Column

Time to breach the contract

GPs’ contracts have altered little since 1913, but the advent of PCGs may change all that, says Charles Webster

Only recently has salaried practice by general medical practitioners become a realistic possibility, and even now it is permitted only in exceptional circumstances.

The comments by Katy Gardner and Jim Ornum in issue 36 of healthmatters suggest that the time is ripe for reappraising the profession’s long-standing refusal to contemplate universal implementation of salaried service.

GPs’ participation in the NHS as independent contractors has always constituted an awkward anomaly and one of the most damaging inflexibilities within the modern health service.

Their independent contractor status represents a hangover from the Lloyd George National Health Insurance system, and indeed it possesses even deeper roots. As a consequence of this, GPs’ terms and conditions are determined by a contract hammered out with such difficulty that it is almost impossible to change in any radical manner.

The GP contract introduced in 1913 has been revised on only three occasions, in 1948, 1966 and 1990. All the revisions were conducted in an atmosphere of friction, which effectively reduced the opportunity for rational reassessment and limited the scope for change.

Nor has change been in only one direction. For instance, by emphasising capitation, the 1990 contract reverted back to the 1948 arrangements and reversed the hard-won reforms of the so-called Family Doctors Charter of 1966. As a result, the 1913 contract lives on.

Thanks to their independent contractor status, GPs now find themselves with a contract entirely inappropriate to their duties under the new primary care groups.

Judging by past experience, any further revision of the existing contract is likely to produce a worst of all worlds solution, rewarding to the entrepreneur, but expensive for the taxpayer and yielding a poor return in terms of service and further frustrating the conscientious doctor.

The importance of adopting salaried service was not lost on the planners of the National Health Service. Indeed, as demonstrated in John Stewart’s new book on the Socialist Medical Association, the case for salaried service was completely accepted by the Labour movement in the 1930s. In the course of their private discussions, Ministry of Health planners saw no merit in continuing the independent contractor system. They recognised that this was only appropriate to a competitive system in which young doctors incurred huge debt at the outset of their careers, and were therefore obliged to build up a large ‘panel’ practice in order to provide a degree of security while paying off their debts and building up a private practice.

In this system, the panel supplied a reservoir of second-class patients, who were recipients of the proverbial two-minute consultation and bottle of coloured water. In the very first survey of this problem, in March 1942, an official concluded that the panel system lent itself to corruption and placed a premium on incompetence and negligence. Assistants were exploited and conscientious doctors were likely to lose money and see their lists eroded. Even supporters of the panel system recognised that it was scandalous and urgently needed reform.

But no amount of reform could render it suitable to the incoming NHS. It was envisaged that private practice would no longer exist, and doctors would no longer work in competitive isolation but as groups practising co-operatively in health centres. Advances in treatment and the need to import genuine teamwork into practice meant that a more rational system of payment was required.

The above arguments proved conclusive. In November 1942, Sir John Maude, Permanent Secretary of the Ministry of Health, advised ministers that the panel system should be completely scrapped. He knew this would be unpalatable to the medical establishment but Maude believed that the circumstances of war had tilted the balance in favour of change, since some 6,000 forces’ doctors were likely to favour the new arrangements. Maude believed that ‘there is now a general consensus of opinion that the conception of the doctor carrying on in isolation a general practice cut off from the public health service of his locality, from the body of consultant opinion available in hospital, and from his rivals in general practice, is becoming obsolete’.

Indeed he believed that under the NHS the traditional boundaries of medical practice would gradually break down. The new system sought emancipation from any idea of linking remuneration to the numbers on the list or allowing members of the new health centre teams to compete for patients.

Maude concluded that ‘the general principle applicable to public service, civil and military, that exceptional competence or zeal should find its reward in the shape of promotion in the service must, in our view, apply to the present case’.

During the Second World War the case for salaried service was accepted by planners and politicians of all parties, and by a large body of opinion within the medical profession, but it was anathema to the old guard of the BMA. Thereby a major cornerstone of the NHS was dislodged – and it has never again been set in place.

The evolving primary-care led system and establishment of PCGs provides a fresh opportunity to revive the argument for a salaried service. The case for this alternative seems just as pertinent today as it was during the Second World War.