Saturday, 19 March 2016

A discussion we need to have in Scotland

While the big news is the split in the Conservative Party over the EU is now a chasm with the slithering Duncan-Smith resigning and blaming his 'personal war on the most needy and vulnerable' on the idiot Osborne's austerity policy. Meanwhile, in the back of the broom cupboard where Labour's Scotch Eggs are having their party relaunch for the nth time, Dugdale is promising us a GP service I guess most of Scotland already enjoys, access to their GP when medically needed on the same day or within 24 hours. This leaves me wondering just what the point of the 48 hour promise actually is? 

As many know NHS Helpline routinely gets calls for medical emergencies such as 'running out of nappies' phoned through to it. In some cases, because the punter does not get the 'emergency help' from the NHS Helpline, they then go and phone 999 or 911 for help with the nappy problem. In effect Dugdale's promise on GP access is on a par with phoning 999 because you have run out of nappies. 

There is a big problem with Scotland's GP services which is the NHS Scotland contract for GP services is no longer fit for purpose. As a result GP's in GP services have been complaining for around two decades about work load and annual rounds of under funding of GP practice. In doing this they have helped create the current GP recruitment problems they are suffering which have, in part, caused the increasing workload, along with a related increased micromanagement of GP Practice by NHS Scotland. 

Let us be clear GP services in Scotland are not yet at the level of melt down or crisis which is increasingly common across England where practices are shutting their doors as GPs retire without replacement, leaving tens of thousands without any GP cover. Neither are we, in Scotland, immune from the impact of the last of the post war 'baby boomer' generation coming towards retirement as GPs. 

The problem after two decades of GPs in Scotland complaining about their lot, the new generation of recently qualified doctors are avoiding GP training pathways, if at all possible. Those who have followed the GP training pathway are not interested in signing up to the current GP sub-contract and prefer to work as either salaried or locum GPs, rather than joining a medical practice as a partner which up until ten years ago would be the norm. Throw in over 50% of UK medical and dental graduates are now female and are likely to take time out to have families in their late twenties and thirties and you have an inherent GP partner recruitment problem. These ladies normally come back to work in their late thirties and early forties but routinely job share, as this makes child care easier to organise, some ladies do return full time and there are those who never marry or never have children.

To understand why the current GP contract is unfit for purpose and increasingly a block to young doctors training as GPs we have to go back to 1947. In 1947 Bevin was having problems as neither the GPs nor the Consultants were buying into his plans for the NHS. The BMA committees representing both these groups were digging their heels in, basically saying, "over our dead bodies". Bevin's Parliamentary Secretary, Michael Foote, asked his boss how they were going to get round this impasse to which Bevin's answer was, "I am going to stuff their wallets with so much cash they can not refuse."

To do this Bevin allowed the GPs and Consultants to, in effect, remain private contractors (thus keeping all their related tax benefits) committed to a certain number of heavily subsidised hours of NHS work each week with all sorts of add on benefits if they carried out 37 or more hours of NHS work each week. Over time the GP contract excluded any mixing with private practice in the same building, until by the late sixties virtually all GP practices were NHS practices and private GP practices hardly existed outside of Harley Street in London. 

The GP contract's bones have remained those of the original 1948 contract with the principle doctors as nominal 'private' practitioners taking on NHS contract work. We also need to consider the modern multi GP practice is a recent concept, starting in the late 1970's as the demands on GP services became more complex and meeting them, as a single practitioner, became ever more expensive. Pooling financial resources and sharing investment costs became the norm, as did the increasing centralisation of GP services in 'Health Centres' as partnerships between individual NHS sub-contracting doctors grew in size. Throw in the paperwork created by ever more complex employment law, health and safety, drug control, cross infection control, hazardous waste disposal and environmental protection issues, along with increasing NHS Scotland micromanagement, and would you be interested in investing upwards of £150,000 to be a partner in the average GP NHS Practice in Scotland.  

Even with tuition being paid for Scottish under graduates training in Scotland, the average Doctor or Dentist is sitting on, in excess £60,000 of debt on qualifying from a Scottish University which the BMA estimates will take until their mid thirties to pay off. At the same time, to ensure these doctors and dentists move up the training ladder, they are also having to put their hands in their pockets to pay for courses and Royal College examinations, as they follow their preferred specialisation. A cost which is upwards of £15,000 depending on their ability to pass these exams first time (the pass mark is routinely 80+%). So to become a GP, by your mid thirties, you will have to manage a debt of around £75,000 while possibly trying to buy a home and look after a family. Just when you get all that paid off, the principal GP in your practice asks you to cough up £150,000 to become a 'full' partner and all the hassle, regulatory burden, additional responsibilities and angst that involves you with. 

At that point you hear a numpty politician trying to get elected on a promise that is an insult to you and your profession and wonder why be a GP, just to be a political whipping post?

So you decide life is far better being either a salaried or a locum GP, even though it will inevitably mean the collapse of GP services as we, the patient, knows them when no GP's are left who are willing to take on a NHS Scotland GP principal contract number and the costs and burdens that currently encumbers you with.

The real problem is neither the GPs' negotiators in Scotland nor NHS Scotland appear to be willing to think about the inevitable collapse of the current GP practice system which will begin to happen over the next decade, just as it is already happening in England. Solving the looming problems within NHS Scotland's GP services needs more than the current 'sticky plaster' approach or 'blame game'. 

I suggest we need a radical overhaul of how NHS Scotland funds GP provision, away from the Bevin style contract 'with knobs on' they currently use. Primarily because the traditional contract is killing GP practice, starving it of its most vital resource, young doctors, and is no longer as cost effective a way of providing GP services, as it once was, given the level of NHS subsidies which are thrown at GP services. The proposed new GP computer system being a case in point - not to be mixed up with the £1 billion plus IT disaster which currently hangs around the neck of NHS England.

A salaried GP service, in my opinion, is inevitable as it is the best way to encourage new graduates into GP training schemes (being salaried appears to be their preference) and allows for a better ironing out of the problems of the numbers of lady doctors taking time out to have a family in their thirties and job share in their 40's.

Bevin's GP contract has had its day, as has the day of the 'Aye Beens' of the BMA's GP Committee in Scotland and NHS Scotland. Time to look forward rather than back and address the realistic needs and expectations of both GP doctors, as providers, and patients as users of NHS Scotland GP Services rather than just yet another cheap, political stunt.

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