Rise and fall

If you travel almost anywhere in the world and talk to family physicians, you will find that they regard the British system of general practice as an ideal. Some of its central principles—including continuity of personal care, and acting as a “gatekeeper” for all hospital referrals—are widely envied, and have provided a model for other primary care systems. Yet British general practice is now in serious trouble. General practitioners in Britain are locked into a dispute with the government, and the outcome may be ugly. On the surface the argument is about opening hours and money. Underneath, the issue is about professional autonomy and privatisation. This battle is only the most recent one in a war that has been going on for at least two decades. During that time, some of the features of general practice that were most admired, such as 24 h responsibility for patients, have already fallen by the wayside. The process has gone so far that a recent editorial in the British Journal of General Practice, by a leading GP professor, had the title “The end of general practice”. Most GPs would probably not demur from this description. How have things come to such a pass?

INDEPENDENT CONTRACTORS

The causes are deep rooted. When the National Health Service was first created, GPs and hospital consultants joined it with different arrangements. The consultants were paid more, and became direct employees of the state. GPs earned less, but kept their status as “independent contractors”. The government became their sole direct customer, offering them contracts to look …