Bad Summer for General Practice?

Primary Care

A bad few weeks for general practice. First came the MPIG scuffle in June, as the government announced unilaterally that subsidies that guaranteed general practitioners’ incomes would be phased out, over seven years. This government is no friend of a Minimal Practice Income Guarantee, which protects GPs from market discipline. The withdrawal of MPIG affects 60% of around 11,000 general practices, but in 98 mostly small rural or inner city practices it is an existential threat. The government seems to have calculated that the political fallout from all this should be manageable. The BMA has assisted by negotiating for the money saved from MPIG (around £116 million) to be distributed across all practices, and not ‘lost’ to the NHS. A small flurry of petitioning and protesting has gained some publicity, and the BMA has criticised the government for leaving the solution to local NHS England managers to sort out, but behind the scenes plans for mergers of small practices will proceed.

Then The Times (and the Sun) carried a news item provided by the Royal College of General Practitioners on its front page on July 28th. The story was that millions could not get appointments with their family doctor, and more money would be needed to keep general practice going. This news prompted Stephen Pollard, writing the Times’ ‘Thunderer’ column, to condemn the RCGP for blackmailing the citizenry and urging GPs to open at the convenience of the public, not themselves. He noted the high incomes GPs earn, their limited face-to-face contact with patients (22.5 hours per week on average) and their escape from out-of-hours’ work.

Pollard described only part of the problem in NHS general practice. The management of long term conditions is now within the remit of general practice and fills working time. General practitioners are not working less, only less hours. The amount of face-to-face contact with patients is in part determined by the quantity of audit and reporting required by the GP contract introduced in 2004, as well as the interminable debates about commissioning promoted by this government. General practice is industrialised and micro-managed, features that fit a personal service industry poorly. The spectacular hike in income after 2004 restored general practice to parity with other professions for the first time since the late 1960s, and it is being clawed back, piecemeal. And there are some difficulties in recruiting doctors and nurses to general practice, partly because new graduates are watching to see what happens before committing themselves. Finally, the argument is awash with dubious statistics, it being difficult to count things that do not happen –consultations allegedly forgone being an example. Nonetheless Pollard had a point. General practitioners are independent, for-profit, contractors to the NHS who do not want to eat into their profits by hiring extra staff to meet demand. The number of appointments is set by general practitioners, who are working to rule having written the rule themselves.

Then it got even worse. The Royal College of General Practitioners was criticised for ‘perpetuating a trench war of specialities’ by the Lancet on July 26th, a warning that hospital specialists may not come to its aid in any future rumble with the government. The RCGP’s claim, on July 30th, that there were 16 days left to save general practice (by getting one million patients to sign a petition) adopted the histrionic, catastrophist tone that is now obligatory in NHS politics. Projecting an image of lengthening queues of patients and growing unmet need does the NHS no favours, and an outward show of inflexibility makes general practice look ripe for privatisation. The RCGP should be careful what it wishes for. It is time for some savvy leadership.