The Faustian deal that changed general practice

Back in the 1980s, my average working week would have been considered typical – nine surgeries, across the morning and evening, each of around three hours, in which I would see 30 or so patients. In between, there would be administrative issues to settle and perhaps a couple of house calls to the immobile and seriously ill. Plus, there was the on-call rota: one night a week and one weekend in four. I rather enjoyed being on-call – the vicarious interest in seeing patients in their homes, relieving their pain and even, on one memorable occasion, bundling a middle-aged man with crescendo angina into the car and racing to A&E. But, over the years, things changed. Most patients are entirely reasonable but some came to regard it as their right to summon a doctor – as in: “Get down here doc, my son’s got earache.” Not much could be done about this sense of entitlement until prime minister Tony Blair initiated a process that would revolutionise general practice. During a television interview in 2000, he made the (unscripted) promise to increase NHS funding by a whopping £12billion a year. There were no plans as to how this might be spent but the BMA recognised an opportunity to boost their GP members’ earnings. However, if GPS were to be paid more, they would have to do more, while the priority for many was to do less and shed those (increasingly) irksome on-call commitments. Following protracted negotiations, there was what appeared to be an ingenious solution. GPS would no longer be responsible, at least nominally, for their patients’ welfare around the clock. In exchange, they would demonstrate “increased productivity” – specifically, a substantial part of their income would be dependent on success in increasing, for example, the proportion of their patients taking medication to lower blood pressure or cholesterol levels.

It is impossible to convey the complexities of being “paid for performance” in this way but, in essence, the priorities of general practice would shift towards generating the maximum number of “financially rewarded points”, reflecting endeavours in hitting 76 separate targets across 10 medical conditions. This, “the boldest proposal to improve the quality of general practice anywhere in the world” (according to the British Medical Journal), would, it was anticipated, drive up standards. When polled, more than three quarters of GPS voted in favour – a sensible decision, as under the new system earnings would rise 40 per cent to £110,000 a year: a tidy sum for a now reasonable working week with no on-call commitments. It has proved to be a Faustian deal: the “soul” of general practice sold in exchange for a technical function. There are, after all, no “financially rewarded points” for being accessible or sympathetic. Most GPS, no doubt, are as dedicated and committed as ever, despite these new arrangements, which anyhow have had to be modified in recent years. Still, the acrimonious dispute between the Government and BMA necessarily prompts questions as to how and why family doctoring has changed so profoundly over the past 30 years.