an alternative is to do away with GPs altogether. So, people could choose to go to see a specialist without having to see a GP first. Wes Streeting has strongly hinted this might be what he is thinking. France has a model a bit like this.
But in that case who does the person who has the typical GP presentation of 'tired all the time' go to? Without the advice of a generalist, who do they refer themselves to? And worse still, what about the old person 'off their legs' (as it is commonly put)? Who are they going to?
Come to that - what is the cause of dizziness (another commonplace presentation, I am told) that the patient can readily diagnose and then self-refer themselves to a specialist about? Expert help would be needed to decide that. The expert is called a GP.
So, we can have a system where people self-refer to specialists, but you will get enormous waste of specialist time as a result, and you might also get massive delays in finding a diagnosis, if you ever succeed.
The body is not the machine Wes Streeting seems to think it is. Or to put it another way, there is enormous power in generalism, which also has that all important capacity to tell the patient 'there really is nothing to worry about'. And GPs take the necessary risk of doing so.
So, what is Labour's answer to all this which will remove the murkiness that they have, wholly inappropriately, said exists under the terms of a GP contract that was, in its current iteration, largely a Labour creation? Who knows? They have not said.
In that case in my opinion Labour should have, in the first instance, found an answer to propose before speaking out. That is what Starmer said he was going to do when promoting solution focussed politics last week. He's already failed on that promise.
Second, Labour needs to realise that there is no perfect answer to this question, but the one thing that is certain is that to totally reorganise all GP services to abolish partnership-based supply now would create more NHS upheaval than anyone has created in 75 years.
And the last thing the NHS needs right now is an upheaval like that when the service is already pushing those working in it and those relying on it to their limits.
The third thing Labour needs to appreciate is that except in economic theory there are no perfect outcomes in the real world. Economic theory teaches there is such a thing as equilibrium - where everything is optimal. But to be polite, that's utter nonsense. It never happens.
The reality is there is no optimal way to supply GP services. Right now a salary-led service would create untold chaos, so forget it, even if it is thought desirable. Keeping a GP service going is more desirable. That leaves two options: capitation and fee for service.
Totally unsurprisingly the existing GP contracts mixes these two because neither is optimal. So, most care is on a capita basis. But many things considered desirable e.g. vaccinations, are fee for service to make sure they happen. I simplify, but the point is compromise works.
The current GP contract is, then, suboptimal. But like democracy, which in its current iteration in this country is decidedly suboptimal, the service we get from the suboptimal arrangement we have is better than any of the alternatives readily available for the time being.
It should have taken Labour about 90 minutes to work that out. Then they might have thought a lot harder about telling patients that their GPs' have murky finances, casting a wholly unnecessary cloud in many cases simply, it seems, to fuel anger for no good reason.
I suggest then that Labour does what Starmer says it would do and begins to talk about solution focussed politics. In this case it has not, and has shot its mouth off wholly inappropriately when I strongly suspect it knows of no answer to the question it is posing.
Labour needs to do a lot better than this. It also needs to set the record straight on GP finances, and apologise before any harm is done because right now that harm is possible, and that's utterly unacceptable.
And before anyone says I am picking on Labour, I pick on Tories, LibDems and the SNP too. This is not about party politics. I just want some grown up, thought out, well reasoned politics from all parties, not just Labour. Is that really too much to hope for?
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This is Labour across the board, they are well aware of all the major issues in society but have no answers to any of them so instead, the create a wedge and smash it in with a big hammer…bit like the Tories do! Anyone would think they’re using the same script!
Well said Richard.
You are right – GP funding is a morass.
I’ve always felt that giving GPs more management to do was the wrong thing when they should be seeing patients. The NHS should do more of that.
And there are wider health issues, life style issues in a deregulated world. We often talk of ‘preventative medicine’ – diet, exercise etc., to help lessen demand, improve physical and mental health but then government is loathe to interfere with markets essentially delivering crap food, polluting environments and bad choices to consumers.
Laboured and Stymied are just lazy in my view and haven’t got the minerals to get their teeth into the real issues.
GP funding is not “murky”. The contract is published. https://www.england.nhs.uk/gp/investment/gp-contract/
One important factor that is often overlooked but must be taken into account when considering any so-called “optimal” service is resilience. GPs provide this to some extent as a risk sink, as you mention.
We should accept solutions that are more expensive than the “optimal” if they are less likely to fall over, because the cost of failure is even greater.
The NHS has run “hot” for years – too little money, too few beds, too few people – and is it frankly a miracle that it has not failed in a spectacular fashion already.
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I am not expert in either medical or educational matters…. but teachers and doctors are. What grates with me about this Labour announcement (and the Sunak on “maths to 18”) is that the policy is determined/announced with an eye only on how it will go down with voters today. What will be the “soundbite” played on News at 10? Etc..
Where is the real analysis? It is completely absent.
Now, it is self evident that something needs to change in the GP service. Too few want to be GPs, too many are burning out, patients are unhappy with access etc. But what? Let’s hear from GPs… (and I suspect you have done !!)
The NHS/GP/Specialist ecosystem is very complex and I think you are spot on to call for a hybrid system that allows flexibility. If I recall correctly, at the last major renegotiation with GPs (on “out of hours” service) the government found that the whole system revolved around dedicated people and a lot of good will…. and that when you try to formalise all this through contracts you end up paying more for less and losing huge amounts of that goodwill. They should be careful.
If my lawn mower engine is failing I will top up fuel, check the oil etc. to get it running smoothly. Only if that fails will I start making wholesale changes. Similarly, the first step for GPs is to get the current system working as best it can before making major changes… and to my untutored eye that means more people (GPs and others) in the current set up.
Perhaps the BMA, Patients Association, Kings Find, Lancet and other interested parties should all get together and work out an equitable and humane GP referral and salaried system before Labour plinges in with wild suggestions leading to more privatisation..
Ever the cynic I would have thought that the “murkiness” surrounding MP’s finances being clarified would have been much more fruitful and would lead to better standards in public life.
The current work of MP’s has brought the country to its knees, at least the GP sector is still functioning.
The other thing that GPs are expert at, as well as being generalists is recognising and managing the many people who present with physical symptoms where psychological or social causes are strong contributors to the problem. Partnerships, given the opportunity and when they are not overwhelmed are also able to make rapid changes to improve care. Just look at how quickly the covid vaccination programme got off the ground, mainly due to GPs to start with.
While I raised the question yesterday of why the sort of consultant contract that works for all other kinds of specialist doctor shouldn’t also work for GPs …in essence I agree with you. At this moment the huge priority is to take the NHS as it exists now and make it work for the public.
Sure there are a few things that have to change, such as the way the current system means the patient-facing administration is under-resourced while there are backroom beancounters who don’t enhance healthcare. But mostly it needs sorting out resourcing, and in particular staffing. Once the system is “good enough” – approximately back to where it was when the Conservatives took responsibility for it – is the time to start meddling with organisation which might be beneficial longterm, though that doesn’t rule out limited pilots in the meantime.
(But I should point out that current salaried GPs are not on anything like the consultant contract; if they were there might be pressure from the bottom for reform which is much better than it being imposed from the top).
Has nobody noticed that since last July the NHS has changed?
https://tribunemag.co.uk/2022/07/nhs-health-and-care-act-icbs-we-own-it
This means fewer face-to-face consultations with GPs.
Who owns the surgery and where matters too.
“Dozens of GP surgeries and medical centres caring for more than a million patients are in the hands of off-shore companies, it can be revealed, amid concerns NHS cash is disappearing into tax havens.
Analysis by i of more than 90,000 properties owned by overseas companies – from car parks to luxury homes – shows that the titles on nearly 100 primary care buildings in England are held by private firms registered in Jersey, Guernsey and the Isle of Man.
The property title of one surgery in Kent is even registered to a firm 4,000 miles away in the British Virgin Islands. ”
From an article in the i last March.
My wife worked in a practice where the building was owned offshore but the partners just rented it. They did not own it. And the practice itself was U.K. resident entirely. Data of this sort has to be interpreted with care.
But should it happen at all? Shouldn’t GP’s actual surgeries be owned by people who are tax registered in this country? Or even, dare I say it, by the NHS itself and rented from the NHS?
12 years ago when we moved to this village there was a surgery and a council run care home for the elderly. We now have a brand new surgery and a few flats for over-55s which can be bought or rented from a housing association. No care home in the village now. The GPs said that a new surgery was needed because the old one wasn’t large enough.
This morning I had an appointment for a blood test. While at the surgery I never saw more than one other patient. In fact, one was not a patient at all yet, but her surgery had closed down and she had tried to get through on the phone but could not as she wasn’t a patient yet, so had brought down a letter from her previous surgery to try and get on the books.
When this new set up was in for planning there was a meeting in the village, to which my husband and I went. I read through all the written documents, and the words NHS were not in them at all. My husband, being an architect, started talking to the architect present. He asked him who would own the centre. The architect himself did not know who the client was.
I am not sure anecdotal claims help here
And there is always going to be a boundary between the NHS and private sector somewhere
Sorry, I thought I was just following up on your mention of your wife’s practice.
While writing that I checked up on the practice and found out that the sole GP in the practice retired last month. Only 5000 patients in the practice and can’t find out who owns it or works in it now. That’s a worrying anecdote.
Fair!
Re the possibility of structural reform in the NHS, it would stand a better chance of being effective if it’s left to the medics and the politicians are kept out of it. The Tories record of meddling in NHS policies and organisation is very poor – just think about the whole fiasco of the “internal market” imposition in the 1990s that has left the NHS in England fragmented. That policy was foisted on Scotland and Wales too (can’t be sure about N Ireland) and cost a fortune in consultants’ fees to impose, but following devolution both have been quick to revert to regional management structures which have proven to be much more effective. However, I suspect the Tories will force their policies on England in order to please their donors in the private health insurance industry and the same goes for Labour if they get into power.
I agree entirely Richard. There is a very real problem in general practice but Labour are pro posing is a badly thought out solution to a non-existent problem. Streeting’s proposals will simply reduce morale and capacity even further for no possible benefit
This link is not about GPs but shows how insidiously the boundary between the private and NHS sector is being eroded.
https://www.northumbria-health.co.uk/
This is from KONP North East. The private group does not have any hospitals of its own, but uses all NHS hospitals in Northumbria. Just looking at the list of specialties makes me shudder. There is even a spinal surgeon doing private work in NHS hospitals. Knowing the state of the NHS at the moment I cannot see how any surgeon can justify taking resources away from the NHS.
I’m a retired GP. A very potted history might inform the debate
The original 1948 GP contract was a compromise in order to get the private GPs to join the NHS. It was based on a contract encapsulated in the “Red Book” rules. This defined GP payments which were largely based on weighted capitation and some extra payments for things like maternity services. Though able to see private patients most GPs lived off the red book. These payments were increased in the early 80’s because GP income was not enough to retain the workforce.
This system encouraged a “family” practice model and red book subsidies for practice staff helped the formation of primary care teams. Community services such as health visiting and midwifery were well integrated because of close local links with local authority and secondary care services. Though imperfect in many ways the system worked – many practices were inventive, there was little conflict between GP income and services because of the way in which the payments worked. Some unscrupulous GPs abused the capitation system, but most restricted list sizes in order to maintain service quality.
It all changed when neoliberal economics hit the NHS. The 90’s saw the purchaser/provider split which drove a wedge between primary and secondary care. Fundholding arrived in order to turn practices into small businesses that would manage their allocated funds and succeed in the new market. The result was financial abuse, no benefit to care and the idea was abandoned. The 2004 GP contract effectively privatised out of hours services and was another nail in the coffin of an integrated service. The most perverse effect of this contract was to make GP pensions dependant on practice profits – hardly the best way to encourage investment in clinical services
With 2004 contract came the era of micro management and targets. Having disrupted the more collaborative model it was decided that GPs couldn’t be trusted to do a good job without a whole series of clinical targets linked to funding. The clinical value of this system is uncertain but what it certainly did was to move the focus from personal care to data collection and administration. Thus the highly complicated (“opaque” to Labour ) payment system.
Then came the 2012 Health and Social Care Act with the formation of GP consortia and more emphasis on market competition. Practices moved away from the partnership model to employing salaried GPs and other clinical staff. Funding restrictions, changing demographics and finally COVID created a crisis in a service that had been interfered with, undermined and underfunded for years under a succession of governments obsessed with the ideas of market competition while refusing to accept their responsibility
to adequately fund the service.
Having created this mess there are now attempts to re-integrate the service while maintaining the underlying neoliberal market obsession and insisting that the State is unable to provide more money. General Practice has been interfered with, manipulated and undermined for years. That it no longer gives the kind of care that people and presumably the Labour Party want is not the fault of the GPs
Thanks