The Demise of British Primary Care
By Dr Bob Gill
Britain’s primary care system has been the foundation of the National Health Service (NHS). Current spending on primary care is less than a tenth of the total cost of the NHS yet accounts for 90% of all patient contacts with the service. UK healthcare’s overall ranking remains high compared to similar economies (1) and public satisfaction had improved in 2019 (2) with outpourings of support during the height of the pandemic. Politicians and the media joined in the acts of appreciation which for the majority was cynical opportunism to portray themselves as supporters of a system they have been actively undermining for years in preparation for American corporate takeover.
By the inception of the NHS in 1948, general practitioners (family physicians) had been persuaded to join this revolutionary social advance, with the promise of secure funding based on their registered patient lists. GPs would become independent contractors within a heavily regulated system that paid them for caring for their registered patients, trained new doctors, provided access to community and hospital services for their patients and provided them a state-funded pension on retirement. The system was the first in the world to provide universal, comprehensive, tax funded care, free at the point of use and facilitated the more even distribution of medical resource, previously concentrated in the affluent areas. The NHS a central pillar of the post-war welfare state helped deliver the greatest improvement in quality of life for working people.
With the election of Margaret Thatcher in 1979 and her government’s free market ideology which saw the privatisation of public utilities and natural resources, it was only a matter of time before public services would receive the neoliberal treatment. Out of necessity NHS privatisation had to be heavily disguised and incremental to avoid political suicide.
Legislation currently before the British parliament will complete the long series of well planned legal changes that repurpose the NHS into a corporate cash cow replicating American Medicare and Medicaid programmes – publicly funded, privately controlled and privately delivered healthcare.
The pandemic has provided cover for a more direct assault on exhausted and demoralised health professionals with the fundamental overhaul of primary care that will see GPs relegated to corporate functionaries in a system devised by and for the benefit of globally expanding American medical industrial complex (3) that delivers worse patient outcomes at more than twice the per capita cost.
Rolling back Beveridge
The 1942 Beveridge Report (4) set out proposal for the Welfare State which the post-war Labour government set about implementing. The NHS was to provide the nation with universal and comprehensive medical, dental and eye care funded through general taxation.
Prior to the Thatcher era market reforms, the administration costs were less than 4% of total NHS budget with the remainder spent on staff, buildings and medicines. As a result healthcare was extremely cost-effective, delivering great improvements in life expectancy, infant and maternal mortality. With GPs in every community, preventative health programmes and continuity of care contributed to further health and cost gains.
In 1990 the internal market was introduced splitting the NHS into GPs as purchasers and hospital as providers of care. The bogus neoliberal rhetoric of improving efficiency ushered in the commercial personnel, methods and language while perversely driving up administrative costs by an additional 10% raising it to 14% by 2006 estimates (5). Some GPs grabbed financial opportunities to adopt market reforms such as becoming fundholders with most generous rewards to early adopters, creating winner and loser practices. So began the divide and rule tactics and behavioural conditioning using financial incentives and administrative penalties to reconfigure primary care.
Entrepreneurial GPs dragged the profession along the commercialisation road taking a leap forward with the 2004 GP contract which created a two-tier GP status of partners and salaried doctors, out of hours care responsibility was removed and opened up to commercial providers. For the first time private companies could prise open primary care funding winning contracts which until then a state funded monopoly with doctors providing the services.
Doctors’ incomes that previously contractually bound to actual patient contact were decoupled so that clinical work could be delegated to cheaper salaried doctor substitutes. Many boosted incomes further by providing clinical window dressing for more commercialisation and marketisation. A greater proportion of GP income also became conditional on performance targets thus introducing another control mechanism to shape GP behaviour by incentivising particular patient care activity, but also non-clinical and administrative work to deliver system and ethos change not improve patient care.
The Health and Care Act 2012 created new geographically based organisational bodies called Clinical Commissioning Groups (CCGs), formed of GP practices with GPs on the boards. CCGs were modelled along the lines of private insurance systems and empowered to reconfigure hospital services including outsourcing of profitable elective care, rubber-stamping hospital emergency department closures and bed cuts (6). GPs had effectively been co-opted into destroying the Beveridge model of healthcare.
Consensus and cover-up
Cross-party political consensus has been essential for the privatisation of the NHS to succeed. When asked about her greatest achievement, Margaret Thatcher famously answered (7):
“Tony Blair and New Labour. We forced our opponents to change their minds.”
In power from 1997 to 2010 New Labour perhaps achieved more to accelerate this agenda shielded by the reputation of being the party that created the NHS.
Private Finance Initiative (PFI) schemes were used by Blair’ government to fund the building of new hospitals. The NHS was saddled with £11 billion of private debt which would cost £88 billion in repayments. PFI destabilised hospital finances creating a funding problem for which the solution was more contraction of bed capacity, rubber stamped by CCGs. At the end of the loan repayments, ownership of the assets remained with the private investors. Just imagine buying a house with an extortionate mortgage and not owning the house when the mortgage was paid off. That’s the scam of PFI (8).
Profitable elective surgical treatments were outsourced for the first time since the founding of the NHS (9). Major GP contract changes and privatisation of out of hours primary care provision preceded the co-option of the health unions with the Social Partnership Forum agreement in 2006 effectively neutralising their opposition to privatisation in all but rhetoric (10).
Corporate media silence on the decades long assault on the NHS is quite remarkable. Reporting on the NHS simply echo press releases, politicians escape proper scrutiny and policy is not adequately challenged. System failure due to lack of resources or fragmentation as a direct result of health policy is seldom highlighted but instead used to undermine faith in the NHS model. Dissenting voices are rarely granted a platform on mass media which actively manipulates audiences with praise for our beloved institution whilst covering up its demise.
The British Medical Association perhaps deserves the greatest condemnation among health unions and professional bodies. A membership organisation and a union which is funded to defend the interests of doctors has actively colluded against their interests and the interest of patients by providing cover for the market reforms. Successive legislation has not been actively resisted and the profession marinated in a manufactured ignorance to the implication and ultimate goals of the reforms.
The BMA endorsed the 2004 GP contract which in the short term was a welcome boost in income but effectively bought off the principle of public NHS provision of tax-funded primary care and created a second class of GP. In 2006 the BMA signed up to the Social Partnership Forum agreement, covertly aligning with the market reform agenda, and failed to oppose the 2012 Health and Care Act which removed the Secretary of State for health’s statutory ‘duty to provide’ healthcare effectively abolishing a founding principle of the NHS.
In 2016 the union sabotaged its own potentially game-changing junior doctors’ industrial action (11), destroyed the momentum of the dispute and squandered overwhelming public support, ultimately delivering consent for the originally imposed contract that significantly worsened pay and conditions for doctors. Helping deliver a cheaper workforce with fewer protections ahead of future transfer to private corporate operators has contributed to the recruitment and retention crisis in primary care and NHS as a whole.
In February 2021 the BMA endorsed the Health and Care White Paper which preceded the Bill currently before parliament (12). The bill will complete the NHS transition to an American style healthcare systems.
The 2008 financial crash unleashed yet more economic fundamentalism in Britain doubling down on Thatcherite policies that led to the crash and spiralling wealth inequality. By the eve of the coronavirus pandemic the NHS had endured a decade of defunding and contraction.
From 2014 to 2021 the stewardship of the NHS had been in the hands of Simon Stevens, ex-President of American private insurance giant UnitedHealth’s global expansion division, who had set out two years earlier his former employer’s solution for developed countries’ healthcare systems at the World Economic Forum (13). His prescription was to replicate America’s private insurance industry dominated by its ‘managed care’ model. Stevens as Chief Executive of NHS England had engineered the dire state of the NHS leading up to the pandemic.
The government’s pandemic response was to squander billions of pounds on private companies with no experience in healthcare and often without due probity (14). It has been one of the most expensive, most privatised and least effective public funded health programmes in the world.
GPs were effectively excluded from participation in the early phase of response, unlike in other countries (15), replaced by the outsourced telephone triage system NHS111. Access to doctors was limited by government instruction leading to significant unmet need, delayed treatment and diagnosis and damage to trust in primary care services.
The right wing press scapegoated GPs blaming them for growing patient dissatisfaction and diverting attention from the government’s catastrophic performance, capped with the forced discharge from hospitals of infected patients into nursing homes leading to over 20,000 preventable deaths (16).
A year into the pandemic with the profession exhausted and demoralised, the government took the opportunity to publish the legislative plan endorsed by the BMA, other health unions and medical Royal colleges. Despite the enormous implications the 2021 Health and Care Bill has escaped media scrutiny (17).
The ultimate corporatisation of primary care within the new American-style Integrated Care Systems (ICS), created by the Health and Care Bill, has been championed by pro-market Policy Exchange (18), was revealed by ex-banker and current Health Secretary, Sajid Javid MP (19). The Times headline is a masterful example of Orwellian double speak: “GPs nationalised in Javid plan to reduce hospital admissions”. The intention is that the existing GP independent contractor status is to be replaced by a totally salaried doctor arrangement which has been initiated in Wolverhampton (20). The article neglects to inform the reader that the ‘nationalised’ GPs will in due course be working for corporate run ICSs.
Most importantly, the GP practices’ registered patient lists with their capitation budgets are swallowed up by the ICS to include all public health and care funding from which profits can then be siphoned out by the controlling corporations, including UnitedHealth.
Few recognised that this was the ultimate goal of the GP contract changes from 2004 and further progressed in 2019 with the creation of Primary Care Networks (PCN) using a new contract which the BMA endorsed as a harmless additional funding stream, without meaningful debate or a vote of its membership.
The PCN contract solution for GP workforce crisis was not to directly recruit or retain more GPs but to fund the ‘additional roles reimbursement scheme’ to expand the number of non-doctor substitutes. Private healthcare always seeks to reduce cost which includes down-skilling the workforce, eroding quality and safety along the way. The PCN contract introduces explicit incentives to reduce medical spend on patient care (21):
“We will also offer primary care networks a new ‘shared saving’ scheme so that they can benefit from the actions to reduce avoidable A&E attendances, admissions and delayed discharge…”
Or as President Nixon’s adviser Ehrlichman put it so clearly when describing the essence of this healthcare model in 1971 (22):
“All the incentives are towards less medical care, because the less care they [HMO/ICS] give them [patients] the more money they [HMO/ICS] make”.
Working for the PCN within the private corporate operated ICS designed to create profits will inevitably diminish the status, autonomy, job satisfaction for medical staff and quality of care for patients. Doctors are seen as a cost centres in privatised healthcare so the fewer there are, the weaker their authority, and the more incentivised they are to save money, the better for the bottom line. The evidence for the devastation caused by the programme of shrinking bed capacity and closing emergency departments has been laid bare by the pandemic (23). Even a leading pro-market think tank assessment of the ICS programme is that it is a failure (24) but government remains hell bent on replicating the dystopian American system which has medical error as the third leading cause of death (25).
There are a small minority of GPs who will prosper under the new arrangements – by continuing to exploit salaried doctors and medical teams at scale then selling out to corporations like insurance giant Centene (26), or by securing lucrative appointments within the new system’s bloated management bureaucracy or an establishment honour as reward for past co-operation or ideological alignment. But the vast majority will lose out, as will their patients.
Overdue collective realisation
GP morale is at rock bottom (27) enduring press attacks (28), loss of public trust, reduced numbers to cope with increased workload (29) generated by growing waiting lists and overstretched hospitals. A crisis of government creation is being cynically exploited to destroy what’s left of traditional general practice that has served the patients well (30). GPs are in survival mode and many look for an escape from the front-line while the BMA continues to assist the profession’s demise.
It will be difficult to adjust to the growing unmet need and preventable suffering of our patients that will inevitably arise from the denial of care for patients. The pandemic inflicted societal psychological trauma and helped to erode standards and expectation but there is still some way to go as waiting lists are allowed to grow and more services are stripped out of NHS provision. The magical thinking associated with hyped potential of virtual and remote services (31) is cover for abandonment of the social contract to care for the sick.
Further loss of continuity of care and dilution of GP involvement may provide some protection against any ethical or moral tensions raised by the corrupted system. Being relegated to just one of many functionary cogs in the ICS machine will also diminish the sense of professional responsibility. For others the psychological burden will hasten their exit. Memories of public service ethos, effective patient treatment and advocacy will be suppressed out of necessity to satisfy commercial objectives.
The vast majority of doctors have to work to live and also rely on the NHS for healthcare when needed. We have a shared interest with our patients to have high quality healthcare delivered by competent, well rewarded and ethical doctors who have no other consideration than to treat the sick in the best way possible.
First they came for the cleaners, then the caters, then the porters, then the student nurses, then the junior doctors and now they are coming for the GPs.
Is it too late for an effective push back? Can enough brave, informed and energetic doctors, patients or concerned citizens create and effective resistance?
Only with understanding of the threat, discarding the fallacy that our politicians and media are serving the public interest, bypassing co-opted and controlled channels to reach out directly to the mass of the public can we build the necessary citizens movement to win back our NHS (32).
5. Microsoft Word – FinalReportFinalVersion (whatdotheyknow.com)