The Founding of NHS General Practice
General Practitioners have been self-employed providers of care to the British public since the early 19th century, being recognised and remunerated by the British Government after the introduction of the 1911 National Insurance Act. With no organisation in place to readily employ doctors who set themselves up as community generalists, the self-employed route was a pragmatic solution. Inception of the National Health Service in 1948 introduced the registered patient list and the consequent need for primary and personal medical care services and General Practitioners became the gateway to specialised hospital based care. The rise of the partnership business model of General Practice grew subsequent to this as independent practitioners found it increasingly difficult to work alone and found effectiveness, resilience and efficiency working in small groups.
The Current Crisis in the NHS
The 21st century has since brought new challenges to the NHS. An aging population and advancements in medical technology has meant that the NHS has more to offer a discerning British Public who are educated about their health needs and wants. The NHS is now struggling to meet the demands placed upon it as the public purse becomes bare and resources available to the NHS diminish. By 2020, the NHS is expected to suffer a £20 billion funding shortfall. General Practice is far from immune to these demands. In 2015, GPs provided 90% of the consultations provided in the NHS with only 9% of the total NHS funding, down from 11% in 2005. Along with an 11% rise in the number of consultations undertaken in General Practice between 2010 and 2014 GPs have had to become imaginative in meeting the rising demand despite a reduction in resources.
Increased Hours
Whilst the independent contractor model has been a flexible stalwart of primary care, its flexibility has recently been heavily criticised as the reason for its current demise. General Practitioners have become the sponge of the NHS, absorbing patient demand beyond the limits of capacity. Some speculate that UK General Practice is no longer a safe place for clinicians to practice or patients to be treated. Due to the increased demands on the NHS, GPs regularly extend their working hours beyond what would be recognised by the European Working Time Directive as safe, often with no regular breaks. GPs are monitored by a number of authorities including the General Medical Council, Care Quality Commission and NHS England’s Maintaining High Professional Standards Committee to ensure that patients are cared for appropriately which includes ensuring that patient’s reasonable needs are met. In reality, for independent contractor GPs this means staying at work until the job is done, irrespective of one’s own needs, health and family. In a time of plenty, the ideal solution would be to employ more front line clinicians to cope with the increase in patient demands. Unfortunately, this is not the world in which the NHS currently operates.
Lack of Resources
The self-employed NHS General Practitioner is beholding to their political master. The General Medical Services, Personal Medical Services and Alternative Provider of Medical Services contracts all have clauses limiting private practice of clinicians and strictly prohibiting the sale of medical services or devices to their registered list of patients. As demand within the NHS rises, so does the need for resources to meet the demand. Without an increase in funding from a commissioner of NHS healthcare, there are limited ways in which the independent GP contractor in the NHS can increase revenue to fund resources to provide healthcare. It appears that without new investment in primary care from commissioners of NHS healthcare, GPs are struggling to afford to invest in new or existing staff leaving the “flexible” independent contractor to pick up the strain of their business.
Further to this, self-employed GPs are not paid a wage for working in the NHS but make drawdowns of profit from their business. Consequently, it is essential for a NHS GP that their business is in profit otherwise they will not be paid for their work. Whilst we know that GPs tend to have altruistic personalities, we cannot expect GPs to work for free and in a market economy where the transferrable skills of a GP are highly sought after in other industries outside of the NHS, the NHS needs to remain competitive in its financial remuneration of GPs as one way of ensuring that they stay within the workforce. Not only are GPs struggling to invest in new or existing staff, but our current GP workforce is being tempted away from the NHS by the offers of greener grass in other industries, compounding the current supply and demand problems in the NHS.
Recruitment and Retention Problems
The increased hours worked by the average GP, lack of investment by NHS commissioners in primary care and the increased costs of being a self-employed GP has led to the increase in emigration from UK General Practice, early retirement of seasoned colleagues and the reduction in junior doctors applying to take up specialist training in General Practice. It is estimated that 48% of foundation training doctors choose to leave the NHS rather than move into specialist training. With a reduction in the UK GP workforce and a limited number of junior colleagues rising to take on the challenges of the future of primary care, General Practitioners have once again to consider what the future of primary care needs to look like to ensure its sustainability. A recent workforce study estimates 30% of GPs are likely to retire over the next 5 years. Consequently, workforce design must take into consideration the needs and wants of our junior colleagues to ensure that we attract applications from junior doctors to replace our retiring workforce.
Austerity Driven Evolution or Revolution
One of the driving forces behind the current NHS development outlined in the Five Year Forward View is financial sustainability. We know that hospitals are expensive to run and drive demand within a service where care is provided on a cost per case basis. The current market of hospital delivered healthcare is perverse in its nature, incentivising activity through payment. And so in recognising this, care is being pushed into the community in a move to drive down the cost of providing healthcare and deliver sustainability for the NHS.
However, GPs too are an expensive resource, and there are an increasing number of cheaper alternative care practitioners who are able to see, assess and treat patients with minor conditions. For commissioners of care and employers alike, this is an attractive option in terms of financial sustainability and profit replacing the GP workforce who are retiring or not applying to become GPs whilst maintaining an acceptable level of income for those remaining as independent contractors to the NHS. The workforce pool of alternative healthcare providers is also larger than the GP pool providing an immediate solution to the aforementioned recruitment and retention problems.
The potential unintended consequence of this is the fundamental change in the role of the GP from frontline clinician who sees patients to the Consultant in Family Medicine who coordinates a team of alternative healthcare providers who see patients. In reality, we know anecdotally from our colleague GPs that this shift has already begun. The rise of the Physician Associate might be seen as evidence of this. Whether or not this is a career that junior doctors want, we do not yet know, and therefore we do understand the impact this will have on future applications to GP speciality training. We could be witnessing the death of the General Practitioner as we know them in England and the birth of the Family Medicine Specialist. Whether this is evolution to an efficient and effective way of working or forced revolution through circumstance is yet to be seen.
Whatever the outcome of this austerity driven evolution or revolution in General Practice, it is clear that without sufficient new GPs to succeed our retiring GP independent provider workforce, we will see a number of General Practice contracts ending or being tendered out to alternate providers. This is a consequence of there being a limited pool of independent contractor GP successors to the current GP contracts. Whilst we can expect many of these contracts to be taken up by private providers who may not have previously operated in NHS General Practice, currently there is no reason why GPs cannot too compete in this market to maintain as independent contractors to the NHS. So, for now, the independent contractor GP status is not dead, but it may be dying.
The Future of the Independent Contractor Status
It is not sufficient to postulate the future of the independent contractor status as a balance of positives versus negatives for our current and new colleagues. One must consider whether the self-employed GP contractor to the NHS is actually an option for the future.
We have discussed that financial austerity is a significant driving force behind this latest round of NHS reorganisation as the NHS will not be solvent by 2020 unless significant changes are made. The current model of providing care to the nation is no longer affordable without forcing cuts in care, raising taxes or changing the way we work to be more efficient. As a consequence, we have already seen a reduction in resources to deliver care, longer working hours for independent practitioners, a reduction in GPs applying to be part of the workforce and early retirement of skilled colleagues. This heady mix has resulted in a deterioration in working conditions for our current workforce.
The NHS has responded by a move to a less skilled but more diverse workforce. In need of supervision, we can expect that this workforce will be overseen in the near future by the same GPs who are responsible for the core GP contract. However, as this pool of GPs diminishes and GPs find it hard to continue the partnership model of care to share the burden and responsibilities of life as a GP, it may become difficult to oversee a clinical team and be responsible for the running of a small business at the same time.
According to figures from 2012, it took 10 years at a cost of £498,489 to the UK taxpayer to train a typical GP. It is not unreasonable to expect a return on this investment for the taxpayer in wanting a professional doctor to concentrate of practicing medicine rather than being distracted by the complexities of owning a business.
So, what options does the independent contractor have available? Remain as a clinician and relinquish the burden of management, or relinquish medicine and rise to the challenge of business ownership in the NHS? Is the future General Practitioner a business person or a Doctor?
Whilst there is currently plenty of life left in the independent GP contractor status, and for some, there always will be, it is not hard to understand why some might want it dead.