Independent Bullshit Revisited

"Doctor, doctor: How can you justify a 10% pay increase?" Asked smartarse Jeremy Laurance in the Independent last week. Well Jezza, the answer is 'quite easily actually'- and who are you to be the judge on this anyway?

Dr Rant re-read this piece and got more wound up by it the more he studied its detail. As regularly readers will know, Dr Rant spends much of his time in a wound up state, but happens to be one of the more noteworthy occasions. Here is a more detailed analysis than previously offered, with Dr Rant's observations in italics:


It's not what you expect from members of a "caring profession". (Why not? Who says earning well and caring are incompatible concepts.) Medicine is supposed to be a vocation. (It was once, but with this kind of piece around it gets ever less of one. And who says that you should earn less well because you have a vocation? Do you want to reduce GPs to the tawdry shabbiness of underpaid Church of England vicars?) and doctors are renowned for putting the interests of their patients first. (Mostly we still do, but we are having to fight a rearguard action against journalistic assaults.) Yet family doctors have boosted their earnings by awarding themselves a larger slice of the NHS cake – at the expense of their patients. (Absolutely false- 2 inaccuracies in one sentence. GPs have earned fairly under an agreed contract, and have actually delivered more services to our patients. We have not earned at the expense of our patients, except in the sense that our patients are taxpayers, as are we. We have not awarded ourselves anything at all. We have worked within the terms of a freely entered trading agreement drawn up between the Department of Health representing patients and the GPC representing GPs. To suggest that we have awarded ourselves anything is a slur on our profession. We do not control NHS monies, and the suggestion that we have “awarded ourselves” anything is a slur on our good character.)

Official figures published yesterday show GPs' pay soared to an average of £110,000 a year in 2005-06, a rise of almost 10 per cent on the previous year and 35 per cent in the two years since their new contract was introduced in 2004.

British GPs are now among the highest earning family doctors in the world. They have enjoyed a bonanza (an overdue improvement) at a time when the NHS was struggling to balance its books by closing wards and cutting services. (Because it’s run by shit for brains who waste the money on NHS direct, NHS 24, PFI, C+B, NHS IT, management consultants etc as described on here often. Anyway they are not service cuts they are reconfigurations as any new Labour stooge should know.) A poll last week found they were the happiest in Europe with their pay which has increased from £100,170 in 2004-05 and £81,556 in 2003-04. (Income maybe, but satisfaction is reducing and support is lacking.)

Part of that rise, it turns out, has come because they have chosen to pay themselves more. GPs are self-employed (Well noticed! We have been since 1948, and before that too) and are paid a gross sum (£245,020 in 2005-06) out of which they are expected to hire staff and buy equipment to run their practices. What is left is their "profit" or income for the year. (A long standing and hitherto uncontroversial arrangement for many years, and not altered under the new GMS contract. Neither DH nor GPC had any wish then to alter the arrangement.)

Not content with six-figure incomes, the report from the NHS Information Centre published yesterday reveals that, during 2005-06, they spent less on their practices and kept a larger profit for themselves – for the second year running. Over the two years, the extra they have pocketed amounts to £10,000 per doctor

Last January, Patricia Hewitt, former health secretary, accused GPs of helping themselves to more than they were entitled (As usual she talked 'per rectum' -there is no element of entitlement or not in this. There is no definition of what GPs are entitled to or not, beyond the gross amounts paid to practices. We are self employed, not salaried.) to after it emerged that the amount they pocketed increased from 40.5 per cent of the gross amount they were paid to run their practices in 2003-04 to 43.5 per cent in 2004-05, equivalent to £6,900 per doctor. (We told Hewitt to fuck off and mind her own business then, and we say the same now to Mr Laurence. When you see your solicitor do you try and tell him what part of his bill goes to lighting, which to rates, which to staff and which to his income? You would not dream of it, and you should not try this trick on any other business or service. Unless you are an auditor or accountant who gets to find out this kind of detail. You do not own your GP, and you do not have the right to tell him how to run his practice. If you want to take the GP service over and employ us on fixed salaries then make the case for that.)
She said: "I think if we had anticipated this business of GPs taking a higher share of (practice) income in (personal) profits we would have wanted to do something to try to ensure that the ratio of profits to total income stayed the same and therefore more money was invested in even better services for patients." (Here there is a false conflation of “practice income” with “services to patients” First of all the GP is the service to the patient- he or she is what the patient wants to see. Everything else is the window dressing. GPs are paid by a defined contract to provide certain services, at certain times, to patients. How they run their business, and deploy money and staff is a practice’s private business decision, not a matter for ministerial arbitration. And is the suggestion here that I as a GP should cut my pay to subsidize the NHS…as well as pay taxes? Work for the bastard organisation and pay for the privilege…twice? What would Laurance say if I asked him to cut his pay to increase his paper’s profits…or to pay for a new fax machine?)

Yesterday's figures show the imbalance deepened in 2005-06, with an increase to 44.9 per cent in the proportion of gross income that GPs paid themselves. That adds up to an extra £3,430 per doctor, or £10,330 over the two years. (The ratio of expenses to income goes up and down each year. It’s not a fixed percentage, and cannot be a fixed.) The Department of Health declined to comment on the new figure. (Sensibly- they got hammered last time they tried to comment on what is an internal matter of practice administration, not an issue of public policy.)

You might expect bankers to increase their profit margins but it is hard to understand how it could happen with doctors. (No it isn’t. Any sensible self employed businessman knows his or her income, expenses and profit margins. GPs are not just employees, and have to run their practices as well as they can. Some are very good at this and some are not.) It suggests that the sums injected into general practice, and the rest of the NHS, over the past five years – £45bn extra in total – have been so huge that they have been beyond the capacity of the average doctor to spend, and so have ended up in their pockets by default. (No they have been misdirected to management redisorganisations and grandiosity. GPs have got a very small fraction of the increased NHS budget.)
What could the average four-doctor practice do with an extra £40,000 a year? I have a suggestion. (So do we- Shut up!) Hire a couple more receptionists to answer the phones. (Who asked you? What do you know about running any sort of business? Jeremy- you are probably a salaried employee and have no idea how to run a business.)

Last year, the British Medical Association defended the extra that had found its way into GPs' bank accounts in 2004-05 on the grounds that it would take time for doctors to invest their NHS windfall. But, it turns out, they did not do so in 2005-06 either. Now the BMA is claiming, in a statement issued yesterday, that the figures are out of date and the average GP has suffered a cut in income since 2006.

Have patients benefited from the largesse handed out to doctors practices? The answer is: up to a point. The chief reason for GPs' large pay rise since 2004 is that their new contract set a number of targets, with payments attached, designed to incentivise specific areas of care, such as treating blood pressure and helping smokers give up. (And we have invested here to achieve here. Sensibly we invest where the return will come from.)

NHS Employers which negotiated the contract, underestimated the number of targets GPs would hit – they did far better than expected and earned much more than intended. (NHS employers have consistently underestimated how much and how competent their contractors and staff are. They made a similar mistake when they realised how many PAs they would have to pay consultants as well.) Ministers who had agreed and signed the deal then castigated GPs for doing what they were asked. The BMA complained, with justification, that GPs were pilloried for achieving the goals they had been set. (this bit is true at least.)
But that is not the whole story. GPs' pay has soared at a time when GPs become harder to see. They have dispensed with their out-of-hours responsibilities, (No, the contract took these off us and gave them to PCTs.) they are holding fewer (though longer) consultations and more are working part time, as a study of their workload published by the NHS Information Centre revealed last summer. (Full time GP is becoming too stressful to be compatible with sanity.)

Many patients complain that they have difficulty getting through to the surgery and making appointments. (Yes, not surprising given the incentives towards quality in the new contract. In new contract quality is valued more than quantity. So GPs do more work per patient i.e longer appointments, and so have fewer available slots per day; the days of 5 minute appointments are now thankfully over. Access has inevitably dropped with this. If the incentives get altered then GP behaviour will alter. Like most people GPs respond rationally to economic incentives.)

Ministers got us into this mess and ministers must now get us out of it. (indeed) Gordon Brown pledged on the eve of becoming Prime Minister last June to improve access to GPs. Alan Johnson, the Health Secretary, has demanded more flexibility with opening times and more Saturday surgeries and threatened to make GPs' lives a little less secure by bringing in competition from private companies. (No he simply threatens to waste money on unnecessary alternatives and destabilise good practices, and distract PCTs as well. He’d get a better deal if he phoned up BMA and started negotiations on a variation to the contract. It’s clear the new contract is not delivering what is really wanted either by patients or doctors, or ministers, and so it needs altering to a mutually agreeable solution. Journalists attacking GPs as this piece does simply draws up battle lines, and shows just how little journalists know about how the financing of general practice works.)

In short, the Government wants a bigger bang for the extra bucks it has invested in general practice – and so do patients. (Get the incentives and profit margins right, the rest will happen. But a private market is much better at aligning rewards, and incentives so maybe GPs should leave the NHS rather than put up with incompetent administration any longer? Godot will come sooner than sensible public administration in Britain.)


Finally, Dr Rant would like to ask a question for a change:

Was this piece by Jeremy Laurance a report or an opinion piece?

Inability to distinguish fact from opinion is dangerous.

To his credit, Mr Laurance has responded to many outraged medical correspondents. He said to one “The central charge in my piece was that GPs have helped themselves to more than they were entitled to by a factor of a third in the two years from 2003-4 to 2005-6 (£10,000 out of their £30,000 rise) - and so far none of those who has contacted me has answered it.” Dr Rant hopes this line by line rebuttal, allied with these letters, does answer him.