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Rise and fall
  1. John Launer
  1. Dr John Launer, London Deanery, 85 Sutton Road, London N10 1HH, UK; jlauner{at}londondeanery.ac.uk

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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 after two or three thousand local citizens each. In exchange, they continued to function as private businesses. They could own their premises, employ their staff, and have profit and loss accounts, much like solicitors or accountants. It was a strange compromise between a profession that still operated a Victorian business model, and a welfare state.

To the astonishment of many people, this system still exists as the basis of most general practice in the UK. We continue to have a national system of health care that is “universal and free at the point of care”, just as its founders intended. At the same time, the majority of GPs are still self-employed, own a financial stake in their surgeries, hire and fire their staff without the interference of human resources departments, and meet their accountants annually to sign off a division of the profits between the partners. Although a minority of GPs work for salaries, the dominant model of general practice is still that of an independent cottage industry, nestling within a huge centralised public service. If the same model was applied to the armed forces, it would be like the navy operating independently, with each ship having a self-employed group of officers and a private crew, while the army and air force remained directly accountable to the government.

GOVERNMENT CONTROL

While the structure of primary care in Britain has remained the same down the years, the scale and expense of medical care have expanded vastly. Because of this, successive governments have tried to seize more and more control of the health service. In the case of hospital care, direct management has made this relatively easy, even if the process has been controversial or unpleasant at times. With primary care, gaining control has been incomparably more difficult. Since GP practices are bound to the state through business contracts, the government has to renegotiate these each time it wants to bring about change. In theory, practices can walk away from a new contract, leaving the government with no change, or—if they want a real confrontation—no primary care at all. There have been at least four major revisions of the GP contract over the past 40 years. Each one has achieved greater central control over the profession and the services it provides, but at the expense of bruising negotiations, rumblings about mass resignation from the health service, and big hikes in GP earnings and pensions. Broadly speaking, each has resulted in care that was better technically but less personal.

Given all this history, you may well ask why the government has never bought out general practice completely, turning it into a managed and salaried service like hospital medicine. There have certainly been ministers who wanted to do so, and some GPs who would have preferred this too. However, most GPs still regard their independent status as their last barricade. They have an enormous sentimental attachment to their independence. In GPs’ minds, it is tied up with a sense of being on the patient’s side, and against the machine. Another obstacle has been the cost of property. GPs own a vast amount of private capital in the form of their surgeries. The cost of buying out thousands of high street shops, Edwardian semis, purpose built clinics and the rest would be phenomenal. Historically, then, the big dilemma for governments has always been this: how do you make GPs accountable to a public service, while they remain private businesses?

PATIENT CHOICE

In the last few years, both sides of this equation have changed dramatically. Ideas like choice and competition have now come to the fore, and have entirely altered the meaning of a “public service”. Overall, the NHS may still be funded by taxes, but increasingly large parts of it—from cleaning and catering to diagnostics and elective surgery—are now being farmed out to profit making companies in the belief that this will be better value. “Private business”, no longer a thorn in the flesh of the NHS, is now being promoted as its saviour. In the last year or two, general practice has been opened up to competition. Local commissioners have acquired the power to withdraw contracts from practices they regard as offering a poor service, and they are putting these out to tender. Corporate predators have already entered the field. Some have bid successfully against traditional GP partnerships.

If, as everyone expects, the government now demands that practices stay open longer—for little extra pay or staff reimbursement—the choices for GPs will be severely limited. Leaving the NHS may still be an option in wealthier areas, where patients might sigh but pay up front to see GPs, as they have done for dentistry. But in most of Britain, resignation is no longer a credible option. It would simply make it easier for local commissioners to transfer their service contracts to private companies. These companies would no doubt offer to re-employ the same GPs as before, but for less pay. The word one hears most commonly on the lips of British GPs today is “stuffed”.

At the heart of the current crisis, there is a political paradox. The government that brought in the NHS after the second world war was explicitly socialist. People in the west abhorred the harsh Russian version of socialism, but they still wanted free welfare systems that shared the same ideological roots. Although few British GPs would ever have described themselves as socialist, the philosophy underlying the health service remained crypto-socialist for many years. General practice only survived in the form of small businesses because it was underwritten by the collectivist system in which it operated. But when the Cold War ended in the 1980s and the Soviet Union collapsed, governments in western Europe lost interest in collectivism of any kind. Instead, they fell in love with the victorious economic model: the market. Since then, the last vestiges of socialism, and even the name, have all but vanished. With it, the protection afforded to general practice has also gone. Small businesses must now give way to big business. Having resisted nationalisation and clung to their private status for 60 years, GPs are now finding it is their Achilles’ heel.

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Footnotes

  • Competing interests: None declared.

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