When British Prime Minister David Cameron defended his reforms of the National Health Service against a series of aggressive attacks from critics this week, he fell back on a familiar argument – that his reforms would hand control from bureaucrats to clinicians. But the reforms don’t, in fact, hand power to clinicians generally – they hand responsibility for commissioning in the NHS largely to general practitioners (GPs), our answer to US family practitioners. I think it’s worth spending a bit of time explaining quite why, because as other bloggers have written on this site, US policy experts often find it surprising that in the UK such a high status is afforded to family medicine.
GPs in the UK often earn more than their specialist colleagues, and they do so because they have a much more central and wide-ranging role in the British NHS than family practitioners do in the American healthcare system. GPs are in traditional terms, the gatekeepers, and in updated terms, the navigators for the NHS. Patients can’t simply book themselves in to see a hospital doctor – the great majority of first contacts with the health system are with the GP practice. GPs are highly trained, following their medical degrees with two foundation years and then three years of specific GP training (with pressure to extend that to four or even five years).
Although they’re generalists, the profession is regarded as a specialism – and its expertise is measured partly by its ability to manage as many patients as possible in primary care, without the need for referral to hospital. GP care has proved highly cost-effective, both by controlling the numbers of patients who access expensive hospital treatment, and by directing patients to the most appropriate part of the NHS when they do need specialist attention. And in an NHS facing unprecedented cost pressures, that’s given them an enormous amount of power, and is about to gain them a whole load more.
British health secretary Andrew Lansley has identified GPs as the people who can make or break the NHS – determining whether or not it stays in budget by controlling how many patients have access to that expensive hospital care. And he has calculated that if GPs are to be persuaded to control costs by keeping the flow of patients through to hospital to a minimum, then they must be made responsible for those costs, by holding them to account for the management of large parts of the NHS budget. It’s a grand plan, but it does have one or two flaws. One of them is that GPs are, for all their influence on the NHS’s financial position, most definitely doctors rather than accountants. They tend to like to make decisions about whether to refer to hospital in partnership with the patient, and on clinical grounds, rather than in order to come in under the bottom line. Increasingly, prototype clinical commissioning groups – made up of groups of GP practices – are placing their members under pressure to drive their referral rates lower and lower, with referrals in some areas falling by an astonishing 30% in a year, and by an average of 4%. Numbers like that look fantastic for the NHS money men, as they attempt to deliver £20bn in efficiency savings by 2014/15. But it doesn’t feel very much like the promised land that Mr Cameron was describing, of a health service run by doctors, not bureaucrats.
Richard Hoey is editor of Pulse, a weekly magazine for UK primary care professionals and physicians. He writes Pulse’s editorials and muses on general practice in his weekly blog. You can follow him and read other news about the NHS at pulsetoday.co.uk.