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Margaret McCartney: Dementiagate—how politicised pay diverts GPs from working for patients

BMJ 2014; 349 doi: (Published 24 October 2014) Cite this as: BMJ 2014;349:g6446
  1. Margaret McCartney, general practitioner, Glasgow
  1. margaret{at}

I’m wondering if this is Dementiagate—a defining moment when the UK public discovers the ugly truth about how most GPs are paid. The news from NHS England, that GPs were to receive £55 (€70; $90) for each new diagnosis of dementia, has been met with widespread condemnation and disgust.1

NHS England wants GPs to identify potential dementia patients through screening in those supposedly at risk, including people over 60 who smoke, drink too much, or are obese.2 But this is hugely problematic because such screening has not been shown to be accurate, effective, or useful.3

Who do doctors work for? For patients? How many things do we do because we are paid to, rather than because they benefit patients? Incentivised health checks have taken doctors’ time away from sick people and redistributed it to healthy attendees. We spend hours filling in anticipatory care plans, even though evidence is scant that they will improve patients’ quality of life.4 And waiting times get longer as we are diverted by time consuming, bureaucratic nonsense.

The general practice contract has become an unfunny joke. We are mostly small businesses, contracted wholly to the NHS. We are not simply paid a wage and expected to get on with our work. Rather, we are paid separate sums for each service rendered—flu vaccines, cervical screening, referral management, fitting contraceptives, and so on.

We pay for staff, running costs, premises, ourselves; and we have to chase contract payments. For example, we are currently being denied payment for palliative care meetings last year: the contract said “three monthly”; we had meetings every three months; the health board now says that it meant every 12 weeks.

Financial instability poses the risk of running primary care into an era of unbridled, market oriented medicine, in which multinationals get short term primary care contracts, consumers must become “buyer beware,” doctors and patients lose long term relationships, and our most vulnerable citizens miss out.

Worse still, we risk losing our patients’ trust, and being mistrusted is a miserable way to practise medicine. I’m not alone in being frustrated and demoralised by political micromanagement and the misery of the tick box contract. The natural position of patients and doctors is on the same side. But politicians have pushed their own self interest between us—targets, to meet meaningless election pledges.

Doctors cannot change this on our own: we need patients to advocate change for us. Let’s hope Dementiagate is the catalyst.


Cite this as: BMJ 2014;349:g6446


  • Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: I’m an NHS GP partner, with income partly dependent on Quality and Outcomes Framework points. I’m a part time undergraduate tutor at the University of Glasgow. I’ve written a book and earned from broadcast and written freelance journalism. I’m an 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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