Primary care: core values Contracting for general practice: another turn of the wheel of historyBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7149.1953 (Published 27 June 1998) Cite this as: BMJ 1998;316:1953
Series editor: Mike Pringle
British general practitioners often assert their pride at being “independent contractors,” without remembering the origin of the term. Dr Ransome, pictured on his rounds as visiting physician to the local cottage hospital (box), was one of my predecessors in practice, and his extract from Kelly's 1908 directory of trade and professional people reminds us how most of our medical forebears earned their living.1 Others of my 19th century medical ancestors are entered in such directories as Surgeon to Waveney Valley Branch of Great Eastern Railway (Dr Adams, 18752), Surgeon to the Dispensary for the Poor (Dr Garneys, 18283), and Surgeon to the Rational Sick and Burial Association (Dr Johnstone, 18904).
This collection of contracts included occupational and public health services, treatment and certification of subscribers to friendly societies, care of inpatients at cottage hospitals, and a very basic service to the indigent poor (whether inside workhouses or on “outdoor relief,” as the forerunner of social security payment was called).
Although these arrangements initially seem to be relics of a bygone age, the modern general practitioner immunises children and adults, sees patients at the surgery or in the home, visits residential homes, and has hospital practitioner contracts at a community hospital or in a district hospital specialist department—he or she has a spectrum of work that bears a remarkable resemblance to that of Dr Ransome and his Victorian colleagues.
As well as these contracts, these doctors would have undertaken private consulting practice. John Scott, a well to do local diarist, records that he consulted Dr Garneys about his feeble sister Charlotte3 and, on behalf of concerned local worthies, about the 1849 outbreak of cholera in the town5. On New Year's Eve 1828 Dr Garneys was even called on to “dissect” Scott's gardener, James Baker, who died of “Billious Fever and Metastasis … leading to congestion of the brain.” 3
General practitioners have held multiple contracts since the last century
After the NHS was established general practitioners became dependent on it for income, to the exclusion of other income streams
Recently their income in the NHS has fallen below that of other professional groups in the private sector
Rising expectations, coupled with increasing public resistance to taxation, mean that to maintain income general practitioners may have to develop a wider portfolio of contracts, including private consulting practice
For personal care from general practitioners to survive, doctors may have to adapt to economic and social realities that may not be to their taste
General practice in the NHS
The NHS arose from the atmosphere of social cohesion and unity of national purpose that developed during the second world war. It is neatly expressed in the famous “assumption B” of the Beveridge report, which gave rise to the NHS:
That a comprehensive national health service will ensure that for every citizen there is available whatever medical treatment he requires, in whatever form he requires it, domiciliary or institutional, general, specialist, or consultant, and will ensure also the provision of dental, ophthalmic, and surgical appliances, nursing and midwifery, and rehabilitation after accidents.6
After the foundation of the NHS in 1948 general practitioners became used to receiving ever higher proportions of their gross income from NHS sources. Many have now spent their entire working life within the NHS:
“I qualified [in 1952] and will retire from full-time clinical practice in 1988; the NHS allowed me to do my own work and refer my patients to the whole range of specialist services during an entire working lifetime, without ever having to collect a fee. Several generations of British doctors have followed, with essentially the same historically novel experience.”7
RANSOME, Gilbert Holland. LRCP Lond, MRCS Eng. Physician & Surgeon. Medical officer and public vaccinator to Bungay District Council. Medical officer to Wangford Union and 4th District. Medical officer to Loddon and Clavering Union and 2nd District. Medical officer to Depwade Union. (Kelly's Directory of Suffolk, 1908)
End of the NHS era
The social consent needed to fully fund a comprehensive NHS, free at the point of delivery, can, I fear, no longer be relied on—a reality which general practitioners may be the last to recognise, despite their falling income against comparator professions since 1980.
Neither of the two major political parties in Britain has committed itself to raising taxation in order to increase spending on the NHS and other public services. The public has shown increasing tolerance of erosions at important margins of the NHS over the past three decades (under both right wing and left wing governments), including the progressive partial privatisation of care of the elderly, optical services, and dental services; the private finance initiative; and enormous leaps in prescription charges, all tolerated without political damage. Public consent for privatisation is not expressed through lack of commitment to the NHS, which is highly valued, but through a reluctance to accept the increased taxation that is necessary to deliver Beveridge's “assumption B.”
The public is also willing to pay for supplementary health services and products, including burgeoning publications and telephone advice lines on health, private general practice on demand in railway stations and other locations, a steadily increasing market in over the counter medicines, and private elective surgery. On the other hand, compared with other developed countries, the United Kingdom still has a strikingly low proportion of private health spending.
A mixed economy between NHS and private work is accepted by many dentists and consultants as part of their traditional pattern of work. This does not sit so easily with general practitioners, however, who are inhibited from mixing NHS and private work for the same patient not only by philosophical inclination but by their terms of service.
Despite this, general practitioners in the closing years of the century may have to bring a higher and more flexible proportion of private funding into general practice, given that the opportunities and political will to invest in the NHS from public sources seems increasingly limited.
Recognising GPs' limits
General practitioners, on the whole, remain fiercely committed to a comprehensive NHS. Yet recent developments in general practice signify their willingness to recognise the personal and professional limits of doctors' ability to meet the quantity and nature of demand, in a way that would have been unthinkable a decade ago.
After a crisis in out of hours primary care in 1995,8 doctors, patients, and the government alike recognised that a service based entirely on home visits could not satisfy rising demand within existing financial constraints. Consequently, and with modest additional funding from the government, general practitioners began to offer out of hours care at primary care premises and to work together in cooperatives covering larger areas and larger populations.
At around the same time general practitioners demanded set limits on the scope of their practice.9 This arose mainly from the considerable shift in work from the secondary to the primary care sector, without shifted funding, following the internal market reforms in the NHS of 1990.
The publication of a clear definition of core general practice in 1996 allowed family doctors to draw a line in the sand, showing the myriad small tasks farmed out from hospitals, and the care of patients sent to nursing homes who would, formerly, have occupied places in long stay hospitals.
General practitioners have responded to the definition of core services in various ways. Some have been keen to take additional training to contract for new non-core tasks or care for more complex groups of patients under supplementary contracts. Others have insisted that they do not wish to undertake the non-core work, even under contract. The 1997 Primary Care Act10 opened up further contractual possibilities for general practitioners. General practice can now be provided under a contract made by health authorities with a trust or group of practitioners instead of having to be provided under the traditional and highly regulated environment of part 2 of the 1977 NHS Act. In the new style of practice, patients will register with the trust rather than with an individual doctor, and responsibility will be held by the organisation. The employed doctors will have contractual responsibilities to their employers. This model has been further encouraged by the labour government's white paper The New NHS, which encourages doctors to move towards primary care trust status.
The future of contracts
The future general practitioner will probably have a wide network of contracts. As resources fail to expand to meet demand the NHS contract for general practice may be increasingly focused on the poorest and most deprived patients, leaving the better off to make private provision from the proceeds of a low tax economy.
General practitioners with wide ranging skills and interests may, however, contract to care for specialised groups in nursing and residential homes, to provide surgical services and procedures within their practices, to perform occupational health examinations and give advice, to provide services to a corporate provider in the primary healthcare business, and, eventually, to contract individually with private patients.
Whatever general practitioners do, they always need to remember the nature of their core business. The following words from an early draft of the BMA's statement on core services encapsulate what general practitioners are best at and what they see as their central expertise, regardless of whether the funding comes from public, private or mixed sources.
The irreducible essence of general practice is the care of people who are or believe themselves to be ill. Sensing unease within themselves which is not resolved using their own perceptions or the resources of those around them, people seek a consultation to secure an understanding of what is happening to them, what it means and what might be done with what effect. This aspect of human behaviour transcends history, geography and culture and will survive the ephemeral health policies of transient governments. Providing a response to these concerns is what most GPs feel they are best at and are happiest doing. By identifying the heart of our craft as the response to this timeless human need, we at a stroke restate our raison d'être and define our sovereign professional territory at a time of doubt and demoralisation.11
Adapt or perish
Sadly, the public's aversion to taxation means that general practitioners are still prone to the sort of pressure and exploitation in the public service that Punch magazine satirised a century and a half ago (box), and which survives today in the form of the Doctors and Dentists Review Body. The survival of personal medicine requires, as it always has done, imaginative adaptation by doctors to the economic and social realities that surround the timeless human need for access to healers.
Chairman: “Well, young man. So you wish to be engaged as parish doctor?”
Doctor: “Yes, gentlemen, I am desirous—”
Chairman: “Ah! Exactly. Well, it's understood that your wages—salary I should say—is to be twenty pounds per annum; and you find your own tea and sugar medicines I mean—and, in fact, make yourself generally useful. If you do your duty, and conduct yourself properly, why—ah—you—ah—”
(Punch: “Will probably be bowled out of your situation by some humbug who will fill it for less money.”)
Conflict of interest: None.
This article has been adapted from Primary Care: Core Values, edited by Mike Pringle, which will be published by the BMJ Publishing Group in July.