GP partnership model is “no longer fit for purpose,” says Lords inquiry

BMJ 2017; 357 doi: (Published 05 April 2017) Cite this as: BMJ 2017;357:j1713

Re: GP partnership model is “no longer fit for purpose,” : Where is the evidence?

Having read the House of Lords Select Committee Report on the Long term Sustainability of the NHS, including all the related documents that describe the supporting evidence, and transcripts of oral evidence from expert witnesses, I was dismayed at the single summary recommendation that relates to primary care: “The traditional small business model of general practice is no longer fit for purpose and is inhibiting change.”

Apart from the fact that two witnesses used the impressive sounding ‘no longer fit for purpose’ description in a statement of opinion, as if it was factual, there was no evidence submitted throughout the entire process to substantiate the first half of this claim. That is not to say that the independent contractor (IC) model is perfect. However, there is overwhelming evidence that the IC model is extremely cost effective. It is likely that the government has not strived to take over the service because it cannot afford to directly manage the service and fears any attempt would cause a marked reduction in productivity. If central governments in the UK had been serious about moving to an employed/salaried model, they would have organised capital funding programmes to buy out the existing premises or invested more in brand new build premises owned by the state. The government would be hypocritical to take such a recommendation seriously.

The only ‘evidence’ to support the second half of the claim, which is perhaps even more damning, came in the questions posed to the witnesses. These questions revealed panellists’ alarming ignorance and prejudice against GPs. Indeed, the witnesses should be commended for bearing the questions, and some of the inappropriate comments made by panellists, with remarkable grace. What came across clearly from most of the witnesses was the frustration of senior health service stakeholders at the short term planning from the government and Clinical Commissioning Groups; the disconnect in health service planning across a grossly fragmented semi privatised health service; the disinvestment in general practice, social care of the elderly and the district nursing and other community nursing forces; and the historical obsession with secondary care based targets that ensures hospitals continue to hire more and more consultants as the service attempts and fails to meet rising demand, etc. Much of the chaos has arisen from, or been exacerbated by, the Health and Social Care Act 2012, a far reaching piece of legislation which was itself passed by the House of Lords....

Having studied routinely collected data for several years now in an attempt to explain the cause of the NHS’ problems and, therefore, how to solve them, I conclude that faulty health service planning from the centre is responsible. The policies mentioned above have conspired to leave us with an oversubscribed hospital service that is expensive, of variable quality and unsympathetic to the needs of patients. The danger is so obvious that one wonders if the plan from the start was to ensure that the sustainability of the NHS was doomed and the ground laid for complete privatisation.

The solution is an emergency rescue involving substantial additional funding directed to the GMS funding stream, safeguarded by curbs on profiteering, or even capping, of personal GP income. GP leaders who called for more GPs in their testimony were absolutely right to do so. The money would be most efficiently used if dispensed by GPs, including to employ staff within functional multidisciplinary teams they lead, rather than by CCGs, or other intermediaries.

The secondary role of the BMA, which was barely touched upon in the Report’s section on primary care, in the problems facing general practice, is more subtle than the obvious crime committed by government in deliberately starving general practice, the key gatekeeper of the entire NHS. Faced with gradual and sustained real term declines in funding in the face of rising workloads, the BMA has become more protectionist towards the interests of its members, resisting progressive attempts to increase the gradient of the funding formula against social deprivation despite overwhelming evidence of the need to do so, and keeping a lid on increasing personal income gaps. Neglected issues include financial accountability, the absence of high quality income data per GP, the risk of excessive profiteering by a small minority of GPs, and the exploitation of new recruits in the present IC model. All of these issues require attention but do not negate the overall highly efficient nature of general practice for the small expenditure (ranging from just 7-9% of total NHS expenditure, depending on the UK country). These problems have undoubtedly become worse as a result of the disinvestment and should be studied and addressed in an open and evidence-based fashion, rather than used, on ideological grounds, as a stick with which to berate GPs, most of whom are working hard to keep the NHS functioning.

The last statement within the recommendation: “The review should assess the merits of engaging more GPs through direct employment which would reflect arrangements elsewhere in the NHS” also merits some attention. There has been a steep rise in salaried GPs in England culminating in per capita rates of provision that are substantially higher (13.3 per 100,000 in 2016) than those seen in Scotland (8.4 per 100,000 in 2015 workforce survey). Scotland, in contrast, has substantially higher per capita rates of GP partner (58.4 WTE per 100,000 in 2015 workforce survey) compared to England (38.6 per 100,000 in 2016). The evidence suggests that Scotland’s devolved NHS is doing considerably better than in England in terms of achieving secondary care performance targets, which is a marker for the ability of GPs to absorb workload in the community. It is possible that the increasing reliance on salaried GPs, in England more than in Scotland, is part of the problem rather than part of the solution.

Demoralisation and disengagement of clinical staff ‘elsewhere in the NHS’ is a big problem that was discussed by the Select Committee. Are we sure we want to move the rest of the medical workforce to that arrangement of direct employment? It is legitimate to ask if hospital and community NHS managers have earned the right to manage GPs, without whom the NHS would not have survived to 2017.

Never mind its long term sustainability, the NHS is at serious risk right now, and in the short term, from ill informed and misguided health service planning from the top.

Competing interests: No competing interests

21 April 2017
Helene J Irvine
Consultant in Public Health Medicine
Directorate of Public Health and Health Improvement Directorate, NHS Greater Glasgow and Clyde
West House, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow, G12 0XH