Most GPs are worth it

Published in the Evening Standard 20 April 2006

If everyone was shocked by this week's report that some GPs are earning upwards of #250,000, then those of us who live in Stoke Newington were all but knocked over by the Standard's revelation that one of the very highest earners works right here. There on yesterday's front page was Dr Satya Gupta and his Oldhill Medical Centre, a shabby looking building on a rundown street in one of the poorest boroughs in Europe. As if to demonstrate the contrast between his personal wealth and the community he serves, the photo showed Dr Gupta's red Mercedes parked outside - complete with personalised numberplate.

First instinct: there must be something wrong with that picture. Surely it can't be right for anyone to be trousering that kind of cash from the public purse. After all, it's our taxes that paid for that Merc. There's probably an extra queasiness that Dr Gupta and the other quarter-millionaire medics have made their money off the backs of the sick. That in an area like Hackney, rife with social deprivation and its accompanying ills, from drug abuse to diabetes, there's money to be made from the illness of others.

Those are the first instincts, but they might not be the right ones. For one thing, even the Association of Independent Specialist Medical Accountants, who carried out the latest study, admit it is only "a handful" who are earning £250,000. The national average is likely to be closer to £100,000, rising to £125,000 for London GPs.

Second, there's only so much outrage to go around - and I can muster less of it to hurl at doctors, doing a tough, skilled, valuable job, than I can at, say, the hedge fund managers and investment bankers for whom £250,000 looks like a particularly heavy drinks bill. In a world where Wayne Rooney can earn that money playing a few matches, where Jonathan Ross gets £530,000 for three hours of (admittedly inspired) broadcasting on a Saturday morning and where Lakshmi Mittal can amass a £15bn fortune, spending £57m of it on a house in Kensington Palace Gardens - not quite twice the reported £31m he laid out on a six-day wedding party for his daughter, which featured entertainment by Kylie Minogue, washed down with 5,000 bottles of vintage champagne - I can't get too irate about doctors who break into six figures checking the phlegmy throats and wheezy chests of the sick.

These, after all, are people we really need. To be an inner-city doctor, dealing first-hand with the pain of urban life at its poorest and toughest - from teenage pregnancies, through rising rates of TB to the obesity that comes with poverty - is not glamorous, but it is truly necessary. If we are to attract good people to do these jobs then, as any employer knows, we have to pay them properly.

And it is a sound investment. The key explanation for this latest rise in GP salaries - estimated at some 23% - is the General Medical Services contract, introduced exactly two years ago. That established a points system, rewarding those GPs who provided good quality care and, especially, took on valuable preventative measures, like checking older or overweight patients for cholesterol and blood pressure. That saves money in the long run because it prevents illnesses that would eventually force patients into hospital, where they would consume many more precious NHS resources.

Which is not to say things are perfect, far from it. Clearly, the government goofed badly when it drew up these new contracts. Under the new system, in which "points make pounds," GPs were expected to earn around 700 of the available 1050 points. Instead doctors have surprised ministers by notching up 900 or more, with many clearing the 1000-mark. The result of this "over-performance" by doctors has been a financial overspend by the NHS of some £300m.

the Department of Health, then under John Reid, simply set the bar too low. "I think they were just unfamiliar with the nature of general practice," says Laura Sharpe, Chief Executive of the City and Hackney Primary Care Trust, which, as it happens, pays for the services of Dr Gupta. Another insider is more candid: "They were too bloody soft."

That means the rules have to be redrawn, to make mega-earnings less likely. The government allowed themselves to be outplayed by the masterful negotiators of the BMA and now they need to recover some lost ground, to get a better deal for taxpayers.

But they, and we, should also have a larger rethink about GPs. Most of us see our local doctor as the face of the NHS - yet how many realise that GPs are not even employees of the NHS? Each practice is, in fact, a private contractor which sells its services to the NHS, via Primary Care Trusts. That's partly why they always have an eye on the balance sheet. As Laura Sharpe puts it, "GP surgeries are small businesses."

This is not a mere technicality; it has a real-world impact on patients. The charity Action against Medical Accidents, or AvMA worries that GP practices can be "a law unto themselves", beyond the reach of NHS accountability. There is no institutional mechanism for ensuring mistakes are not repeated or that lessons are learned across the profession. This point was made repeatedly at the public inquiry into the deaths caused by the GP Harold Shipman.

One solution would be to iron out the anomaly and make GPs direct employees of the NHS. But that is not likely to find much sympathy with a government keen on more, not less, private provision in health. In which case, NHS managers could insist on more co-ordination among GP practices, ensuring that they operate as a coherent branch of medicine, not as thousands of separate businesses.

Change is necessary. But let's not imagine it will come cheap. We all want our doctors to be well-trained and efficient. And if we want that, we should be ready to pay for it.

Posted on April 20, 2006 11:08 AM

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