Image: Dr Bob Gill. National Health Action Party
The NHS needs ‘fundamental changes’ to save it from ‘disaster’, the Kings Fund told us last week (as they seem to most weeks). New NHS plans mean GPs ‘will deliver more integrated services in the community’, they tell us. GPs already have lots of ‘autonomy’ and can embrace ‘disruptive innovation’, be more ‘flexible’ over payments, take on new ‘leadership’ roles, and ‘collaborate’ better with a wider range of ‘providers’, including (it is left implicit) private healthcare corporations.
The Kings Fund seems to be living in a parallel universe. As a GP, I see my colleagues having lost autonomy, morale and now income to such an extent that they are leaving in droves - clearing the way for the private sector. And what’s caused this fundamental disaster now rapidly unfolding in General Practice? The pro-private sector policies pursued by politicians for decades. Policies that the once highly respectable Kings Fund now promotes as effectively - if more circumspectly - as more obviously right-wing ‘think tanks’ like the Adam Smith Institute have done for years.
How the private sector is usurping what your GP used to do
Since taking over a small family practice on the London and Kent border, I have endured multiple reforms imposed on general practice. The reforms have been cleverly crafted and spun using the privatiser’s favourite language of ‘patient choice’.
In 2004 New Labour’s GP contract allowed GPs to give up responsibility for organising out of out of hours care by paying £6000. Already overworked, the vast majority of GPs did so - having been given the impression that the service would be provided by already long-established co-operatives of GPs sharing the work.
But the old GP co-operatives have found themselves side-lined in favour of the corporates, who know how to play to new the new ‘tendering’ system. By employing fewer doctors and favouring cheaper less qualified staff, they can undercut established NHS services.
There have been some alarming results. Virgin was heavily criticised by the quality watchdog the CQC for allowing unqualified receptionists at an urgent care centre to assess patients. In Cornwall, Serco was found to have had only one out of hours GP on duty to cover a county of 532,000 people at one point, and to have falsified their data rather than admit patients were regularly waiting far too long as a result.
But it’s not just GP’s out of hours role that is being increasingly usurped by the private sector.
The New Labour ‘reforms’ also changed the system of GP employment. From the outset of the NHS, most GPs had been classed as ‘independent contractors’ - an integral part of the NHS family, trained in the NHS, paid by the NHS and part of the ethos of public service. This arrangement remains, for now, but now the numbers working as salaried GPs were significantly boosted.
Sold as allowing doctors to practice without the headache of running a practice, this was in fact another entry point for the corporate profiteers.
Not only did GPs not have to run practices - now, you didn’t have to be a GP to run a practice.
Private companies for the first time could instead employ salaried doctors to run practices and skim off profit for their trouble.
And they moved in fast. Virgin acquired a 75% stake in Assura Medical in 2010 serving a population of over 3 million patients.
These changes dealt a blow to the continuity of care for patients as private providers like United Health bid low to win contracts and then sold off or closed down GP clinics that weren’t profitable enough.
The new funding arrangements also removed the ‘principal allowance’ which was paid dependent on how much time GPs personally offered for direct contact with patients.
Some ‘entrepreneurial’ doctors exploited the new system too, delegating their clinical work to others, pocketing large incomes without having to spend much time seeing patients. We began to see headlines about ‘fat cat’ GPs, a useful by-product in demonising the profession.
How to make GPs compliant - the carrot…
Practice income was significantly boosted with the introduction of performance related pay through the Quality and Outcomes Framework (QOF) in 2004. High achievement on reaching multiple clinical targets for controlling long-term conditions such as high blood pressure could add up to more than 20% in practice income. Some commentators believe the Government underestimated how well GPs would do with QOF. For a while, GP morale and recruitment improved - the latter up by 4,000 in 5 years.
But something else had changed. GPs were being incentivised to perform tasks for which there was little scientific support. They were encouraged to over-prescribe and over- investigate. With this came an erosion of professionalism and an acceptance of managerialism. GPs were being driven by targets rather than what the patient wanted. And consultations were contaminated with the need to collect data which we diligently trawled for and recorded, little suspecting this would be handed over to the health insurance and pharmaceutical industries several years down the line through the care.data scheme.
The compliant GP workforce was being unwittingly softened up to play their role in the next key step of privatisation - a huge extension of ‘commissioning’, ie the parcelling up of NHS services to be sold off to the lowest bidder. The phoney buying and selling of services between different parts of the NHS had already been established, its bloated bureaucratic infrastructure ready for the logical transition to an external market open to all comers.
When it came, the transition - under the Health & Social Care Act 2012 - was daringly disguised as ‘giving power to GPs’, as it closed down the previous local NHS commissioning bodies (Primary Care Trusts) and replaced them with even less accountable ‘Clinical Commissioning Groups’ decorated with a few GPs on the board.
Often it was the same few entrepreneurial GPs who had flourished under GP contract changes and off-loaded their patient care to others, who were ready to take up the challenge (and income) of ‘Clinical Commissioning’. Lacking the necessary skills to actually scrutinise ‘commissioning’ decisions to dismantle acute hospital services themselves, they read from the scripts written for them by the army of expensive management consultants and accountants - merely increasing the success of the deception on their GP colleagues. Blatant conflicts of interest were no barrier to these costly and unnecessary consultancies swallowing up hundreds of millions of pounds previously destined for patient care.
…and the stick
Having now established Clinical Commissioning Groups (CCGs) to give hospital cuts and closures the cloak of local clinical endorsement, politicians no longer need GP compliance. Now political attention turns to the destruction of traditional primary care. The operation of a free market finds it most inconvenient to have expensive and independent minded GPs as the main healthcare gatekeepers, obedient as the vast majority of them are to higher laws than profits (such as professional ethics and the Hippocratic Oath). So General Practice is now being dismantled through a combination of regulation, funding squeeze, privatisation and propaganda that lowers morale and recruitment.
Changes to QOF have meant have made points (and therefore income) harder to attain. The proportion of total NHS spending on primary care has steadily fallen despite more work being done in surgeries as a result of government imposition and cuts to hospital services. Fragmentation, privatisation and cuts make services increasingly hard to access for patients - and for their GPs, now often subject to tightly managed ‘referral limits’ on their patients imposed from above.
GPs are blamed for increased pressure in casualty departments, conveniently forgetting the impact of government policy on hospital closures and bed reductions. The corporate heist of Out of Hours care, particularly the dumbed down 111 service which replaced doctors with computer based algorithms, has been a disaster. Seven day working for GPs is being pushed as the remedy but this will merely damage morale and recruitment further. Being a GP becomes even less attractive for young doctors, and senior GPs look for a way out. Bring on the ‘doctor’s assistant’ and more momentum behind surgery closures. The soul destroying bureaucratic burden is worsening as a new CQC inspection regime increases administrative burden and stress on overstretched practices. Requirements are being ratcheted up to destabilize smaller practices. CCGs are being given the power to ‘performance manage’ the mass closure of local surgeries deemed unsuitable for one arbitrary reason or another.
The mood music from NHS policy makers is to have practices merge or ‘federate’ leading to consolidation onto fewer sites. None of this is backed up by evidence or necessity. The ground is being prepared for further corporate takeover, perhaps disguised yet again as ‘GP-led consortia’.
The unsuspecting majority of general practitioners struggle to cope with the day to day job and find it difficult to contemplate quite what is happening around them. Our medical leaders show little desire to shed light on the devastation facing primary care. True to form they follow and react rather than lead and prepare. Meanwhile those still left at the coalface are, for now, resigned to struggle on providing care the best they can for as long as they can cope.
We are slowly but inexorably drifting closer to the death of traditional general practice which provided convenient high quality care and effective gatekeeper role to specialist care. This major strength of the NHS was both cost-effective and professionally satisfying. It is being replaced by a highly profitable American style system which excludes many, is vastly more expensive and wasteful whilst returning worse outcomes for patients. It does not provide continuity of care or strong preventive medicine, and trust between patients and health professionals is low. US medicine is a commercial transaction focussed around profit maximisation not patient care.
Successive governments have effectively deployed a minority of doctors to help with the destruction of hospital services, erosion of quality and access for patients to vital services. The public and NHS staff have been betrayed by carefully selected and often handsomely rewarded ‘leaders’.
The majority of UK family doctors, familiar, trusted and local, with knowledge of you and your loved ones will be a thing of the past. And who better to deliver this vision but Simon Stevens, head of NHS England and former UnitedHealth executive. His ten years of experience at the largest health corporation in the world and his stated intention to replace the outmoded ‘corner shop’ model of primary care should leave the attentive in no doubt of our final destination.
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