A very short letter from a Tory MP in response to a detailed and serious letter from a constituent raising concerns about the government’s proposed NHS reforms:
Thank you.
Are GPs private contractors?
Should they be nationalised and made salaried state employees?
Sir Peter Bottomley MP
To answer a constituent’s seriously considered letter of concern with a rhetorical question is bad enough, two rhetorical questions borders on contempt.
Nevertheless the first ‘question’ pops up quite frequently, though usually as a statement, “GPs are private providers! (ah ha, I bet you never thought of that, all your arguments against privatisation are now null and void!”) Usually that is the breadth and depth of their contribution to the debate.
The first ‘question’. Yes GPs are private business, but …
A GP working in private practice sees private (non NHS) patients. That is people who prefer to have a different service (longer appointments, unusual hours) or do not qualify for NHS care, eg. diplomatic staff, etc. The majority of GPs work to NHS contracts, follow NHS guidelines and see NHS patients. They do not compete for patients, or profit in the way competitive providers of healthcare do.
GPs services are increasingly being run on APMS (Alternative Provider of Medical Services) contracts. The ‘traditional contract’ is GMS (General Medical Services). GMS terms are set nationally and renegotiated from time to time with GPs. APMS contracts were introduced in 2004 by New Labour to allow some ‘constructive discomfort’ for existing providers by encouraging ‘any willing providers’ to run primary care services. The ‘privatisation of the NHS‘ was started years before the present government, hence the reforms are ‘evolutionary’. The pace, the restructuring and the cuts mean that they are also ‘revolutionary’.
There have been two main consequences of opening up general practice via APMS.
The first was the introduction of ‘alternative providers’. These are the private health companies who had been lobbying the department of health, private equity companies looking for new profits, and entrepreneurial GPs. They include Richard Branson’s Virgin group who operate at least 350 GP surgeries and Sainsburys who have 6 GP ‘surgeries’ and are planning to open more in-store surgeries. Opening up the NHS also helps MPs with private healthcare business interests. These are described in detail in the book, The Plot Against the NHS.
The second was to allow practices, including all their patients, to be treated as commodities to be bought and sold for profit. Chilvers McCrea was set up in 2003 by GP Rory McCrea and Nurse Sarah Chilvers. The company began with the management of a failing GP practice in Chelmsford, Essex and by 2009 had APMS contracts for over 35 GP surgeries and three walk-in centres. They were bought by another private company, The Practice in 2010, thanks to investment from venture capitalists, MMC Ventures. They have been criticised for their staff contracts and for closing a practice in Camden this year. This year the UK branch of US health insurance giant UnitedHealth, UnitedHealthUK sold its six practices to The Practice.
Traditional general practice is a cottage industry. The old system of independent GP surgeries allowed GPs to provide a long-term stable service to a community and over the years build up a detailed knowledge of their patients and the local area. In my own practice, the retiring partner has been here for 28 years and there are over 100 years of combined experience amongst the other 5 partners. We have personally invested in the practice and the community. General practice for us is a ‘labour of love’ more than it is a business opportunity.
Comparing traditional general practice with the new private players may be like comparing Arthur’s cafe with Starbucks. It may not matter if your barista changes every couple of months, but for people with long-term conditions, a long term relationship with a GP is vital. There are already examples in general practice. International IT company, Atos origin won a tender for a GP practice in East London after bidding against established local surgeries. They lost the tender only 3 years into a 10year contract because they could not provide the service needed at the unrealistically low price they had bid. Too much emphasis was placed on cost and too little on local knowledge. Patients complained that there was a high turnover of salaried doctors and continuity of care was very poor. Atos have also had severe criticism for their work capability assessments.
Reasons to support ‘alternative providers’.
One reason supporters of NHS reform give for ‘alternative providers’ is that they want to introduce competition and break up the NHS monopoly. There is no monopoly in General Practice. Or at least there was not until the APMS contracts started. Now The Practice are running nearly 60 surgeries. This is unprecedented in the history of the NHS. Private company Care UK run 13 GP surgeries. They were bought by private equity company Bridgepoint last year. Very soon there will be more consolidations and fewer independent GP practices as this report from the NHS federation details. Before long, your local GP with a long-term committment will be replaced with the part-time salaried employee of a global giant and there will be very limited or no choice at all. This will be a disaster for continuity of care on which our most vulnerable patients depend.
It is very uncommon for a traditional GP surgery to go bust and be forced to close, but large corporations do so with alarming frequency. Circle Health is Europe’s largest healthcare partnership and has been given the contract to run Hitchinbrook hospital. Uncritical journalists and politicians fall over themselves to laud it as the saviour of the NHS, but as an article published today reveals, it is in dire financial straights. Richardblogger goes further with his analysis. Southern Cross runs 752 elderly care homes with 31000 residents, and is in a desperate bid to avoid administration.
The consequence of ‘alternative providers’ is that some will become ‘too big to fail’, raising the ugly spectre of massive multinational corporations having to be bailed out with taxpayers money. All over again. The alternative is that they will be ‘too big to save’.
The second reason supporters of the government’s NHS reforms give for allowing ‘alternative providers’ is to allow entrepeurism. One such entrepreneur is Dr Paul Charlson. According to Spinwatch,
Dr Paul Charlson, is indeed a GP in favour of Lansley’s reforms. He also runs a private centre which specialises in cosmetic anti aging treatments (Botox), not typical of most GPs. Charlson is also spokesperson for a lobby group called Doctors for Reform, which is supported by the free-market think tank, Reform. Funding for Reform has come from the UK’s largest private hospital group, General Healthcare Group and other private health companies set to benefit from Lansley’s reforms.
Dr Charlson and I both spoke to the Health Committee last year,
Dr Tomlinson: I don’t believe that it is in patients’ interests to have lots of people competing to do your blood test. Why do not all of my patients have it in my surgery? Why have somebody open up, next door, for instance, saying, “Blood tests. Come here and get them done even quicker than Dr Tomlinson”? What’s the point of that?
Dr Paul Charlson: It is innovation. That’s the point. It is encouraging innovation. That’s what you need because that’s why we have been stuck …Okay, but the fact is we have been stuck, for years and years and years, not being able to innovate. I am a real innovator and I have been incredibly frustrated by the restraint of what we have at the moment. We just cannot innovate and provide better services for patients. That’s what it is about.
For Dr Charlson and others, entrepreneurism means profiting. It has nothing to do with addressing the needs of vulnerable people. Private companies are not queuing up to provide drug and alcohol rehab or psychological treatment to people around here. I know a lot of innovative GPs who are not ‘incredibly frustrated’. Many GMS surgeries already offer a wide range of services that patients need that were previously only available in hospital, like physiotherapy, psychotherapy, minor surgery, blood tests, heart tracings and so on. None of the GPs I know would consider replicating or cherry picking a perfectly good service just because they could make some money. None of them believe that patients are consumers or that health and healthcare should be treated like commodities to be traded for profit. All of them are committed to improving patient care.
In answer to Sir Peter Bottomley MP’s second question, I would say, ‘possibly’. The advantages of a cottage industry of independent GPs is most eloquently argued in this essay by an American GP (Family Practitioner) David Loxterkamp, The Dream of Home Ownership. He contrasts the traditional model with the corporate model where GP surgeries are owned by large corporations or hospital networks. This is what we should be comparing, because whether I believe that nationalised, salaried general practice is preferable to the traditional model or not, it is not the choice we have, or are likely to have in the near future.
Updates
US study finds smaller, physician-owned practices have lower rates of hospital admissions. (link to study) 19/08/2014
When the privatisation of GP practices goes wrong Guardian 19.12.2012
The Rise of the Corporate Physician, and the “Metastasis of Big Corporations”
Healthcare renewal blog, “Public discussion has raised more questions over the last few months about physicians taking care of patients as corporate employees”
08.02.2012
Private firm closes flagship GP practice in north London Camden New Jounal
GP practices in north London have been told they must absorb 4,700 patients in the next two months after the leading private health provider The Practice Plc announced it will close a high-profile GP practice less than a year after taking over the service. The Camden Road Surgery – a long-standing GP practice which has been at the centre of the NHS privatisation debate ever since it was taken over by US health giant UnitedHealth in 2008 – will close its doors in April, with plans in place for a ‘mutual termination’ of its APMS contract with NHS North Central London.
No plans to open new surgery Camden New Journal Feb 16th 2012
Dr Douglas Russell, medical director of the North Central London sector NHS trust, was speaking at an emergency debate at the Town Hall last Thursday about the closure of the Camden Road Practice.
Its private operators, The Practice Plc, announced last week that the surgery will close in April leaving 4,700 patients astounded.
Dr Russell said that under government reforms the NHS could no longer employ its own doctors or buy new premises for a new surgery in the area.
He added that tendering for a replacement would simply invite more private firms looking to profit from the NHS in Camden.
Dr Russell said: “I am struggling to understand what the alternative action is. We don’t provide services directly, we are not allowed to any more.
“A few years ago, we would have been able to take the practice over ourselves and directly employ staff and doctors. We are no longer allowed to do that. Surely you are not asking us to go through another tendering exercise – are you? Be careful what you wish for.
“My experience is that other providers find it incredibly difficult to make a success of general practice.”
It’s is very rare indeed that a ‘traditional’ GP surgery closes.
Patient protest at troubled surgery run by Concordia Health Isle of Thanet Gazette June 22nd 2012
A Better NHS 
It would appear that MPs have been given a list of killer facts to silence the opposition to the health reforms amongst which is the revelation that GPs are not state employees. In this case the killer fact has been turned into a killer question or two. The contempt for a concerned constituent is palpable.
Perhaps they are so bereft of more persuasive arguments that they feel compelling to vent their frustration with nasty put-downs.
Can you imagine any sensitive doctor responding to a patient complaint with two such curt questions? Even if you disagreed you would at least be mollifying and show some understanding of their issue.
It’s good that you have published this letter. I still have a letter from his wife that was equally disparaging. It is pinned up on the noticeboard at work. I wrote, many years ago, expressing my concern about the Guatanamo inmates. I was dismissed with quotes about how these people were hardened terrorists. The killer fact wasn’t even a fact at all. I didn’t feel that my concerns had in any way been registered. Events have shown that they should have been.
As Mr Wilde might have said: To ask one rhetorical question, Mr. Bottomley, may be regarded as unfortunate; to ask two looks like carelessness…
And let us not forget that Pweter is of course married to none other than How Do You Solve a Problem Like Virginia Bottomley. Both have form when it comes to Tory health policy. And Pweter’s brief letter (and Dr G’s response from his wife) remind us once again that these Tories are Tories from The Nasty Party.
The traditional independent contractor status of general practitioners, and so the fact that they are already private businesses, is a potential Achilles’ Heel, but only because most people don’t realise that this is so, and so the revalation is something of a shock. But the ‘answer’ to that rhetorical question (which attempts to suggest a revelation that GPs are sneaky capitalists themselves) is simple: yes they are private contractors, and and have been so from the start of the NHS. So it’s not exactly news then, is it, and if has been in effect for 60+ years without producing a national monster of capitalist greed, then maybe the rhetorical question is a non-question.
The supplementary answer to the first rhetorical question also covers Pweter’s second question (itself a restricting question of the ‘Is it black or not black?’ of a red car variety). The primary reason why GPs were given independent contractor status was not so that they could stuff their mouths with gold (that offer was made to the consultants), but because the idea of independent doctors becoming state employees (with the implication of state control) was a abhorrent to doctors at the time…
…and as an afterthought we might add: Oh! How the mighty have fallen!
“Many GMS surgeries already offer a wide range of services that patients need that were previously only available in hospital, like physiotherapy, psychotherapy, minor surgery, blood tests, heart tracings and so on”
Good for them. My GPs have visiting phlebotomists for two hours three mornings a week, not by appointment, just wait…; doctors outside hospitals don’t it seems take blood now, patients will have to return to the surgery, on one of the three days, in the morning. No physio.. No psychotherapy. Yes minor ops and ecgs. So if you need an ecg and are well enough to get to the surgery for an appointment (ringing at 8 am) and then to go back for an ecg appointment, fine.
And these are very good GPs… .
GPs are private contractors who don’t have to compete. Nice work if you can get it.
And by the way. My local Starbucks offers more comfortable seats and better service and a wider range of coffee than any of the local Arthur’s Cafes. One of those cafes, though, does terrific bacon and egg. The thing is, I can choose.
Thanks for your comment, you raise an important point, one that is raised as frequently as the one about GPs being private contractors.
The assumption is that patient choice and competition between GPs will improve quality and access, it would seem to underline the intention to introduce markets and competition throughout the NHS. My intention is to show how compicated healthcare provision really is, the risks inherent in any proposed reforms and the significant industry lobbying and paucity of published evidence supporting them. Choice and competition risk skewing priorities towards the choosiest patients rather than the most unwell, and towards services that generate profits rather than those that address clinical needs. I have addressed these issues in different ways throughout this blog.
The issue of choice is obviously very complicated, and for me it really cuts to the heart of one aspect of this debate. What both the previous government — and the current one — seem to want to have is ‘choice’ for the suppliers (large corporate providers can choose to compete/undercut smaller providers as they wish) and not for the ultimate customers (we’re still stuck in catchment areas).
I am most certainly *not* a fan of profit-driven healthcare provision, but ptl *does* have a point — when I last moved flat, I found that in my new area I could only choose between three providers, all of whom had *terrible* reviews on NHSChoices (a piece of misleading marketing if ever there were one). Even allowing for the fact that happy healthcare receivers are less likely to post comments, the reviews relating to booking appointments, receiving care, and discussing options with consultants made it seem like my best choice was to use the local hospital’s walk-in service instead.
I dislike Starbucks’ coffee, but at least I can decide whether to go with them, Arthur’s, or my local independent. So why I can’t do this for healthcare? I would travel further to get to a locally-run clinic with consistent care and long-term stability, but surely there should also be *some* penalty for providers who, year-after-year unfailingly provide bad service? But if you’re limited to two or three options in your area and they are *all* bad then what are we supposed to do? Go without? Who will put these clinics out of business?
I *did* find several well-reviewed clinics on the NHSChoices site, and they were about the same distance from my home as the ones that were badly-reviewed. But because they were on the ‘wrong’ side of the street I couldn’t use them. I was told that catchment areas have to do with out-of-hours service provision, but why can’t I elect to forgo that option — in a real emergency I’m going to the hospital anyway, and at any other time I can get myself down the street regardless — as part of the sign-up process? It’s true that patient choice *could* reward the choosiest at the expense of the most vulnerable, but neither group is well-served by the current system in which it’s really a lottery as to whether you’re in the ‘right’ area or not in terms of care.
I look forward to hearing your thoughts on how this type of issue could be addressed!
Thanks for your thoughtful comments. There is a real problem with variabilty of quality of care in the NHS and I believe that reform of the NHS to address this is urgently required. I believe that the experience of markets in health care with competition and patient choice leads to even greater variability in quality of care and to worse access. The OECD rated the NHS as top of 21 surveyed countries for access. This, probably more than any of the other criteria, is a measure of the system of care, rather than outcome data which is highly determined by social and environmental factors. It is interesting that the commonest complaints about the NHS are over access. I have not seen data from other countries.
I’m saddened that there is very little serious debate from politicians, health policy experts (I am not one, I am a ‘jobbing GP’), the BMA, health economists and so on about ways to reduce variablity and improve quality other than by using choice and competition. I believe that if there is a silver lining to the dark clouds in this bill, it is likelihood that GPs will have to take responsibilty for their peers in commisssioning consortia. I believe, as the Royal College of General Practitioners has previously argued, that GPs should be federated to achieve this aim. Unlike the commissioning model, I believe that there should be no purchaser-provider split because it hinders rather than facilitates collaboration. Unlike the commissioning model, the federated practices should not be able to choose who they federate with (so cherry picking and lemon dumping) but should be given joint responsiblity for a geographical area of approximately 500k patients (depending on the density of population) There should be independent members of the federated body to ensure fair-play between practices. The responsiblity for outcomes should be shared not only among the practices, but the hospital and other providers, so that we are all working towards the same aim. Again, this only possible by abandoning the purchaser provider split. Given the safeguard of a number of practices taking joint responsiblity, I believe that patient choice would be less risky than it is under the present or proposed system where it is of little interest to anyone if a practice is underperforming and already practices are being highly selective about who they join up with to form consortia. If we moved to this model, I believe that there would be less variation, better quality overall and less demand (or need) to change GP.
I’m glad you’ve covered this. I’ve been quite worried for a while now about the corporatism of primary care and I do not think the public would like what the final effects of this policy will be.
I live in a small town, about 22k, and there are two GP practices (less than 100m between their surgeries) both are convenient for me. When we moved here we more or less chose randomly. However, one neighbour who moved here a decade before pointed out to me that she chose her GP – not the one I use – because they had a female doctor and the one I use didn’t. Things change. When we moved here both practices had female doctors. Did competition change things, so that the all-male practice decided they must get at least one female GP? I don’t know, I’ve never asked. But now female doctors are in the majority at my practice, most likely reflecting the gender of graduates.
However, the talk of phlebotomy is interesting. When we moved here I could have blood taken at my GP for a GP appointment or for an appointment at the local hospital. The blood is tested at the same place anyway (there is a pathology network here, so several hospitals use the same facility). Wonderful! I have a choice – go to my GP or go to the hospital.
Then something changed – sorry, I was not paying attention to health policy at the time, but I guess it was the re-introduction of the Internal Market – I was told that the phlebotomist at the GP would only take blood for GP tests, if the blood test was for a hospital clinic then I would have to go to the hospital. (In fact, it was slightly different to that, the *hospital* phlebotomist would stop visiting the GP, and the new phlebotomist that the GP would employ would not take blood for a test for a hospital clinic.) I was told that this was because of “who was paying for the test”. I cannot remember when this was 2000?, 2002? dunno. But my choice was taken away, and since I live considerably nearer to my GP than the hospital the change meant I was inconvenienced, so it wasn’t done for my benefit. Whatever decision it was, the effect was to stop collaboration between the hospital and the GP.
I am afraid these reforms are meant to be more of the same. If you have a market of providers you cannot have collaboration. These reforms are not about choice, they are the natural development of the Internal Market and the Internal Market is not about patient choice. It may be about commissioner choice, but the patient is largely left out of that decision making.
Can you explain a bit more how federation would work?
I can certainly see the advantages to collaboration over competition at the local/regional level in order to ensure efficiency of provision (e.g. go to the nearest provider for ‘x’ test and we’ll have the results forwarded to your GP), but what does it mean to me as an end-user of healthcare? Even in the absence of poor-quality doctors in a particular area, it’s obvious that a good relationship with a patient can improve quality-of-care and that giving patients more choice would, generally speaking, be a good thing. So how does federation work to foster accountability and flexibility in end-user healthcare?
Shifting to reflection for a bit… there is always going to be a tension between the best global outcome (decent healthcare for all) and the best individual outcome (best healthcare for me) that any universal service will have to wrestle with. God knows that targets were a terrible way to do that, and so a shift to outcomes (if they’re not just easily-measurable targets under another name) is a small step in the right direction. But I can’t help noticing that all governments think that major changes in direction and structure will somehow save money and deliver better outcomes, particularly when done quickly. It’s as if mechanics were expected to fix planes… while they’re in midair.
Federating would have several strands, including peer review of referrals and much improved referral criteria. A merging of primary/secondary/social care (Muir Gray is a proponent of this and has written more) There would be frequent interdiscipinary meetings and better communication.
Choice would make this difficult. For example I just about manage to meet with our local diabetic, psychiatric and neurological specialists, I meet with our health visiting team, midwives and district nurses. Choice would make these face-to face meetings impossible, there simply is not enough time to meet with several of each, it’s almost impossible now.
The other problem with choice is that almost every GP I know complains that people making decisions about primary care ignore the importance of ‘continuity of care’. This improves safety and efficiency. Choice, conflicts with continuity.
The probably irresolvable tension is between a minority of chronically sick, vulnerable people who account for the great majority of our work who need continuity and stablity, and another minority of relatively healthy, highly articulate people, who would prefer the NHS designed around them. I don’t count you amongst them, given the serious concern you have shown, but I do count many people in positions of considerable influence r/e NHS reform. The majority of people fall somewhere inbetween these minority groups.
r/e the federating. For example. A federated area includes 500k patients which includes 3000 people with diabetes. The care of those people is shared between the patients, the community speciaist nurses, the GPs and the hospital(s) All the different parts have to work together for the highest possible standards of care, learning from the best examples and sharing best practice. The proposed system, does not enable this kind of collaboration, or give sufficient attention to improving the care in outlying practices.
First, a few thoughts on choice. Choice in a market works (according to classical economists) when you have many small providers, many small consumers, and everyone knows the score (perfectly informed). So, works quite well where products are identical (“how much is your large tin of Heinz BB?”) or differences are WYSIWYG (“I don’t like the taste of your coffee, and prefer theirs”). This doesn’t apply in many markets (we’ve seen the consequences repeatedly in financial services), and health is a very good example. Provision is monopoly or oligopoly (few large providers), and information is poor. Worse, because the superficial impression of quality (soft furnishings and bedside manner a la Shipman) may be poor indicators of clinical quality. Finally, in order to share risk, all developed health care systems have elements of insurance, with it’s risks (look up “moral hazard”, for example). All this leads, at very least, to heavily regulated, and still highly imperfect, markets.
Next, competition in the NHS. Apologies to all those who think there’s never been competition in the “NHS Family”, but I think there’s always been competition, mainly over resources, but also for influence, prestige, even staff. Teaching hospitals compete over who gets the paediatric cardiac unit (witness recent JR case on this), and we wouldn’t want (but often get) the situation where every teaching unit has one that’s too small to be any good, with everyone, particularly local politicians, colluding to pretend it’s for the best. Practices compete (we’ll see competition soon for the best managers); clinical teams compete. What we’ve seen less of is overt, commercial competition. A few thoughts on price. First, tariff currently only applies to a part of healthcare in UK. Hospitals earn a lot outside tariff (see non-tariff drug costs, if you doubt this), community and mental health care (most areas largest programme) have comparatively little tariff. prices already vary. Also, in selected circumstances, a wise commissioner might wish to pay more, or less than the given rate. If a provider was able to offer a much better service, and convinced me it needed to cost a significant amount more (say 1%), I might be prepared to pay that. Also, if a provider came to me with a transformative technology, and said they could cut costs, I might like to share their savings. So, taking price completely off the table is like giving me a toolkit to fix my bike, but denying me a torque wrench. I wouldn’t want it very often, but it would be bloody useful when I did.
Finally, to the point, competition vs cooperation. Some recent colleagues and I used to talk about 3 Ps: Provide (DIY), Purchase (buy/ commission), or Partner. Bearing in mind we were in a commercial setting, you may find this surprising. IMHO, our best relationships were among the partnerships. Built on values, as well as commercials. What NHS managers (including clinicians) is the behavioural flexibility to do whichever P is appropriate (I would never try to partner certain organisations, it will always have to be different). Final point is that you can’t legislate for these things, so forget the White Paper, the Bill and being “Liberated”, JFDI. Just remember, not everyone else will do it back.
P.S. The estimate of number of diabetics in 500K population is way under.
Very clear,as always. If we assume that there are 8000 practices in England what % are in different categories.I am not even sure abour the number of categories eg community interest co, private partnership, not for profit company,for profit co standalone, pms owned, owned by private equity
Thank you for the clarification. This is something, as you say, that was begun many years ago by another Tory Governement is it not?
Both my parents were Nurses in the NHS and I always remember their comments when the wonderful “Matron” was done away with in favour of a Hospital Manager – who was more often than not brought in from a completely different non-medical background.
Things have been going down hill ever since. Of course the NHS needs to be run profitably but it is not a run-of-the-mill business.
Peoples lives should not be gambled on profit margins.
Thanks Mellojohnny for invitation to comment.
Our experience in Australia is thus:
We have a mix of private and public (medicare or bulk billed ) billing. We have a mix of privately owned and corporate practices and like the UK are seeing the demise of smaller solo practices for a variety of reasons, alot of which may be related to lifestyle.
Anyhow in our outer metropolitan regions which are generally (not always) of lower socioeconomic demographic there are shortages of GP’s .
Corporates move into these areas as well as inner urban, however the business practice is different. Overseas trained Dr’s are mandated upon entry to work in Australia to serve some time (like jail) in areas of high workforce need; that is undersupplied with Drs. Unfortunately these Dr’s are sometimes impoverished themselves upon arrival into Australia.
The medicare payment here generally favours quantity over quality consultations which suits in my cynical opinion the govt who do not understand nor care to understand the professional requirements of general practice. Anyhow poorer patients without a choice now have a corporate run clinic with often overseas trained Dr’s ( OTD’s) under all sorts of pressures to see the high volume of patients very very quickly.
Patients can choose their Dr here, however without a choice of practices in outer areas they are not so lucky.
And I am not disparaging my OTD colleagues as I believe they are taken advantage of by both Govt and corporate’s alike.
The idea of a profit from a professional practice (like medicine accounting or law) leads to all sorts of perverse incentives and starts to view the medical consultation as a transferable product rather than as a trusted service. the therapeutic relationship such as we call it in Geneeral Practice is completely ignored. This is akin to conveyor belt medicine, a rat in a rat wheel etc and dont the economists love this idea of ticker tape syphoning off of a dollar very every interaction. The govt loves the idea of “efficiency” and thus the professionalism of medicine; the control we have as Dr’s to provide quality care diminishes.
I think there is something wrong with the MBA types who still think Robert Macnamara economics works but even he said at the end of his life that not all things can be measured in numbers. For instance he thought he could tell who was winnning the Vietnam war by the number of Allied vs Communist body bags. A totally different kind of war.
Robert McNamara was Ford Motor cars president and then American Secretary of defence. Loved his “numbers” and a clever man. Unfortunately spawned a whole lot of economics based on measuring numbers. As we know in General Practice and in Helath in general, whilst numbers play a part (for certain) it is not the whole picture. Trying to understand Medicine from a purely numeric point of view you will miss the understanding of it.
Which is why corporates who only wrangle a general ledger, participate in quarterly reporting and serve the profit god, will savage our industry which is a service based on professionalism not a product based on a number. I am a passionate believer in Doctors being the masters of their own destiny as the complexity of advocating for patient care is overrun by Governments looking to save money via the word “efficiency” and business interests looking to make a profit.
Anyhow I am a female GP , the lowest paid of the medical profession, as we see longer ,more complex consultations in general (Beech report based in Aust). We are no less efficient than male GP’s however we are selected by patients alot of whom are women or elderly. We are also less likely to own our own practices so efficiency income quality care and numbers are really thorny issues for us.
I have a number of other soap boxes but I had better stop right here!
Good luck wrestling control of professionalism from all the players trying to wrangle a measurable outcome from our long and noble tradition of caring for patients.