One of the biggest ongoing changes in the transformation of the NHS is the role of the GP.
Once described as the backbone of the NHS, GPs are the gatekeepers between consultants and a range of tests and NHS treatments.
The family doctor is now typically part of a small business made up of a group of doctors, who together form a GP practice.
GPs are self-employed and fiercely independent. They attract income from the NHS, not just for the number of patients they have registered, but for the range of services they offer and their success in hitting government targets. This coupled with the government’s desire to shift services away from expensive hospitals has led to an increasingly entrepreneurial culture best summed up as: “You make it worth our while and we will consider doing it.”
The government has sought to encourage more doctors to go into general practice as part of shifting health services away from the acute/hospital sector and encouraging operation from group practices rather than single-handed ones, believing these can offer a wider range of services.
The new GP contracts were set up with this in mind and although they have been characterised in the media as “more money for less work”, it is unfair to blame the British Medical Association for negotiating a good deal for their members. It does, however, demonstrate how keen the government is to promote primary care. GPs are at the top of the primary care hierarchy - one made up of dentists, occupational therapists, physiotherapists, district nurses, opticians and other related professionals.
The relationship between the primary care trust and GPs is best illustrated by two recent issues: the extension of GP surgery opening hours and GP prescribing habits. PCTs were under instruction from government ministers to get GP surgeries open in the evenings and weekends, so that they are more accessible to people who work. GP reps responded by asking who exactly was going to pay for this? PCTs hold the budget for drugs but GPs spend it. PCTs say the millions of pounds spent by the NHS on drugs could be significantly reduced if GPs would use generic rather than brand name drugs. GPs are fiercely protective about their professional independence when it comes to deciding which drugs are best for their patients. PCTs are reduced to saying there is only so much money in the pot - if we spend less on drugs we could spend more on the things GPs argue we should fund.
GPs are critical of the services they can access for their patients - for example, mental health services. GPs complain that a disproportionate amount of surgery time is taken up by patients who do not have a specific medical problem but have what one GP described to me as “shit life syndrome”. That is to say, they may have family problems, a pregnant teenage daughter, a delinquent son, an unemployed partner, a mother in law with early onset dementia and mounting debts.
Understandably, they find it difficult to sleep and are perhaps concerned they and their partner may be drinking too much. The GPs would like access to low level mental health counselling services but the joint social service and mental health services don’t consider this a priority, as government targets are aimed at supporting those with severe mental health problems or at risk of suicide.
Of course, if commissioning does transfer from PCTs to GPs, then they will be the ones calling the shots.