Why is primary care in crisis?

By Dr. Eddie Chaloner - Consultant Vascular Surgeon



Amid the constant jeremiads of doom regarding the lamentable state of Britain’s NHS, the clamour about the problems in the primary care system are prominent. Given that 300 million GP consultations are carried out per year in the UK, perceived shortcomings in access and performance of the system rapidly become a major source of public discontent.


Non-medical readers may be forgiven for wondering why a professional group with average salaries of £100,000 per year (https://www.gponline.com/average-gp-pay-rose-28-england-2019-20-faster-uk-nations/article/1725154) are constantly complaining about terms and conditions, to the point where the British Medical Association is on the verge of balloting on industrial action (https://www.bma.org.uk/bma-media-centre/bma-s-england-gp-committee-rejects-government-s-rescue-package-and-moves-towards-a-ballot-on-industrial-action).


To rationalise the argument, it is necessary to understand how the current structure of General Practice evolved. The transition in 1948 from private GP Practices charging patients fees for service to a nationalised system free at the point of use was not easy. GP groups stubbornly resisted change and had to be coerced into joining the NHS. Patients were encouraged to sign up with practices joining the new NHS scheme to receive free care. Practices resisting enrolment therefore saw private business evaporating and were forced to join the new system.


The key concession family doctors obtained in 1948 was to retain an element of independence from government. They argued successfully for a contract for services, rather than a contract of service – hence they retained their self - employed status as individual contractors within the NHS, paid on a capitation fee basis depending on how many patients were registered with each practice.


GP partners remain owners of small businesses, with their remuneration proportionate to profits from the practices – albeit in a heavily regulated market with one overwhelmingly dominant customer. General Practices are therefore ‘price takers’ in economic terms – they must accept the price the state is willing to pay for their services because there is no other source of income, but efficiently run and entrepreneurial practices can still generate substantial returns.


Over the years, the NHS has become more demanding and intrusive, driven by political and economic factors. Hence the burden of administration incumbent on GP practices has increased. GP partners frequently complain that running the business side of a practice draws them away from their clinical duties and that they have not been trained in business administration and development. (https://www.bmj.com/content/375/bmj.n2626.long). Such complaints have elements of ‘cakeism’. On the one hand GP partners want to retain their self -employed status within the NHS, allowing them greater control of their working lives and to benefit from profit sharing arrangements. On the other hand they don’t want the stress and hassle of running a business.


Further, the anomalous employment status of GPs within the NHS system has created two different types of family doctor – the GP partner and the salaried GP. Salaried GPs are contracted to a practice on a nationally agreed set of terms and conditions, but do not own a share in the business. The upside is that salaried doctors don’t have the burden and responsibility of practice management. The downside is they don’t participate in any profit share and generally their remuneration is lower than GP partners. (https://www.bma.org.uk/pay-and-contracts/pay/other-doctors-pay/salaried-gps-pay-ranges).


Some GPs prefer to work outside the salaried system as locum doctors – filling gaps in rotas on a temporary basis at various practices but with higher per hour remuneration to compensate for lack of contractual protections.


This structure creates differential incentives and tensions within the GP workforce. When the NHS imposes more demands on primary care, GP partners respond by squeezing more from salaried doctors. In response, salaried doctors push back by demanding more money, or join locum agencies, which in turn increases manpower costs for GP partners.

Discussions are taking place around bringing the entire primary care system under the control of the NHS – in effect the state would take over thousands of privately owned GP practices and employ all family doctors on nationally negotiated contracts as for hospital clinicians.


Whilst this model has some attractions, there are also substantial downsides. For a start, valuation of practices and compensation of GP partners would not be a straightforward matter. Further, the NHS does not necessarily want direct accountability for General practice administration and performance. In any event, nationalising the entire system would not solve the central problematic issue of a mismatch between medical workforce numbers and public demand for healthcare free at the point of use funded by direct taxation.


The gordian knot of primary care has led some commentators to wonder whether our current system is appropriate for the modern age (https://www.spectator.co.uk/article/do-you-really-need-to-see-the-gp-in-person). Simply put, would it be preferable for patients to bypass GP practices and be able to access specialist care directly? At Dr Loxley, we think it might.


At Dr Loxley, our team can direct you to the very best care with the latest treatment innovations, join us at www.drloxley.com


Published by By Dr. Eddie Chaloner, Consultant Vascular Surgeon


MA(Oxon) BM BCh FRCS(Edin) FRCS (Gen)