Education And Debate

Primary care–opportunities and threats: The changing meaning of the GP contract

BMJ 1997; 314 doi: (Published 22 March 1997) Cite this as: BMJ 1997;314:895
  1. Jane Lewis, professora
  1. a All Souls College Oxford OX1 4AL
  • Accepted 17 February 1997

The meaning of the GP contract has changed since the last major upheaval in the mid-1960s. The government has always dealt with general practitioners as independent contractors, but the way in which it treated them in 1990 was entirely different from the way in which they were treated in 1966. In 1966, the profession's independent contractor status effectively served to protect professional autonomy. In 1990, with the change in the form of government towards a “contract state,” general practitioners were treated as independent contractors more in the sense of business entrepreneurs. The article finishes by raising the issue of how general practitioners can gain control over the medicopolitical agenda in the future.

General practitioners were extremely hostile to the contract that was imposed on them in 1990. Yet the profession had signed up to many of its provisions. In 1985 Michael Wilson, the then chairman of the General Medical Services Council, wrote to the minister of health, Barney Hayhoe, with proposals for extending the range of services offered by general practitioners to include the extension of cervical cytology screening, a comprehensive scheme for paediatric surveillance, and minor surgery–all specific proposals that were taken up by the government in 1990. Nor were many of the worst fears of general practitioners about the workings of the contract realised. Pay increased (though the increased delivery of items of service was deemed by the government to have resulted in “overpayment”) the cash limits on reimbursement for expenses proved initially generous; and the increased weight accorded capitation payments did not result in an increase in list size, although it served to thwart general practitioners' longstanding desire for a reduction. Why, then, was the hostility so great?

The answer lies in the changing meaning of contract. Since the introduction of national health insurance in 1911, the …

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