Starting the conversation – the analysis that provoked the discussions that led to this collection

James Kirkup, SMF Director, launches the SMF's essay series "A healthier future: How to make general practice work better for everyone". The series was born out of the responses to a Times article written by James, in August 2021. In this introductory piece, James showcases the article where it all began and reflects on the importance of contributions to this series (and outside of it).

This collection of essays exists because of something I wrote.  As well as leading the Social Market Foundation, I sometimes work in the old trade of journalism, writing columns and commentary about politics and policy.  One of those columns, reproduced below, provoked some strong emotions and passionate responses, from GPs and others.  Some of those responses developed into conversations between me and the authors of these essays, who have all been kind enough to spend time collecting their thoughts and views into the pieces you find here.

I am very grateful to the authors, and to the many other GPs and others who contacted me about this column.  As I told many of them, it was not my intention to cause upset or unhappiness here. I am now even more aware of the pressures on GPs and the unhappiness some GPs feel about their working conditions and, yes, about media commentary on them and their work. I have no wish to deepen that unhappiness.

Yet, nor do I wish to resile from the central point I made in this column. GPs, like all other workers, are economic actors, who respond to incentives – there is no shame in that, and certainly no insult in the observation.  As things stand, public policy does not allocate public money in a way that ensures an optimal distribution of GPs and their labour.  Several of our contributors accept that point, and suggest that the economic incentives for GPs to work in different ways and different places should indeed be changed.

Yet the contributors also collectively and convincingly argue that changing incentives is necessary but not sufficient for a better, more sustainable model of general practice.  I argued that money matters, but I accept that is about more than money.

I have learned a lot from these essays and their authors.  I hope that readers, especially those engaged in public policy around health and care, will do so too.

James Kirkup

8th November 2021



Generous GP pay isn’t working for patients

The poorest and sickest are neglected as many doctors opt to practise part-time in affluent areas and then retire early

James Kirkup | Friday August 27 2021, 5.00pm, The Times

The love of money is the root of all evil, but it can be quite useful too. Used in the right way and the right place, the lure of wealth can motivate people to do good and necessary things. Get it wrong, though, and the power of money creates big problems. Just ask a doctor. If you can see one.

Anyone left frustrated after struggling to see their GP is experiencing a persistent and unaddressed problem of public money and public health. The way doctors are paid means there aren’t enough of them in the right places at the right times. Ministers should fix that, for their own sake, and the country’s.

Health is always a top-rank issue for voters, and one where Tories will always be vulnerable. If patients enjoy a better experience at their GP surgery, it will benefit any party seeking re-election. This government has another promise to keep here. You can’t “level up” an unbalanced country without addressing the most vital inequality: health. The poor are sicker than the rich, partly because they don’t have enough doctors.

GP numbers are a slippery concept. England’s official “headcount” for qualified GPs was 37,293 in June, up 3 per cent from last summer. But that’s the equivalent of only 27,752 full-time doctors, up barely 1 per cent. Such modest rises come despite numerous schemes to recruit more GPs and a growing budget. Public spending on general practice is up almost 20 per cent in the last decade. Yet warnings and complaints about shortages abound. Why is it so hard to see a GP?

The most obvious answer — increased demand for appointments — provides only part of the answer. The rest lies in the supply side of this arrangement: there are fewer doctors working on any given day. This brings us back to money. Many doctors have enough of it to work less, or not at all.

A big factor in GP availability is part-time work. A lot of doctors work less than the standard 37.5 hour week; almost 90 per cent of salaried GPs work less than full time. The British Medical Association (BMA), the doctors’ trade union, says they do so to shield themselves from the strains of a stressful job. That’s understandable, but might raise eyebrows among others who also do tough work but can’t afford to cut their hours. As Alice Thomson wrote on these pages this week, part-time work is lovely, but largely the privilege of high earners. (With average earnings of £100,700, GPs definitely count.) And when doctors exercise that privilege, it has consequences for others.

The prevalence of part-time GPs means training several medics to fill one post. Those staffing figures above show that adding 1,019 qualified GPs to the workforce delivered the equivalent of only 331 more full-time doctors. Most employers who had to hire three people to fill a single post would be looking to change things somewhere. The taxpaying public could be forgiven for thinking if GPs were paid a bit less, there might be more of them available to see patients.

There are problems too, with the way money is shared between GPs. General practice is now majority-female, but even allowing for hours worked, men earn 15 per cent more.

Another drain on the GP workforce is retirement. Most workers accept their retirement is getting further away: the state pension age is rising, and we’ll have to work well into our sixties to put more into occupational pensions. That’s a consequence of rising lifespans; most people accept it as inevitable and sensible. It doesn’t apply to doctors, however. Their average retirement age is 59 and falling.

Again, this is about money. Someone who manages to save just over £1 million into a pension starts to face punitive levels of tax (55 per cent) on money taken out of that pot. Fewer than one in 20 workers will hit that limit, but many of them will be doctors. Those (few) GPs who work full-time and pay into the NHS pension scheme might expect to reach the lifetime allowance ceiling by the age of 55. Some limits on annual pension contributions have been massaged for doctors, but the BMA continues to lobby for a higher lifetime cap, arguing that trying to limit pension pots to a mere £1,073,100 is “going to push doctors out of the NHS”. That’s a revealing confirmation of the power of money to lure doctors away from where patients need them.

The places where those doctors are most needed are the areas where patients have the least money. This is not new. In 1971, Julian Tudor Hart, a GP and researcher, described the “inverse care law” of general practice: poorer local populations have greater health problems and need more care but actually get less of it. Today, GP practices in the most deprived areas have larger lists, get lower quality ratings from regulators and offer shorter consultations than those in more affluent places. Once again, money is the problem.

Worse healthcare contributes to worse health and shorter lives. Men in the poorest areas die a decade earlier than those in the richest postcodes; for women, the gap is eight years. Fixing this will take decades of effort on many fronts. That effort could start with getting more GPs to poorer places, using money to drive them there.

GP practices are funded under a Whitehall mechanism called the Carr-Hill formula, which is supposed to allocate cash according to things such as the needs of the local population. It doesn’t give enough weight to deprivation, which is closely associated with poor health. The result is a system where too many doctors avoid poor places and follow the money to leafy suburbs, where they can get paid the same for treating fewer patients with less complex needs.

Carr-Hill has been reviewed and reviewed over the years but never changes much, partly because the BMA, one of the most dangerous forces in British politics, objects to reforms that might inconvenience members in those leafy places.

Could this finally change? Earlier this year, the NHS Confederation, which represents hospital trusts and other health service bodies, said Carr-Hill needed a “radical overhaul” to better serve different areas. Sajid Javid, the health secretary who inherited a pandemic, isn’t short of work, but he should heed that call and then go further, with a fundamental reform of the way doctors are paid. GP funding isn’t working for patients. Love of money is the root of that problem, and that is where change is needed.


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