We’re publishing an original essay by Jon Garvey, a doctor who retired from General Practice in 2008 for the reasons he sets out here. He thinks the bureaucratisation of General Practitioners spearheaded by New Labour account in large part for the current failures of the health service.
The 2004 GP contract is a handy hook on which to hang the decline of British General Practice into the calamitous state in which we would now find it, if we could ever get an appointment. The usual accusation is that it made GPs overpaid and underworked and enabled them to spend all day on the golf course, but we should know by now that scapegoats are products of propaganda.
I was senior partner of a large General Practice at the time of the contract, and since it led directly to my taking early retirement four years later, certain aspects stick in my memory. One is that it was Gordon Brown (then Chancellor of the Exchequer and in overall charge of the negotiations) whose erroneous belief that GPs already did spend all day on the golf course led to some of its worst outcomes.
In truth, the rot had set in long before, following the same trajectory that some U.S. front-line Covid doctors have identified over there. A profession of inquisitive minds, gaining expertise from seeing patients and from peer-to-peer discussion, gradually shifted towards a top-down model of centrally planned protocols and ‘best practice’, executed by technical operatives and, increasingly, controlled by Big Pharma and government PR.
I came into General Practice at its possible zenith, when it had ceased to be a bolt-hole for people falling off the hospital consultant ladder, and had become a skilled speciality in its own right. It had inherited the early-NHS model of independent practices contracted to the NHS, which once wedded to high professional standards served to put the doctor-patient relationship centre-stage, rather than the relationship between doctors and their managers.
Moreover, recruits came from hospital jobs with insane hours, in my case 112 hours a week on call for my pre-registration house jobs, and then around 85 hours as a Senior House Officer on a General Practice rotation. That made the 65 hours required in my practice to cover 14,000 patients 24/7 seem a perk. Missing one’s family growing up was par for the course, and the pay was pretty reasonable.
Over the years, though, workload increased both through the devolution of increasingly complex chronic disease management from hospital clinics to GPs to save money, and from each new government deciding, without evidence, that obligatory ‘patient checks’ would prevent disease rather than merely wasting valuable appointments. This led to the increasing use of cheaper nurses and other non-medical staff for ‘routine’ work, necessitating rigid protocol-driven care, a trend one of my colleagues dubbed “getting a nurse out of the drawer”.
Now, intelligent nurses, pharmacists or even receptionists can acquire professional ‘nous’ by hands-on experience, at which point they become in effect underpaid doctors. But they lack the authority to step outside the protocols, and so their wisdom usually turns to frustration.
Latterly, Tony Blair had set up the algorithm-driven NHS Direct to virtue-signal that the NHS was open-all-hours. This undid years of training patients in demand-management at a stroke: workload increased both for GPs and A&E departments as non-medical staff referred trivial problems on as emergencies. It is no fun being phoned at 3am because NHS Direct told your patient that her genital finger wart might be cancer and so was urgent.
At the same time, every pay-review body recommendation, apart from whenever a new Conservative Government wanted to reward doctors for voting them in, was decreased for ‘affordability’. The combination of more work for less pay, in real terms, made General Practice a decreasingly popular career choice.
Nevertheless, the majority of decent practices were doing all the extra clinics, if only to get the item-of-service payments to keep their income up. But in 2003 Gordon Brown refused to believe GPs weren’t all playing golf, much as he believed that any member of the public questioning immigration policy was a bigot. The proposed contract would dramatically increase such payments, but Brown simply wouldn’t credit that most GPs were already doing the work, even though the doctors’ negotiators themselves warned him that because of this error the remuneration package would become unaffordable. Perhaps he saw himself as the heir of Aneurin Bevan, “stuffing their mouths with gold”.
The immediate result for me was the best pay rise I ever had, for a while fooling me that at last our hard work was properly valued. That didn’t last long, because Brown, irate that he’d been wrong, started a press vilification campaign to claim that GPs should have spent their pay rise on patient services, although he didn’t say what. Because press propaganda was almost as effective then as now, patients easily forgot half a century of sometimes sacrificial care from my surgery, and started passing snide remarks about golf courses. At some stage I came to the conclusion that it wasn’t worth the hassle for another decade.
Here another anomaly of the contract kicked in. Our negotiators managed to get a reasonable pension deal, given how pension funds overall had been shafted over the years. But it wasn’t as good as the existing arrangement, and that meant that if older GPs were still working when the new scheme kicked in, they’d be paying more for a smaller pension for the rest of their careers. Retirement was a no-brainer.
The new contract offered an opt-out from unsocial hours in return for a reduction in pay. But because of the unrealistic level of this reduction, probably to disguise years of under-remuneration for the work, I calculated that I would actually earn £1K less from co-operative payments if I continued working unsocial hours than if I opted-out. What would you have chosen?
It has been said that the Labour Government’s unstated aim in this contract was to destroy the awkward independence of GPs, and I can well believe it. Even before this, the NHS had tried to get us to display its corporate logo on the building we paid for to do work which in our case was founded on the Christian values of a retiring medical missionary, not on government policies, years before the NHS was invented. We refused to display the logo.
Because most GPs opted out of unsocial hours work, most co-operatives folded for lack of doctors, and these services became the domain of private companies employing salaried staff.
The gradual feminization of General Practice had for some time been raising the proportion of part-time salaried doctors. Many women saw General Practice as a family-friendly part-time career, without the financial risk of premises ownership or unsocial hours. The new contract made this an increasingly attractive lifestyle for men too, and it became harder to find traditional GP partners to replace those retiring.
So what do you do when you are the last property-owning partner standing? You may have to dissolve the practice, sending several thousand patients to join the lists of other oversubscribed GPs. Alternatively, an NHS trust takes over, and the state is then fully in control; or you sell out to a company employing salaried staff for the bottom line alone, adding corporate policy (perhaps financially linked to Big Pharma policy) to State-prescribed ‘best practice’.
Increased patient load on the remaining practices led to increasing shortages of appointments on the patient side, and professional burn-out on the other, so that more doctors retired or moved to part-time work, thus accelerating the spiral of decline. Over time this resulted in a different kind of doctor, both by inclination and by training. What was now required was someone ready to implement protocols and policies during contracted hours for a senior administrator, a corporation and the NHS, and to manage a range of non-medical staff. What was not needed was an independent thinker prepared to use his or her initiative when faced with unfamiliar clinical situations (which, to be honest, is what every sick patient is).
The increasing problems with such a system encouraged increasingly complex bureaucratic solutions, and simultaneously institutionalised obedience to the god NHS amidst the remains of what had once been autonomous professional partnerships. In 2019 the latest fix was the ‘Primary Care Network’, by which groups of practices would share increasingly scarce resources, and this was what made the Covid vaccine rollout – a mere logistical exercise – so efficient. But like any such reorganisation, PCNs depend on tight top-down control in practice, which means extra layers of bureaucracy and inflexibility.
Perhaps it is no surprise that between June 2020 and April 2021 the number of GPs considering early retirement rose from 14% to 32%. Since 2016, when the government promised 6,000 new GPs, the number has actually dropped by 1,800 – a full 10% of the number of GP partners.
The response to this crisis has been more centralized bureaucracy: from July 2022 the NHS intends to combine all health services across areas in Integrated Care Systems, and you can bet the GP representative on the boards of these will be more like Anthony Fauci than Jay Bhattacharya.
Nothing in such a system encourages questioning the norm. Add Covid totalitarianism, and you have the perfect environment for Faucian group-think. Doctors jump to whatever tune the Secretary of State for Health decrees under his chronic emergency powers, or find themselves unemployed or, worse, hauled up before the GMC for heresy.
The NHS, now an entirely top-down institution with the apparent co-operation of a British Medical Association in lockstep with it, rose to the challenge of Covid by working on the ‘temporary’ repeal of the service frameworks by which GPs were required to care for patients with diabetes and the other major chronic conditions that have now been thrown under the bus by Public Health policy. This is in order that GPs, trained for so many years to identify and manage whatever patients come in off the street, can devote their full attention to injecting every man, woman and child with endless boosters of the mRNA modifiers we all know and love. I would like to ask my own GP, professional to professional, how this is working out for him, but routine medication reviews no longer exist, so I can’t, and he didn’t respond to my e-mail.
There is no sign of anything like a return to traditional General Practice. Rather, the future seems to hold even more of the same. Massive bureaucracies lend themselves to control by large corporations, and it appears that the Health and Social Care Bill currently going rather unnoticed through parliament will facilitate this, morphing the NHS into a system more like that in America. As Dr Bob Gill explains:
The model is endemically fraudulent, has massive overheads in terms of cost of administration, extracting shareholder value and paying CEOs. The public will end up paying twice, either through taxation or individually through top-up insurance.
The idea (going back to Hippocrates, I suppose) of an enterprising doctor buying a stake in their local community and tailoring their practice of medicine to it will be completely gone: the doctor will be paid a salary by a distant corporation, no doubt finally owned by Black Rock or the Gates Foundation, and the patients will simply be the source of revenue for that entity, while it remains profitable.
The best hope for us all is that a new breed of enterprising doctors will manage to get trained, somehow, in the old way (only perhaps freed from the expensive Rockefeller model of molecular medicine and patent drugs), and will band together to bypass the state system altogether and offer basic scientific medicine to an inflation-impoverished public at a reasonable cost.
I am not optimistic.
Jon Garvey retired from General Practice in 2008, and has since concentrated on writing, being the author of two published books on science and faith, one samizdat book on our propaganda society, and (since 2011) the blog The Hump of the Camel.