From the President: The rise and fall and rise of British General Practice
Headlines trumpeted the most significant drop in 30 years in public satisfaction with the English National Health Service (NHS), from 70% in 2011 to 53% in 2012.1 At the same time, the NHS was so admired that it was featured in the 2012 London Olympics ceremonies. Where did the truth lie? Since British general practice is the bedrock of the NHS and since it is also an important leader in global Family Medicine, I was eager to better understand the current and future status of the NHS and British general practice.
To advance my understanding, I was privileged over the past two years to speak with more than 200 people on the state of the NHS and British general practice. My conversations involved general practitioners (GPs), patients attending the GP’s surgery, consultants and hospital staff, local and national politicians, and other influence leaders. I visited practices in Glasgow, London, Manchester, and Newcastle, as well as several rural communities. While I do not consider myself an expert on the subject, what follows are some of my thoughts on British general practice. I hope you find my comments to be of value and to provoke thoughtful discussion on what can and should happen as a result of well-intended, but sometimes detrimental, attempts to reform health care. To protect the innocent and the candid, this commentary does not include names or photographs that might identify those who were interviewed.
The British GP
I have long admired British general practice. Revered as trusted advisor, astute diagnostician, and guardian of the community’s health, the British general practitioner seemed a paragon. Every major life event, from birth through death, was commemorated by the presence of the family GP. Attending home births, visiting patients in their homes after hours, and offering spot-on counsel, the GP seemed almost a heroic figure – singlehandedly doing battle with disease and combatting despair. Once the family doctor showed up, things were going to be all right. Even if things could not be made right, the GP offered comfort and meaning for the suffering.
Beyond clinical care, the British GP set the pace for many of the advances in general practice. The organized curiosity of Will Pickles, the innovative practice-based research of Julian Tudor Hart, and the uncommonly common sense of John Fry provided much of the philosophical and scientific basis for modern day Family Medicine. Along with others, these giants in our discipline made generalism a pursuit worth pursuing: satisfying, challenging, ennobling, and even fun.
Reflecting the influence of the British diaspora and empire, the reach of British general practice has extended way beyond the shores of the United Kingdom. One important ex-pat was Ian McWhinney (pictured), a Brit who relocated to Ontario, Canada. The recent passing of Professor McWhinney is a reminder of the tremendous role he had in shaping Family Medicine, especially in the Americas. Another key figure is Maurice Wood who helped bring longitudinal studies to the USA, codified the work of family doctors into ICPC (International Classification of Primary Care), and founded NAPCRG (North American Primary Care Research Group). Testimony to the global prestige of British general practice is the number of general and family doctors, especially in Asia and the Middle East, who seek to become Members of the Royal College of General Practitioners (RCGP), or MRCGP[INT].
British GPs achieved almost mythical status because of the trust placed in them by patients, their commitment to their communities, and their insights on the essentials and joys of general practice. Of course, like most mythical figures, the myth was better than the reality. Serial killers such as Harold Shipman, and John Bodkin Adams before him, abused that trust. Commitment to communities was often fleeting as many GPs tried several practices before settling into a community for an extended period. The job was not always joyful. It was hard work with long hours that could be emotionally exhausting and physically punishing.
A brief history of the NHS2
Established in 1948, the NHS assumed that the British GP would serve as the foundation for a universal health scheme that would provide care to all that was financed by taxes, reasonable in quality, and free at the point of entry. The assumption has proved durable with over 90% of all NHS encounters still provided through GP practices. The World Health Report in 2000, the last WHO report to compare health systems, ranked the UK at #18 for its performance and #26 for the portion of its gross domestic product (GDP) spent on health care services, reflecting good value for the money spent.
In the early years of the NHS, the assumption worked well with a growing economy and population to foot the bill. Then, the world started to change. Rising consumerism, an ageing and diversifying demographic, increasing costs of medical technology and medication, recurring recessions, and a shifting global economy began to tear at the fabric of the NHS. The 1970s were marked by decreased tolerance for queues, growing demands for patient choice, and a public desire to reduce government expenditures and taxes. Regional Health Authorities were created in 1974 in an effort to improve local control of and accountability for health services.
The Griffiths Report of 1983 advocated for “internal markets,” with the hope that they would promote competition, thereby increasing quality and reducing cost. The Tory government of Margaret Thatcher took these ideas to the next level with the passage of the National Health Service and Community Care Act in 1990. The Act stimulated the development of Primary Care Trusts (PCTs), which represented an evolution of the Regional Health Authorities. The Act also envisioned that GPs would become fund holders and negotiate prices and services with consultants and hospitals on behalf of their patients.
In 1997, when Tony Blair and his Labour party were voted in, he promised to remove internal markets and abolish fundholding. By his second term however, Blair’s position had shifted to favoring internal markets. In 2004, the NHS began the Quality Outcomes Framework, which would prove to have a profound effect on British general practice, as will be discussed below. The most recent change has been Commissioning, which empowers the PCTs and local Commissioning Boards with the responsibility of providing needed services and commissioning, or contracting, with outside agencies such as hospitals for services not provided by the PCT. Some have described Commissioning as fundholding revisited. About 80% of the £100 billion spent annually by the NHS is controlled by PCTs.
The impact of NHS changes on general practice
Every few years, British GPs sign a General Medicine Services (GMS) contract with the NHS, which describes the expectations, rights, and responsibilities of both parties for the provision of primary care services. Faced with declining student interest in careers in general practice, committed to moving more care to primary care with its better outcomes and lower costs, and determined to better align resources and goals of care, the NHS undertook several important initiatives with the revision of the GMS contract in 2003. It allowed British GPs to opt out of afterhours care, which many did since such services represented only 3% of practice income.
More important, the 2003 contract paved the way for the QOF.3 A voluntary program, QOF can represent up to 25% of a GP’s practice income and has helped to raise GP income significantly. The practice is measured against 142 indicators and can accumulate up to 1000 points that can result in a significant rise in GP income. Clinical measures (blood pressure, lipids, etc.) represent 85 of the indicators (maximum of 661 points), 45 indicators involve organizational measures such as training of staff, patient education, medical record keeping, and so on (262 points), one indicator looks at the patient experience by examining the length of the consultation, and nine measures are for additional services such as child health surveillance, maternity care, screening for cervical cancer, and contraceptive care (44 points).
Since implementation of the QOF, several trends have accelerated for GPs. Single handed practices have increasingly given way to 5-10 doctor practices, practice nurses have taken on more duties such as serving as the principal practice resource for specific conditions such as diabetes, and GPs spend an increasing portion of their time providing oversight to other health care professionals who actually provide much of the care. The benefits of the QOF include better collection of practice data, proactive outreach to those with chronic or multiple conditions, and improvement of a number of health care indicators. The detriments of the QOF involve an increasing shift of GPs from providers of care to managers of other professionals, the toxicity of a measurement culture (e.g., focusing on QOF measures rather the patient’s agenda), the fragmentation of care across the primary health care team, and the deskilling of GPs who have delegated management of many conditions to other practice professionals.4
Some worry that the QOF and other NHS changes undermine the trusted patient-GP relationship on which the NHS was built and depends. The rush to measure can conflict with the patient’s agenda. One telling example was a woman in her 50s with type 2 diabetes and high blood pressure who presented with a headache during the consultation I observed. The GP had been her doctor for nearly 20 years and knew her fairly well despite her infrequent visits to the practice. He was eager to address her diabetes and elevated blood pressure; she wanted only to discuss her headache. As they negotiated back and forth about what they were going to discuss, they both began to laugh at the absurdity of the interaction. They each took a deep breath and worked out a compromise: her headache would be addressed today and she agreed to come in the following week for her chronic conditions (I don’t know if she returned).
In another practice, I had an informative conversation with a retired councilman who had served on the local PCT and who had strong opinions about the NHS changes that had taken place. When I asked what effect he felt the 2003 contract had on his health care, he replied, “my GP drives a much nicer car, but I rarely see him because he has frequent locums doctors and is not available after hours.” Even more profound was a chat I overheard the following week during a car ride to the Barcelona airport. An eminent Spanish surgeon was driving, I was seated in front and two renowned British surgeons shared the back seat. One Brit said to the other, “I can’t ring up my GP after hours. This is intolerable.” As a family doctor in the USA, which has a very specialist-centric health system, I could never imagine two specialists having such a conversation. Their discussion reminded me of the reliance of many British patients on their GPs, even when those patients are specialist physicians.
The frequent major changes in the NHS make it difficult for patients and doctors to adjust to an ever shifting practice environment. This frustration was captured in the observation a GP when she said, “the greatest problem with the NHS is that major changes seem to occur about every 15 minutes, without necessarily having a compelling need for change.”
Brits take justifiable pride in the NHS, with its emphasis on equity and its promotion of national cohesion. All of the NHS professionals I met were bright, dedicated, and sincerely interested in improving care and health. Many of them however, also seemed ground down by the frequent and often untested changes that were thrown at them. I was struck by the shrinking availability of and declining continuity with the British GP – many of the GPs I observed had only several patient sessions per week and often had consultations with people who were not on their list. It’s not that the GPs are not busy. They seem to spend an increasing portion of their work hours engaged in administrative tasks and personnel management.
While the GP remains a highly valued and trusted member of British society,5 my worry is that the practice changes being driven by NHS strategies and GP preferences will over time erode the foundation on which the NHS is built and which enables Britain to achieve better results at lower costs: a therapeutic relationship with a GP who knows the patient and whom the patient knows and trusts. The genius of British general practice has been an unwavering commitment to person and place. British GPs have a long tradition of showing the way for the much of the medical world. My hope is that they marshal their considerable talents to innovate new approaches toward sustaining and satisfying relationships to better meet the needs of patients in a rapidly changing world.
Professor Richard Roberts
World Organization of Family Doctors
2. Gorsky, Martin. "The British National Health Service 1948-2008: a review of the historiography," Soc Hist Med 2008;21(3):437–460.
4. Campbell SM, McDonald R, Lester H. The experience of pay for performance in English family practice: a qualitative study. Ann Fam Med 2008;6:228-234.
5. Tarrant C, Stokes T, Baker R. Factors associated with patients’ trust in the general practitioner: a cross-sectional survey. Br J Gen Pract 2003;53(495):798-800.