Just as there is gold for drug companies in them thar pills, so there is gold for GPs in them thar patients. Historically, GPs were paid chiefly on a patient head-count basis, topped up with item of service fees for ‘extras’ such as vaccinations and contraception. The simplest way for GPs to boost income under this system was to increase list size, sometimes to absurd levels where the GP could not hope to provide adequate care for all the patients on the list. Some even gamed the system, by sneaking ghost patients on their lists. Governments disliked crude head-count based pay, not least because it offered no scope to influence GP activity. Item of service payments were an attempt to change that, but the capitation fee was still paid whatever the doctor did, or didn’t, do. The below par golfing GP trousered the fee in equal measure to his more conscientious colleague on the other side of town.
It is part of NHS folklore that Bevan got doctors to accept the NHS by stuffing their mouths with gold. But, as is often the way with folklore, it isn’t entirely accurate. It wasn’t all doctors who had their cake holes crammed, just hospital doctors, who in return agreed to become salaried NHS employees. GPs instead got something they then valued even more than money: autonomy, the so-called independent contractor status. They could continue their cherished corner-shop chemist arrangements, contracting with the NHS to provide a service. How they provided the service was largely up to them: good GPs provided a good service, while golfing GPs matched their practice to their handicap.
Then, eight years ago, something rather curious happened. General practice was, as it often is, in a mess. The government, as it always is, was fed up with not being able to influence GP activity. Out of this Devil’s Cauldron a toxic brew came forth. The GP negotiators of the day, unable or unwilling to see how short was their spoon, supped the brew, an intoxicating brew of more money for less work. Mouths stuffed with the sweetest gold, they failed to spot the implications of the bitter medicine within. The 2004 contract contained, in addition to capitation and item of service fees, a new element of performance related pay. Hundreds of markers would measure performance, with increasing pay for better performance. The government had out-smarted the GPs: gold, but in return hundreds of levers of control. GPs might imagine themselves still independent contractors, but in reality they had signed up to micro-management. They had supped with too short a spoon, and swallowed gold, only to find the devil really was in the detail. They had, in all but name, lost their cherished independent contractor status.
Over the last few years, the consequences of this forfeiture of independence in return for gold have become plain to see. Where we had independent GPs looking after individual patients, we now have state operatives pushing state sponsored coercive healthism on populations. The master pulls a lever, and the puppet dances. The gold is indeed the detail, but so too is the devil.
But Dr No dares to hope that all is not lost. The recent outbreaks of caring and sharing mania in some GP quarters are, it seems to Dr No, a heartfelt backlash against being turned into state sponsored inquisitors and statinators. And where there is such a backlash, there is hope.
A wonderful insightful post Dr No – I am enamoured!
Any GP appointment will lead to the QOF question – do you still smoke/drink/eat(unhealthily)/do drugs/eat babies :o]?
Heavens above doc – I have a wart on the end of my nose and you are insinuating it is because I smoke/drink/etc.? Most patients are unaware of QOF and the ‘questions’ certainly get their dander up! Could this be the reason for the (minute) rise in complaints?
From my (rare) visits to GPs I leave exasperated and angry – and I am aware of QOF! This must be intensified in patients who are not.
Long live the backlash and the hope that caring and sharing is rising above ‘the questions’ and patients can leave the consult without feeling they are the agents of their own destruction.
Anna :o]
I visit a prescribing practice nurse rather than the GP; she’s more realistic, listens to me, and we have more than the allotted 8 mins together! I’ve already stated firmly I have no intention of taking statins – and my alcohol consumption is pretty normal. As for smoking, I’ll have to stop when I stop working – but until then, it’ll help the pitiful annuity!
No, No I’m afraid I do not share your optimism, although I would dearly love to. The politician’s know better and will continue to exercise their control and Doctor’s will let them. It’s in their pecuniary interest to do so. They are, after all Pharma’s ‘little helpers’.
Sadly I cannot discern much clamour from the Medical Profession to make any serious change. The recent ‘whitewash’ on Mammography screening goes to prove this. The only clamour I can hear is that of horses hooves as a few called Quixote, charge toward the immovable Windmill of vested interest.
It was not just the GPs who had their mouths stuffed with Gold by the New Labour control freaks. We Consultants moved from a professional contract to one that was all about job plans and targets.
The money was good, but is already heavily eroded by inflation. In another few years we will be back on the same pay, yet will be at the beck and call of the targets. When the master says jump, we will ask “how high?”
I do not share your optomism, and sit with Blackdog. Those that remember better times when doctors had autonomy and control are trudging dispiritedly toward retirement, prodded by the inquisitors of revalidation. Our Junior colleagues know no better, and think this is how it ever was.
I know beer, fags and fish and chips are bad for me, and on my appraisal day shall have all three as a sign of my contempt for those that want to control us.
Dr No is anything but optimistic: he just dared to hope that all is not lost. That last paragraph is two things: a counter to any claim that he is overly negative, and a call to arms to those who do care – and perhaps should share as much as they care, to use the modern idiom.
DN knows the consultants had their cake holes reloaded, and with it further loss of autonomy. But their real cake hole moment was in the 40s; for GPs it is much more recent.
Two lengthy, wordy, and related papers, McKenna on the narrow view of doctors http://libjournal.uncg.edu/ojs/index.php/ijcp/article/viewFile/217/269
And Greenhalgh on the dehumanising power of templates http://bmjopen.bmj.com/content/2/6/e001754.full