On borrowed time – The demise of General Practice Dr Bob Gill GP Welling, Kent February 2015

National Health Service privatisation plan has utilised many reliable techniques including concealment, divide and rule, and playing the long game. The Thatcher plan produced by the Adams Smith Institute in 1988 has been enacted by consecutive governments with only a few being aware. Failure by mainstream media and representative bodies to inform and educate the public and professionals has been an essential ingredient. How else could you disguise the gross betrayal of the public interest being conducted without raising significant public resistance? You can not oppose something that you didn’t know was going on.

Salaried GPs
Since taking over a small family practice on the London and Kent border, I have endured multiple reforms imposed on general practice, cleverly crafted and spun using marketing language of ‘patient choice’ the privatiser’s favourite ‘reform’. In 2004 with New Labour’s GP contract witnessed the break up the general practitioner monopoly on providing out of hour care and also established a two tier system of GP employment. GPs classed as ‘independent contractors’ are an integral part of the NHS family, trained in the NHS, paid by the NHS and part of the ethos of public service and established at the outset of the NHS. This arrangement would remain, for now, but an additional salaried GP status was created. Sold as allowing doctors to practice without the headache of running a practice, it was in fact one of many Trojan horses for the corporate private sector. No longer would it be necessary to be an NHS doctor to run a GP practice. New funding arrangement also removed the ‘principal allowance’ which was paid dependent on how time GPs personally offered for direct contact with patients. Private companies could now employ salaried doctors to run practices and skim off profit for their trouble. Exploited by ‘entrepreneurial’ doctors too, employing others to whom clinical work was delegated whilst pocketing a proportion the income for themselves. It is not difficult to imagine that some GPs with large practices were able to employ several salaried doctors accruing large incomes without seeing patients, generating headlines of ‘fat cat’ GPs, a useful by-product in demonising the profession. Private companies have moved in such as Virgin with acquisition of 75% stake in Assura Medical in 2010 serving a population of over 3 million patients (1). These changes dealt a blow to the continuity of care for patients; allowed some GPs to earn income from general practice without seeing patients through subcontracting to salaried doctors; hived off out of hours care providing entry points for profiteers.

Out of Hours responsibility
The 2004 new GP contract allowed general practitioners experiencing low morale, recruitment and workload difficulties, to give up responsibility for organising out of out of hours care for £6000 (2). It would be down to Primary Care Trust to secure provision, expected to be from GP co-operatives with a long track record of high quality care. The vast majority of GPs voted for the new contract. GP co-operatives were, however, side-lined in favour of corporate for-profit operators choosing to employ fewer doctors and instead less qualified staff and able to undercut established GP co-operatives who now had to tender in the commercialised system. Now there is a plethora of providers delivering care of varying quality (3). We saw the significant failure of Serco in Cornwall who were providing one doctor to provide service for over 250,000 patients. When this was discovered they falsified the data rather than admit their actions (4). Private sector providers are not subject to the same degree of regulatory accountability and safeguards that public bodies have to. Maximising shareholder return is their primary duty.

Performance related pay
Primary care funding was significantly improved with the boost in practice income with the introduction of performance related pay through Quality and Outcomes Framework (QOF) in 2004. High achievement on reaching multiple clinical targets for long-term conditions could add up to more than 20% in practice income. For example controlling 90% of hypertensive patients’ blood pressure would score QOF points. Some commentators believe the Government underestimated how well GPs would do with QOF. Subsequent years saw an improvement in GP morale and recruitment improved up by 4,000 in 5 years as a result of success with QOF (5) and removal of 24 hours responsibility. There have been changes to QOF which have reduced the value of the scheme and made points harder to attain. The proportion of total NHS spending, however, on primary care has steadily fallen despite more work being done in surgeries as a result of government imposition and cuts to hospital services (6).
Something else had changed. GPs were being incentivised to perform tasks there was little scientific support for and encouraged to over-prescribe and investigate (7). With this came an erosion of professionalism, acceptance of managerialism and the target-driven culture. More time and energy diverted chasing target related income and away from what the patient wanted. Consultations contaminated with data collection. Diligently we have trawled for and recorded data little suspecting this would be handed over to Health Insurance and Pharmaceutical industries several years down the line through the Care.data scheme (8).
A compliant GP workforce was now unwittingly softened up to undertake the next key step of privatisation which was commissioning. The phoney buying and selling of services between different parts of the NHS with its obligatory bloated bureaucratic infrastructure which had been established for years under New Labour ready for the logical transition to an external market open to all comers. Commissioning in simple terms is the fragmentation of established integrated services ready to be parcelled up and sold off to the lowest bidder. Often it was the very same entrepreneurial GPs who flourished under GP contract changes, having off loaded their patient care to others, ready to take up the challenge and income from the dismantling of acute hospital services. Not equipped with the necessary skills to actually perform the task themselves or scrutinise proposals, they were only too happy to read the scripts written for them by the army of expensive management consultants and accountants. This arrangement offered the cloak of clinical endorsement increasing the power of the deception on GP colleagues. The plans inevitably ensured long term future engagement of the authors’ own services. Blatant conflicts of interest were no barrier for these costly and unnecessary intermediaries to swallow up hundreds of millions of pounds previously destined for patient care (9).

Regulatory stick
Now political attention turns to the destruction of traditional primary care. General Practice is being dismantled through a combination of excessive regulation, funding squeeze, poor morale, recruitment crisis and propaganda. GPs have to undergo appraisal every year presenting their evidence of professional development which contributes to whether they are revalidated by the General Medical Council every 5 years. The process has created significant stress for doctors and proven to be arduous (10). A new CQC inspection regime will increase administrative burden on overstretched practices. Requirements will be ratcheted up to destabilize smaller practices (11). The mood music from NHS policy makers is to have practices merge or ‘federate’ leading to consolidation onto fewer sights. None of this is backed up by evidence or necessity. The ground is being prepared for corporate takeover. Clinical Commissioning Groups (CCGs) having helped destabilise hospitals and supported closures and no longer needing GP compliance will be given the power to ‘performance manage’ the mass closure of local surgeries deemed unsuitable for one arbitrary reason or another. Out of hours care having been dumbed down from a doctor provided service to the computer algorithm based NHS 111 predictably, pressure in casualty departments has increased (12). The problems have been spun and blame directed at access to GP appointments conveniently forgetting the impact of government policy on hospital closures and bed reductions. Seven day working for GPs is being pushed as the remedy but the diagnosis is wrong if the intention is cure. The impact on workforce morale and recruitment will most certainly be harmful. Being a GP becomes even less attractive for young doctors, senior GPs look for a way out. Bring on the ‘doctor’s assistant’ (13) and more momentum behind surgery closures. The soul destroying bureaucratic burden, fragmented and increasingly difficult to access services will ensure numbers of doctors in primary care will continue to decline as intended.

The chickens are coming home to roost as the unsuspecting majority of general practitioners struggle to cope with the day to day job finding it difficult to contemplate quite what happening around them. There seems little desire by our medical bodies to shed light on the devastation facing primary care. True to form they follow and react rather than lead and prepare. Meanwhile those still left at the coalface are, for now, resigned to struggle on providing care the best they can for as long as they can cope. We are slowly but inexorably drifting closer to the demise of traditional general practice which provided convenient high quality care and effective gatekeeper role to specialist care. This major strength of the NHS was both cost-effective and professionally satisfying. It is being replaced by an American style system which excludes many, is vastly more expensive and wasteful whilst returning worse outcomes for patients (14). It does not provide continuity of care, strong preventive medicine and trust between patients and health professionals is low. US medicine is a commercial transaction focussed around profit maximisation not patient care.

The UK family doctor, familiar, trusted and local, with knowledge of you and your loved ones will be a thing of the past. We have been subjected to perpetual change, increased workload, regulatory and bureaucratic overload and set up as scapegoats for the NHS failings crafted by government. We are surplus to requirement in the dumbed-down and commercialised future NHS. Those GPs that remain will service patients like workers on an unsafe production line and provide medico-legal cover for cheaper less qualified staff. And who better to deliver this vision but Simon Stevens, head of NHS England and former UnitedHealth executive. His ten years of experience at the largest health insurance corporation in the world and his stated intention to replace the outmoded ‘corner shop’ model of primary care should leave the attentive in no doubt of our final destination (15).

1. Financial Times – Virgin buys into Assura Medical NHS clinics
http://www.ft.com/cms/s/0/f4f87ba6-26c5-11df-bd0c-00144feabdc0.html#axzz3RwcLnlmF
2. The True History of GP out of Hours Services
https://abetternhs.wordpress.com/2013/05/10/true-history/
3. The Guardian February 2014 – NHS watchdog says Virgin Care-run clinic put patients at risk
http://www.theguardian.com/society/2014/feb/04/nhs-watchdog-virgin-care-croydon-hospital
4. Daily Telegraph – ‘Disgraceful’ Serco falsified GP out-of-hours figures
http://www.telegraph.co.uk/news/health/news/9913780/Disgraceful-Serco-falsified-GP-out-of-hours-figures.html
5. National Audit Office – NHS Pay Modernisation: New contracts for general practice services in England
http://www.nao.org.uk/report/nhs-pay-modernisation-new-contracts-for-general-practice-services-in-england/
6. Royal College of General Practitioners November 2013 – Patient care compromised as funding for general practice slumps across the UK
http://www.rcgp.org.uk/news/2013/november/patient-care-compromised-as-funding-for-general-practice-slumps-across-the-uk.aspx
7. British Medical Journal July 2013 – Chronic kidney disease controversy: how expanding definitions are unnecessarily labelling many people as diseased
http://www.bmj.com/content/347/bmj.f4298
8. The Guardian January 2014 – NHS patient data to be made available for sale to drug and insurance firms
http://www.theguardian.com/society/2014/jan/19/nhs-patient-data-available-companies-buy
9. Daily Telegraph February 2015 – NHS spending on management consultants doubles under Coalition
http://www.telegraph.co.uk/news/politics/11282888/NHS-spending-on-management-consultants-doubles-under-Coalition.html
10. Pulse March 2015 – Revalidation is bigger burden than expected, finds official report
http://www.pulsetoday.co.uk/your-practice/practice-topics/revalidation/revalidation-is-bigger-burden-than-expected-finds-official-report/20006117.article#.VOU_XvmsWSp
11. Pulse September 2014 – 200 GP practices face closure under CQC inspections
http://www.pulsetoday.co.uk/your-practice/practice-topics/regulation/200-gp-practices-face-closure-under-cqc-inspections/20008036.article#.VOTJ7vmsWSo
12. Pulse February 2015 – Rise in A&E attendances caused by NHS 111, emergency medicine leader claims
http://www.pulsetoday.co.uk/commissioning/commissioning-topics/urgent-care/rise-in-ae-attendances-caused-by-nhs-111-emergency-medicine-leader-claims/20008914.article#.VOJ-HfmsWSo
13. BBC News Health August 2014 – NHS plans rapid expansion of ‘doctor’s assistant’ jobs
http://www.bbc.co.uk/news/health-28896625
14. The Commonwealthfund June 2014 – Mirror Mirror on the Wall