GP Contracts

Ellis Thorpe

How a professional group like GPs operates as part of the power elite in a capitalist society with a free market economy, is revealed in the new GP contract.

A deal signed in London with the New Labour government, with just a passing nod to the Scottish Executive's health minister (or the wishes of the people of Scotland); the contract reveals how little commitment some GPs have to the NHS. Or little regard for their fellow workers in the NHS.

But of course GPs are not workers in the sense of being employees of the NHS. They are private businesses contracting out their services to the state (or government of the day). What appears to be different is that unlike other independent contractors, for example in the oil industry, some GPs are prepared to exploit to the full their market power in order to obtain maximum economic rewards. As the recent GP contract shows full well.

Now in our local communities the "family doctor"; responsible for cradle to grave twenty four hour care, has given way to the "nine-to-five-five-day weeker", the creation of New Labour in our "modernised" market-oriented NHS. GPs are no longer responsible for what is called out-of-hours care, which means in reality no evenings, nights, weekends or public and bank holidays. Care will be provided by the Health Boards, or increasingly by private health care companies.

What rewards has New Labour given for this new breed of GP? Although GP payments are kept from the public, who pays GPs through the stamp and tax, it seems the average GP pay is around £72,000 from the NHS, rising for some to £84,000 a year. A 27% to 50% pay rise for a two thirds reduction in hours of responsibility. However, the icing on the cake is while some GPs wanted out of the NHS, apart from "9-5/5", many want to opt back in for large extra payments; said to be around £400 plus expenses for one session out-of-hours. Nice work if you can get it.

Most people will be familiar with NHS24 and this is the hub of the new out-of-hours system. The change is that in Grampian for example, there are seven or eight centres and a staff of twelve GPs to cover the whole area out-of-hours. The GP from one centre will make home visits if deemed necessary but patients could be told to go to a centre for treatment up to 20-25 miles away.

Is this universal health and medical care for all free at the point of delivery?

It is argued by doctors that GPs were not coming forward because of pay or hours of work, like for example being on call overnight and taking surgeries the following day. How correct are these reasons for the new contract? A recent report from the British Medical Association (BMA) says there are more medical graduates choosing to be GPs than ever. What is worrying are the numbers of both male and female doctors working part-time for the NHS. Who wouldn't if the pay is around £40,000 a year for 2½ days a week. Moreover, can it be said the majority of GPs in health centres throughout Scotland were on call overnight and then took surgeries the following day?

What the new contract means is a greatly reduced service for patients, a huge increase in costs, for example the funds for GPs are rising by 33% this year and for many patients a period of anxiety about the changes. Some GPs in one or two areas, usually remote and island communities, have expressed the view the new contract could put patients' lives at risk. The elderly living alone are expressing worries and lone parents with young children in particular are vulnerable. And of course a large group of working people with no transport. There is also justified concern that as the meat of the out-of-hours service is already provided by the ambulance service and paramedics, these workers will be stretched beyond endurance and for pay considerably less than the average GP.

What should concern the Left is how the new contract is one more inexorable step towards more privatisation of the NHS. Once the "family doctor" was the first line point of contact for all patients with the NHS. Now with NHS24 and the new system of out-of-hours service this is no longer the case. Paradoxically health boards will be recruiting doctors as salaried employees a step in the right direction for the wrong reason. Already in some areas the fall-out from the new contract is health boards getting doctors from Poland and Germany for the out-of-hours service. And some GPs are opting to work only out-of-hours which means the idea of the "family-doctor recedes even further.

Trade unionists experienced in pay and conditions negotiations will appreciate what superficially appears to be the industrial muscle of the "doctors' trade union" - the professional association known as the BMA.

This is superficial as doctors and GPs in particular form a professional elite and are part of the power elite which governs a capitalist society and runs the capitalist economy of the UK. GPs unlike for example the miners with Mrs Thatcher or the firefighters with New Labour, didn't take on the state and win. Rather as part of the power elite, 36,000 GPs demanded and got the contract they wanted, as entrepreneurs - as business people in tune with the neo-liberal free market approach to health care, which is the hallmark of New Labour.

What is interesting in the development of the relationship of doctors with the NHS is how it is a progression of the problems faced by Aneurin Bevan in getting the NHS off the ground in 1946-48. Anyone who is familiar with the history will know how famously, when he was asked how did he win over consultants, Bevan said "I stuffed their mouths with gold". Now for quite different reasons, a New Labour government as part of its own philosophy is rewarding one of its own - a group of already well-paid upper middle class professionals. More importantly - a business elite within the power elite of industrial and finance capital, the military and the political class.

But couldn't it have been otherwise? We have the health centres and already £70m is being spent on upgrading GP premises and building state-of-the-art new ones. The stumbling block in this principled yet practical way forward in providing universal health and medical care 24 hours, seven days a week, in and out-of-hours, are some GPs. They refused to work shifts, even though nurses, paramedics, fire fighters and many others in the private and public sector do and for a lot less money.

What would happen if electricity, gas, water and other essential service workers demanded a new contract like the GPs? Five day week, nine to five fire fighters with a 27%-50% pay rise but opting back into the fire service for a few hundred pounds a session. Wouldn't there be uproar at what would be called a "national scandal, the country being held to ransom"?

Apart from the remote rural areas and the islands, a full service could be given by using flexibly through proper shift working an existing network of health centres. It is likely the difficulties of remote rural and Island communities could be solved by the use of the internet, video linking and a "flying GP service" as operated in Australia and other vast countries.

What the new GP contract reveals is how reasons are used as rationalisations and how an ideology is built up. Of course there are some GPs in single practices on call overnight and taking a surgery the next day. How many though have to do this? Take for example a GP from a rural/island community objecting to the new contract who says as a single-handed GP wants to be on call and is well-rewarded for being a doctor. It is only 12 times in ten years there has been a need to go out at night to a critically ill patient. And it must be borne in mind that it is in the rural and Island areas some GPs have as few as ninety patients to look after.

These instances, as well as the mistaken claim that medical graduates were not choosing to train as GPs, have been used as rationalisations for the deal done by an elite with the governing elite.

GPs may have further enhanced their power position in the NHS but at a cost of undermining the principles and values of the health service; what is often called "the jewel in Labour's crown". But no longer is this true. A deal sewn up in London, signed sealed and delivered for all 36,000 UK GPs, without little or no reference to the Scottish executive, is a sell-out of the NHS by New Labour.

GPs are New Labour's entrepreneurial "shock troops" for the new market-oriented health service, envisioned by New Labour. It wasn't a matter of a democratically elected government (a matter of conjecture in terms of the power elite and the role of the media) being held "to ransom". This a government may claim as often with the workers bears evidence. If GPs promised to "leave the NHS" if their demands were not met, a government committed to the welfare of all its citizens, could have called them up into the army and redeployed them back into the NHS. An obverse in a way of what New Labour did with the fire fighters.

Crucially, the new GP contract is paving the waCrucially the new GP contracts paving the way for further privatisation of the NHS, as private GP companies will move into the market for after hours care not met by out-of-hours systems. This is a graphic example of how a powerful elite of professionals operate as part of the power elite in a capitalist society.