Behind the headlines: Are Labour’s plans radically misguided?

Rhiannon Jenkins looks at the logical inconsistencies in Labour’s proposed policies for general practice in England

The Labour Party is outlining radical proposals for the future of general practice. Shadow health secretary Wes Streeting said in an interview with The Times that he wants to ‘tear up’ the ‘murky, opaque’ GP contract, and consider abolishing the GP partnership model in favour of a salaried service. He also laid out plans for patients to self-refer to secondary care, with GPs no longer the ‘sole gatekeeper’ for specialist services.

Labour leader Sir Keir Starmer backed the shadow health secretary’s proposals in an article in the Sunday Telegraph, saying he would like to be ‘ruthless with the bureaucratic nonsense you encounter every day in the health service’.

But both their pieces included claims that are questionable. Here, we take a closer look. 

‘The truth is that the way that GP practices operate financially is a murky, opaque business. I’m not sure that people can honestly say exactly how the money is spent or where it goes. And from my point of view, as someone who wants to be a custodian of the public finances, that would not be a tolerable situation.’
Wes Streeting

The way general practices are funded is poorly understood, primarily because it’s complex and different from other parts of the NHS. That doesn’t mean they operate in a ‘murky, opaque’ way, though.

While general practices are small businesses, they only have one contract – and that’s with the NHS. Practices are paid directly by the NHS on the basis of the size of a patient list through the global sum. They also get additional funds for reaching targets and offering enhanced services – which isn’t always a simple task, especially when practices are experiencing unprecedented demand. Instead of lining their pockets this winter, GPs have been fighting to stay afloat, with local commissioners attempting to suspend the QOF so practices do not lose out on payments.

The claim that we can’t see ‘how money is spent or where it goes’ is simply untrue. Every penny that every practice receives from the NHS is detailed in the publication Payments to General Practice by NHS Digital, which also publishes aggregated information on GPs’ personal income and earnings. 

And although GPs are technically self-employed, there is little scope for corruption as the NHS is funded from the Government’s health budget. If only the same were true about UK politics.

‘GPs should focus on caring for patients rather than the admin that comes with effectively running a small business.’
Sir Keir Starmer

Regardless of the merits of moving to a fully salaried service versus retaining the partnership model, Labour’s arguments in favour seem weak. 

No GP would disagree with the idea that admin should be cut down, as Sir Keir states. However, many would take issue with the idea that this admin is caused by running a small business. 

If health managers truly believe in the benefit of CQC inspections, appraisal and revalidation, the constant changes to patient data legislation and numerous other time-draining exercises, these would presumably still take place regardless of whether practices were ‘small businesses’. And if they don’t believe in the benefits, there is nothing to stop the Government (including a Labour government) removing them from the GP contract.

A similar case can be made for the QOF and enhanced services – there is nothing inherent in the partnership model to stop the Government removing the bureaucratic elements of the schemes and putting the money directly into core funding. 

Our primary care model isn’t working. Not enough young doctors want its burdens and liabilities when older partners retire.’ SKS

Neither Sir Keir nor Mr Streeting offers any evidence that the partnership model is to blame for the recruitment crisis in general practice. It is true that fewer younger GPs are taking up partnerships. But it is equally true that there aren’t enough salaried GPs – numerous Pulse surveys have shown there are plenty of vacant salaried roles. 

This is not because salaried roles are unpopular. Some 40% of partners who responded to a Pulse survey in May 2022 were considering salaried roles. The problem is that there are not enough GPs in the system. There is no evidence that changing the model of general practice would reverse this. 

Furthermore, an internal analysis by the Department of Health and Social Care found it would also probably cost more than £7bn to move to a wholly salaried service. Sir Keir’s comments have even made Prime Minister Rishi Sunak look reasonable when the PM said: ‘They [the NHS] don’t need another completely disruptive, unfunded reorganisation buying out every single GP contract.’

‘I’m minded to phase out the whole system of GP partners altogether and to look at salaried GPs working in modern practices alongside a range of other professionals.’ WS

This comment ignores the fact that there have been moves to have GPs working in modern practices alongside other professionals. These schemes – including the additional roles reimbursement scheme, which funds primary care networks to recruit non-GP healthcare staff – have had limited success because of a lack of appropriate staff. There is no evidence this would change under a salaried model. 

‘Nye Bevan famously said he had to stuff their mouths with gold because the BMA opposed the foundation of the NHS. There have always been people within the system who oppose fundamental change which, decades later, is widely accepted. I’m always prepared to work with people.’ WS

Mr Streeting’s apparent desire to pick a fight with the BMA and the medical profession by quoting Nye Bevan in this context seems a strange tactic considering how doctors themselves are suffering because of the Conservatives’ mismanagement of the NHS. 

But the shadow health secretary’s comment also ignores the fact that Bevan was actually talking about having to buy the support of consultants, not GPs. He eventually won the consultants over by allowing them to work for the NHS and treat their private patients at the same time. 

Regardless of whose mouths were stuffed with gold, this comment has little relevance to the BMA or medical profession of today as it was made 75 years ago. 

‘Vaccinations are money for old rope and a good money spinner.’ WS

First, the tone of this comment suggests Mr Streeting does not appreciate the importance of vaccinations and the implications of delivering them for GP workload, especially the Covid jab.

Second, his comment ignores the issues around vaccinations for GPs. For example, while GP practices were paid to deliver the Covid vaccine, a Pulse survey revealed that more than 40% of GPs in England said their practices either broke even or made a financial loss by taking part in the first phase of the Covid vaccination programme.

And the problems around the childhood vaccination programme reveal how resource intensive this can be. Because of the way the payment structure works, practices in deprived areas must often go to extreme lengths to reach families to get children vaccinated – including running awareness campaigns and hiring dedicated staff – for very little profit, and in some cases losses

‘Sometimes it’s pretty obvious that you don’t need to see the doctor… I think there are some services where you ought to be able to self-refer.’ WS

‘Would it not be possible to consider self-referral so that individuals don’t have to go to a doctor, use up a doctor’s time in order to get referred to specialist help… If you’ve got back pain and you want to see a physio it should be possible, I think, to self-refer. If you’ve got internal bleeding and you just want a test, there ought to be a way that doesn’t involve going to see a GP.’ SKS

The idea that patients should be able to refer themselves to specialists is not groundbreaking. In fact, patients can already self-refer for a range of services, from counselling to antenatal care and physiotherapy in certain areas. 

However, Sir Keir’s comments in particular convey a misunderstanding of GPs’ gatekeeper role. If patients had open access, we might come to see the current waiting times as halcyon days.

They also display a lack of basic clinical understanding. As GP and co-chair of Doctors’ Association UK Dr Ellen Welch says: ‘If you’ve got “internal bleeding” you really don’t want to guess which tests you need or which specialists to self-refer to. You may bleed to death while deciding.’