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Remember Barbara Starfield: primary care is the health system’s bedrock

BMJ 2013; 347 doi: (Published 30 July 2013) Cite this as: BMJ 2013;347:f4627
  1. Michael Caley, specialty registrar in general practice and public health, Public Health Warwickshire, Warwick CV34 4TH, UK
  1. mikecaley{at}

Barbara Starfield’s research showed that investing in primary healthcare is the way to a successful health system. So why are these lessons not being heeded, asks Michael Caley, and will general practice commissioning help?

The UK government’s Health and Social Care Information Centre published data in March showing changes in the medical workforce of the NHS in England between 2002 and 2012.1 The number of consultants rose 49%, from 27 070 to 40 394, whereas the number of general practitioners rose by only 19%, from 30 312 to 36 105. The proportion of all doctors working in general practice has fallen steadily, from 42% to 37% of the total medical workforce.

So what has driven this disproportionate increase in consultants compared with general practitioners? The answer may be more financial than ideological. The introduction of payment by results for secondary care since 2003-04 enables hospitals to increase revenue, and hence workforce, by increasing activity and from the general increase …

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