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.

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12 Responses for “Minders of the Gap”

  1. Kristen says:

    In lieu of preventative care, increasing the salaries of GPs is another great incentive for decreasing costs and improving quality. In terms of policy, here in DC, the conversation has surrounded ways to align incentives from both the government and insurance companies. http://bit.ly/y2rpCt

  2. Putting doctors in this impossible and largely unethical role is, in my opinion, an outrage, and the need for such role to even exist is unequivocal proof that the entire messaging campaign around “less is better” and how quality care is really cheaper, is just a bunch of nonsense that is aimed at public consumption and not truly believed by those who make policy, on either side of the pond.

    • Peter1 says:

      “Putting doctors in this impossible and largely unethical role is, in my opinion, an outrage”

      Margalit, how would you control costs? If one role of the GP is to also manage scare resources what is wrong with having them be a large part of controlling finite budgets?

  3. tim says:

    If quality care is cheaper, and the problem with America is that proceduralists make more by doing more, and there is an effective cadre of gatekeepers in Britain, then why do British GP’s have to take on financial risk to make quality care happen?

    Say it with me: Death Panels.

  4. Peter1 says:

    “with referrals in some areas falling by an astonishing 30% in a year, and by an average of 4%.”

    Maybe not so bad if outcomes are as good or better.

  5. Joe Flower says:

    > the need for such role to even exist is unequivocal proof that the entire messaging campaign around “less is better” and how quality care is really cheaper, is just a bunch of nonsense that is aimed at public consumption and not truly believed by those who make policy, on either side of the pond.

    I don’t quite see how it is proof of that at all.

    The concept is sound. When you compare it with, for instance, the Alternative Quality Contracts of the BCBS of Massachusetts, what seems missing (or what perhaps I need to hear more about) is to what extent the incentives to control costs are linked to incentives to create better outcomes for people and help them manage their health better.

    From looking at health systems around the world, and variations within our own, it is clear that 1) truly better healthcare actually is less expensive, 2) the foundation of such truly better healthcare is really strong primary care built on good, engaged, trusted relationships with patients, and 3) the devil is in the details in all such attempts. You can’t just incentivize cutting referrals. You have to incentivize good doctoring, doing strong prevention, tracking chronic patients, getting engaged with them.

    If they got those details right in the UK program, they could succeed brilliantly. If they did not, they will fail.

    • Hi Joe,
      Here is my dilemma: If we postulate your #1, i.e. “truly better healthcare actually is less expensive”, then why do we need to have doctors mind the cash register? Why not trust that we are correct in our assumption and encourage them to provide the best care they can provide? Surely the money will fall into place….

  6. Joe Flower says:

    Because not all doctors are the same, and some doctors specialize in ordering things that are not necessary, too dangerous, actually hurtful. Do I need to go over the lists of waste, into the hundreds of billions of dollars, that I have posted here before? Almost all of that waste was ordered by doctors. So no, you can’t just pay doctors to do whatever they want to order done, and expect that “better and cheaper healthcare” will result. In this world, you get what you pay for — so you had better have great clarity just what it is you want, and pay for exactly that. The clearest path in healthcare seems to be to find the healthcare providers whose position in the market, and whose natural inclination and training, makes them best suited for looking after what we actually want — our overall health — and then pay them in a way that they make the most money by seeing that we get it, and that we get it without wasting precious resource.

    There are always incentives in any system. Right now the incentives in the system effectively pay doctors to give us what we _don’t_ want: Too much of the wrong kind of medical activity.

    • Joe, we are discussing GPs here. There is no financial benefits for a primary care doctor to order expensive MRIs. They don’t own free standing surgery centers or imaging centers.
      The only perverse incentive for PCPs in our system is created by our penny wise and pound foolish decision to pay them less than any other specialty, and by an even more peculiar system that limits the number of doctors we train, and tilts the balance towards more specialists.

      So if we doubled PCPs pay and removed the need to churn patients like crazy, by say, paying for time instead of CPT, would you trust that these doctors will provide good care to their patients, and therefore cheaper care, based on your #1 assertion?
      Or do you think that other people in more powerful positions should uniformly dictate what better care means?

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