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At the heart of general practice since 1960

GPs should not have to dig into their pockets to prop up the NHS

It is considered good press if a fellow GP appears to be urging his peers to do more for less - but that is not my view, writes Dr Michael Dixon.

It is good press if a fellow GP appears to be urging his peers to do more for less - but that is not my view. GPs should not have to be digging into their pockets to prop up an NHS that has failed to invest sufficiently in general practice and primary care. On the contrary, I believe that GPs should be receiving a far greater share of resources for doing proportionately more as commissioners and also as extended providers of improved health and services. 

Those improvements have failed to materialise historically because of a singular failure by previous governments and commissioners to make the necessary investment in general practice and primary care. The result has been a trebling of specialists during my professional lifetime, while the number of GPs and the size of their lists have remained relatively static.

Meanwhile, activity and workload in general practice rises year on year. Much of the work previously done in hospitals (such as childhood asthma, much long term disease and the treatment of deep vein thrombosis) is now carried out in general practice. GPs are not paid according to patients seen or hours spent. We have, effectively,  a ‘block contract’. Conversely, the hospital system continues to be paid per unit of activity. It is not sustainable. 

General paactice faces greater opportunities and risks than ever before. Its strengths lie in its flexibility and the provision of holistic continuing personal care . It does this very cost effectively.  That is why the personal list has survived (in spite of many challenges in recent years – as fellow GP leaders will know).

That is why clinical commissioning is itself now predicated on the GP list – effectively turning the NHS on its head and moving the centre of gravity of decision making on health and services away from Whitehall and to ourselves. Unequalled opportunity or poisoned chalice? GP opinion is divided on which but the greatest deciding factor will be how we  react . 

We now hold all the keys from designing health services as commissioners to helping our patients decide which to use when they are with us in our consulting rooms.  We could not be in a stronger position to describe the future NHS landscape. Issues such as private/public, market/integration or done in hospital/done in the community are very much in our court. We would have no say if clinical commissioning did not exist.

As providers of services, the opportunities are equally great but the window of those opportunities will be short. That is, we need to make a strong bid, and fast, for the role of general practice as provider of extended services and as a major player in local health.

It was my remarks on the latter that led to torrents of abuse from my fellow GPs, when it was implied that I thought we should be digging in our own pockets to improve local health. In my own practice, we do provide funding for a health facilitator and other health projects, which have delivered a return on investment through fewer appointments and referrals, and as importantly, through improved higher quality of life for often patients who are often vulnerable and lonely. My point was not that others should follow this example but that general practice should be enabled to take on a far wider local health role, and be properly supported and funded by CCGs to do so, and backed by local health and wellbeing boards.

Integration at practice level

GP practices and our independent contractor status are very vulnerable in a world of global markets, a society committed to consumer choice and European law - on the one hand and the changing face of general practice itself with an increasing part time workforce, no longer responsible for out of hours and with erosion in some areas of the doctor/patient relationship - on the other.  In these circumstances, takeover of general practice by the big corporates becomes a real danger and possibility. Very small changes such as allowing sale of goodwill (which many of us have resisted behind closed doors) or increased profit margins would rapidly tip the balance.

Being prepared for this new world will require that ingenuity and adaptability for which general practice is famous.  Already GP practices in many parts of the country are recognising that there is ‘safety in numbers’ and forming associations of practices, local provider organisations (e.g. limited companies or social enterprise) or merging altogether. Some are already providing extended services and others are preparing business cases to do more. 

The trick for GP principals and their practice managers will be to maintain good personal and continuing care as generalists, while diversifying by extending services offered by practices (often jointly) particularly for those with long term disease and the frail elderly. We must lead the integration of services at practice level and in primary care as we have, historically, been the sole integrators of care. We will need to do this with caution, holding the ring and heeding the words of Lord Hunt, the first chair of RCGP that integration was what the cat offered the canary.

It may sound exhausting and it will be. Less so with good managers and with the right relationships between local GP practices. Less so also with the support that NHS Alliance will be offering GP practices that want to be in control of their future. Staying as we are holds the promise only of increasing vulnerability and diminishing income. Grasping the opportunity will provide the stability and sustainability that general practice now needs.

A major decider in all of this will be the level of morale, confidence and trust at the frontline of general practice.  This is not helped by the current standoff between government and BMA. GPs and practices need reassurances, particularly at this time, about stability of future income. These might then generate a more confident profession that can then take on its new leadership role, which will protect the best of generalism but also create new community services and healthy communities. These are the only answer to long term NHS sustainability.

Dr Mike Dixon is the chairman of the NHS Alliance and a GP in Cullompton, Devon.

Readers' comments (6)

  • Dr Dixon,
    I hope you have the ear of government and can lobby the government pretty quick.

    GPs have reached the end of what they can take and are retiring and emigrating in droves. If this tide is not turned there will be little of general practice to salvage let alone build on.

    We no longer believe that the government has the best interests of general practice or the population in mind.

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  • Prematurely retired, considering emigration, I am still astounded as to what I read everyday from so-called GP leaders. SHAME. If I was a patient, there would have been umpteen serious complaints.

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  • Sadly every other professional group (IN THE NHS) has had to do more for less for years now. GPs in the main have insulated themselves by remaining contractors to the NHS with a stranglehold on that resource. It may be an often abused phrase, but we are all in this together, and GPs cannot continue to insulate themselves from the realities of the NHS.
    They need to carefully consider how much putting their head above the parapet. For years allowances have continued to be paid for patients who cease to exist due to poor data quality, failing to update deaths etc
    Monica is right that the government does not have the interests of the population in mind, what may be different is that this also includes GPs,

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  • My understanding was that QOF was suposed to pay for additional staff and resources for practcies, but sometimes it went into GP partner pockets , giving us some of the highest paid GPs in the work, (and some salaried GPs on diddly squat, and a growing workload for everyone).
    I agree that the workload is unsustainable, but as the other poster says, this is true for everyone. The government doesn't care, they are slowly privatising the lot. this will be great for a few people who own the business and rubbish for the rest of us. GP s have largely done a briliant balancing of capitalism and care, but once the big business boys get a grip on the NHS, apart from the few real entrepeneurs you will all be salaried, and will have to phone up the insurance company if you want to work off-protocol.

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  • GPs should not have to be digging into their pockets to prop up an NHS that has failed to invest sufficiently in general practice and primary care.

    Sorry to only focus on one thing but this statement is galling. For 5 years after the new contract was agreed, GPs, generally, had a great deal giving the enemy of the NHS (Daily Mail) tons of evidence of GPs earning more than the PM. You are a private business, a compassionate and caring one, so investing (or saving for larger projects) in the Practice rather than relying on capital grants from the PCT/SHA for extentions, new builds etc would have been sensible. Any GP earning over £150k, purely from GMS/Enhanced Service work without putting a substational amount of finance into their business is not doing enough. Yes you work long hours, yes you make life and death decisions, yes you have to be a saint when it comes to dealing with some patients, but the PM doesn't? This is not a Party Political Broadcast as I fear, 2 years hence, that the NHS will be a wholly different animal than it is now and I do worry. But the good years are now coming back to bite some of you and whilst it is not right what is happening now, you have helped make that bed!

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  • How will GP salaries be calculated under the new system?

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