Intended for healthcare professionals

Views & Reviews No Holds Barred

How to undermine general practice

BMJ 2014; 348 doi: (Published 16 June 2014) Cite this as: BMJ 2014;348:g4061
  1. Margaret McCartney, general practitioner, Glasgow
  1. margaret{at}

The destabilisation of general practice is underway. Most general practices in England are not paid a regular amount but make their money through the contract negotiated in 2004. Core funding includes the “global sum,” which makes up about half of a practice’s income 1 and now amounts to £66.25 for each patient every year2—cheaper than the cost of health insurance for a pet dog.3

The rest of a practice’s income is earned in bits, bobs, and from ticking the boxes of the quality and outcomes framework. It was anticipated that the 2004 contract would leave some practices vastly worse off, and so the “minimum practice income guarantee” (MPIG) ensures that practices cannot end up with a net loss.

This guarantee is now being withdrawn, and some general practices—often those in areas of high deprivation in London4 and rural England5—may have to close because of the resultant drop in funding. Other practices have stopped paying partners an income in order to balance the books.6

Other primary care income comes from providing “locally enhanced services”—for minor surgery or chronic disease management, for example—but many local authorities and clinical commissioning groups are putting these services out to tender, meaning vast amounts of paperwork to complete and lost income if Boots or Bupa win the contracts.7

The endgame is surely not just to rock the GP boat—but to tip it over. Being a partner will be too risky for those with mortgages, dependants, student debts, or indeed staff to pay and a building to maintain. Waiting in the wings are the private companies—or conglomerates of general practices—with bank balances capable of surviving transitions, and who are prepared to be more rigid with what they offer and who supplies it.

This will not translate into better value for patients: part of the current deal is that the clinical, housekeeping, and staff buck stops with the partners. A salaried doctor will have better ability to negotiate a limit on patients seen—and the time he or she leaves the building.

If I trusted our political masters I’d want to be in a salaried service which could be made free of financial incentives for clinical care. But I don’t trust our politicians, who scarcely understand our work and yet seek to manage the minutiae of our day. Our NHS is fragmenting and dissolving under our watch: what are we going to do about it?


Cite this as: BMJ 2014;348:g4061


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I’m an NHS GP partner, with income partly dependent on QOF points. I’m a part time undergraduate tutor at the University of Glasgow. I’ve authored a book and earned from broadcast and written freelance journalism. I’m unpaid patron of Healthwatch. I make a monthly donation to Keep Our NHS Public. I’m a member of MedAct. I’m occasionally paid for time, travel, and accommodation to give talks or have locum fees paid to allow me to give talks but never for any drug or public relations company. I was elected to the national council of the Royal College of General Practitioners in 2013.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • Follow Margaret McCartney on Twitter, @mgtmccartney


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