Primary care–opportunities and threats: The changing meaning of the GP contract
BMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7084.895 (Published 22 March 1997) Cite this as: BMJ 1997;314:895
The meaning of the GP contract has changed since the last major upheaval in the mid-1960s. The government has always dealt with general practitioners as independent contractors, but the way in which it treated them in 1990 was entirely different from the way in which they were treated in 1966. In 1966, the profession's independent contractor status effectively served to protect professional autonomy. In 1990, with the change in the form of government towards a “contract state,” general practitioners were treated as independent contractors more in the sense of business entrepreneurs. The article finishes by raising the issue of how general practitioners can gain control over the medicopolitical agenda in the future.
General practitioners were extremely hostile to the contract that was imposed on them in 1990. Yet the profession had signed up to many of its provisions. In 1985 Michael Wilson, the then chairman of the General Medical Services Council, wrote to the minister of health, Barney Hayhoe, with proposals for extending the range of services offered by general practitioners to include the extension of cervical cytology screening, a comprehensive scheme for paediatric surveillance, and minor surgery–all specific proposals that were taken up by the government in 1990. Nor were many of the worst fears of general practitioners about the workings of the contract realised. Pay increased (though the increased delivery of items of service was deemed by the government to have resulted in “overpayment”) the cash limits on reimbursement for expenses proved initially generous; and the increased weight accorded capitation payments did not result in an increase in list size, although it served to thwart general practitioners' longstanding desire for a reduction. Why, then, was the hostility so great?
The answer lies in the changing meaning of contract. Since the introduction of national health insurance in 1911, the government had dealt with general practitioners as independent contractors, but the way in which it treated them in 1990 was entirely different. The contrast with the dispute in the mid-1960s is particularly strong. In the 1960s the political culture emphasised planning, corporatism, and expertise; by the end of the 1980s it emphasised the importance of markets and consumers. In the late 1980s there was a paradigm shift in the way in which public services of all kinds–housing, education, and community care, as well as health–were delivered.1 Market principles were introduced into the public sector and contract became the vehicle for achieving the goals of increased efficiency, choice, quality, and accountability. The move towards what some social scientists have called the contract state,2 in which hierarchies and professional values have been replaced by “quasi-markets” 3 and managerial values, has in turn had major implications for the way in which general practitioners have been treated as contractors.
The mid-1960s
In 1966, general practitioners got what they asked for after considerable struggle. The postwar system of remuneration had worked on the basis of a rather rigid and unfair “pool” which, among other things, calculated capitation payments on the basis of the number of doctors rather than patients and which failed to reimburse doctors directly for their expenses. General practitioners successfully demanded a new system of payment, one based on a more mixed system that included capitation payments calculated on the basis of the number of patients, a basic practice allowance, and fees for service. There was as little support for a wholly salaried system as there had been in the 1940s. The famous “charter,” which formed the basis for negotiations in 1965, represented a shrewd strategic move on the part of the GMSC. The four principles of the charter were the right to practise good medicine in up to date, well staffed accommodation; the right to practise medicine with the least possible intrusion by the state; the right to enjoy proper payment for the services rendered; and the right to financial security. The demand for the means to deliver a good service was thus put before pay, and BMA Council members emphasised that the charter was as much a patients' as a doctors' charter. As Dr Ronald Gibson, chairman of the Representative Body, put it: “Our approach must be towards more money for the service and not, in the first place, for ourselves.” 4 This contrasts with 1990, when the language of consumerism was captured by the government, leaving the profession disadvantaged.
General practitioners asked for the means to be given to enable them to do a good job and to be left alone to do it. As one doctor wrote in the BMJ at the beginning of 1965: “We want to be trusted individually and as a profession, and we want to play the game without a surfeit of regulations, orders, and officials.”5 In large measure, this was what general practitioners achieved in 1966. However, this does not mean that the government had no concerns about what actually went on in general practice. A Ministry of Health memorandum filed with the document of the Fraser working party (set up by the BMA and the Department of Health in 1964 to investigate the terms and conditions of general practice) noted that previous reports on general practice had all “refrained from saying anything that would imply that some doctors were bad.” 6 It was not quite that it was assumed in the 1960s that all doctors were good, as Margot Jefferys and Hettie Sachs have suggested.7 The government certainly had doubts about the quality of general practice, but it chose not to do anything about them and to trust the profession to use the provisions of the 1966 contract to put its house in order.
Thus the negotiations of the mid-1960s respected the professionalism of general practitioners and avoided profound underlying issues to do with the nature and content of general practice. However, the issue of quality did not go away and was highlighted in the evidence given by the Royal College of General Practitioners to the Royal Commission on the NHS in 1977 and in a series of reports published by the college in the 1980s, beginning with What Sort of Doctor, published in 1985.8 Quality came to the forefront when the government seized the initiative in 1990, expressing impatience with the notion of professional altruism and determined to use market principles to pursue a consumerist agenda.
Proposals for reform in the 1980s and the 1990 contract
At the core of the 1986 green paper on primary care was a concern about cost and quality. The document advocated the introduction of a good practice allowance, citing the Royal College of General Practitioners' 1985 report on quality.8 However, despite support from leaders within the Royal College, the profession opposed the allowance. The GMSC argued that any payment in recognition of quality had to be achievable by all general practitioners. The proposed allowance would be achievable only by some and would therefore serve only to widen the gap between good and bad practitioners.9 In addition, as Peter Toon has pointed out, there was no consensus among general practitioners as to what constituted good practice.10 The government gave up on the idea of a good practice allowance but, as the language of the 1987 white paper on primary health care showed, it had no intention of abandoning its aim to make services more responsive to the needs of the consumer and to raise the standards of care. In many respects the 1990 contract served as the vehicle for making doctors more accountable for what they did.
In 1990 the gentleman's agreement between general practitioners and the government ceased.11 It was not inappropriate for the government to specify more closely what it wanted to buy from a group of people who prided themselves on their status as independent contractors. However, general practitioners had historically used their independent contractor status as a means to defend their professional autonomy. Now the government seemed to be trampling on this and to be using its statutory muscle to impose clinical direction for which there was little or no evidence regarding effectiveness–for example, in respect of health checks for elderly patients and those who had not seen a general practitioner for three years.12 Perhaps the most despised imposition was that of health promotion clinics, with payments for “patients in packs of 10,” notwithstanding the potential for financial gain. In 1990, the government treated general practitioners as self interested individuals who would respond rationally to economic incentives. This was not an unreasonable expectation to make about people who prided themselves on being independent contractors. However, there was no evidence to suggest that general practitioners would behave as self interested entrepreneurs. For example, Krasnik et al's study of remuneration systems showed that general practitioners were more inclined to seek to fulfil a target income rather than to maximise income, as the model of the self interested professional would have predicted.13 As Rosen put it, while doctors' behaviour is determined in part by payment, it would be wrong to regard professionals as “businessmen without licences.” 14
The new meaning of contract and GPs' independent contractor status
Major changes in the contract were proposed in the 1996 white paper, Choice and Opportunity: a salaried option for general practitioners, either within partnerships or with other bodies; practice based contracts; and a single budget for general medical services, other hospital and community health services, and prescribing.15 These changes are the logical response to the development of the internal market in health care, which has taken on a life of its own, with very rapid changes in the configuration of purchasing and providing, particularly in respect of general practitioner fundholding and commissioning.
As the purchaser-provider split has created both greater centralised control and more fragmented provision, so general practitioners' nationally negotiated contract has come to seem more anomalous. Paradoxically, the operation of the quasi-market has also brought the issue of a salaried service back on to the agenda. There was very little discussion of salary between 1966 and the 1990, when the NHS quasi-market raised the possibility of services being commissioned from practices rather than from individual general practitioners. As the white paper suggests, it is also the case that many general practitioners do not want to make the personal investment and long term commitment required by a partnership and would also welcome more regular hours and the possibility of reconciling work and family responsibilities.
Thus the changed meaning of contract has very quickly served to put a large question mark over aspects of general practitioners' status as independent contractors, which has historically been viewed as the chief means of securing professional autonomy. The changes to the GP contract in the context of the rapidly developing internal market mean that general practitioners must grapple more explicitly with what it is that they do and how far they can exercise control over it. In the 1990s, the profession has realised the importance of regaining the initiative. While they were successful in this respect in the mid-1960s, their role in 1989-90 was largely reactive.
The GMSC's responses
The GMSC has focused on discussing how to define the core of general practice and the extent to which negotiations should be local rather than national. In 1991 it undertook a large survey of general practitioners which achieved a 70% response rate and which served as the basis for the GMSC's renegotiation of the most vexing parts of the 1990s contract and for the development of the council's “core services” strategy. In Building Your Own Future the council told general practitioners that their “unreal” perception of the negotiating process (in terms of underestimating the government's opposition to “collectivism”) was matched “by a lack of understanding of the nature of the contracts of NHS GPs” and by “excessive confidence in the justness of the profession's position.”16 The following year the new chairman of the GMSC, Ian Bogle, told general practitioners that the profession's stance on quality was crucial and that if they wished to stop excessive monitoring by the family health service authorities they should opt for quality assurance and a system of accreditation.17 And in 1996 the council highlighted the question of defining the core in a discussion paper with an interesting subtitle: Defining Core Services in General Practice–Reclaiming Professional Control.18
The RCGP's responses
In its 1995 report on the nature of general practice the Royal College of General Practitioners, which lost many members after the imposition of the 1990 contract, drew a stark picture of professional versus contractual requirements, emphasising the negative implications of the latter, notwithstanding its own record in exposing the inadequacies of the profession in regulating quality.19 The college pointed out that independent contractor status allowed each general practitioner some degree of autonomy in determining the balance of the “practice culture” between population centred and person centred medicine. The first threat to this autonomy was posed by the way in which the new contract began to define the core services that the general practitioner had to provide. The second threat came from the rapid development of general practitioner commissioning, which tipped the balance against the practice of person centred medicine.
General practitioners who emphasised the importance of the quality of the individual consultation–in the humanist tradition of Balint–were not favourably disposed to the population centred performance indicators of the new contract culture. Certainly, the government's 1996 proposals for practice based contracts and some salaried service threaten to erode professional autonomy further. The practice of some general practitioners will be dictated by others or by trusts. General practitioners will no longer be such a unitary body, which poses difficulties for the profession's leaders, although some general practitioners may be content to trade professional autonomy and power for a greater degree of (salaried) comfort.
Differences in the autonomy exercised by general practitioners would also have implications for their status in relation to other members of the primary health team; the Royal College of General Practitioners' 1995 document made a strong case for putting the general practitioner at the centre of the “core primary care team,” as someone with a unique clinical role as a diagnostician. However, by offering general practitioners the possibility of engaging in “total purchasing” by legitimating a unitary budget, the Primary Care Bill may also offer practices greater control and autonomy.
The future
General practitioners should be in a strong position given the government's increasingly explicit commitment to the development of primary care, although making primary care the cornerstone of the NHS “presupposes a degree of strategic incorporation which stands in stark contrast with the semi-detached status it has occupied historically.” 20 The issue of defining core general medical services has become more urgent with the advent of the Primary Care Bill. General practitioners remaining in traditional practice and also those who may form experimental schemes to merge hospital and general medical services funding streams need to know the limits of their general medical services responsibilities.
After what was perceived by most general practitioners as the defeat of 1990, the profession's leaders have shown a willingness to work within the new boundaries. General practitioners stand a better chance than many other groups of professionals of exercising influence and control over the main tools of the new managerialism, chief among which are the measures associated with quality control. Recent research on general practitioner fundholding has highlighted the extent to which general practitioners have become much more involved in local health planning in the 1990s.21
The history of general practice in the late 20th century shows the difficulty that leaders, particularly in the Royal College, have had in persuading general practitioners of the necessity for action in this respect. Historically there have always been general practitioners who were prepared to seize the initiative–for example, in improving their practices after 1966–and those who were not. The circumstances of the mid-1990s open the way for greater divisions between general practitioners. Furthermore, despite the discussions set in train by the Royal College of General Practitioners and the General Medical Services Council, the government remains firmly in the driving seat in 1996, albeit after much more consultation in the form of the “listening process” than marked the beginning of the decade. In the future, much will depend on how far the profession succeeds in setting the agenda. However, the government's commitment to securing greater accountability is unlikely to go away.