It seems to me that the National Health Service has become something akin to a new religion in this country. Its holiness is unquestionable; its integrity is unimpeachable; its right to exist and to grow cannot be assailed. It occupies a position in the nation once enjoyed by the monarchy or the military and I suspect they would give a lot to share the adoration that the NHS now enjoys from the nation.
It is a brave or perhaps a foolhardy politician who dares to suggest it could improve or that we could learn from other health systems. Listening to the seven politicians in the TV debate, I wondered what world they lived in. For most of them, it was clearly a socialist world where command and control was the order of the day and where state monopolies ruled OK. The Scottish and Welsh Nationalists and the barking Greens united in opposing any private sector role within the NHS and in rounding on Miliband and Cameron for seeking to “privatise” the NHS.
Hearing all these earnest politicians pledging no private profit motive in the NHS caused me some merriment. 90% of all health contacts are in the primary care sector through general practitioners – family doctors. These medical practices are changing but, at their heart, they are a business, owned by the GPs themselves who will employ salaried doctors, practice nurses, receptionists and other administrative and health-related staff. The income for those doctors who own their practice is the difference between what they earn from running their practice and what they pay out in salaries and other costs. In my book that is a profit and it makes GPs business men and women. This system was set up in 1948 by Aneurin Bevan and it is still there today. It took some doing and there was tension between doctors, dentists, pharmacists at the time and it still exists today given the overlapping of some of their work. The GPs did pretty well out of Bevan and they have done even better out of the Blair/Brown regime more recently.
The business model for GP businesses is pretty unique and represents a fascinating mix of public and private sector. GP practices are independent businesses, owned by those GPs who are partners. They buy their way in on joining and are paid out their share of capital on leaving the practice but they have some powerful state help along the way. Their funding comes from state fees for their work but they are not prevented from engaging in private health provision alongside. They are entitled to generous funding schemes for the purchase or improvement of their practice premises; the interest costs are funded by the state but capital gains on disposal belong to the GPs – part of their capital in the practice. Like many areas in health, this is one subject to change for a variety of reasons and the future may hold less generous opportunity for profits than the past but they still exist for entrepreneurial doctors. GPs also enjoy a generous and state-funded pension scheme. In short the bets of both worlds.
General practice has changed immeasurably since Bevan founded the NHS and doctors’ surgeries then would be unrecognisable when compared with those of today. Before 1948 general practice was a cottage industry with GPs working independently, frequently from a consulting room in their own house. There were few staff with the GP’s wife (GPs were invariably male!) acting as receptionist. Over the years, practices have grown larger, with their own premises, many more staff and much technology. However, the real revolution in working conditions for GPs was in the renegotiation of their contract in 2004. Until then, GPs were expected to provide 24 hour care, 365 days per year. Cover was provided in a number of ways but the ultimate responsibility was with the GP. In 2004, the British Medical Association negotiated a new contract with the NHS that increased earning capacity hugely and removed the requirement for out-of-hours cover.
I end with a question to the socialist leaders of the Scottish Nationalists, the Welsh Nationalists and the loopy Greens: if you want to eliminate the profit motive from the NHS, will you abolish the current status of general practitioners as business men and women and turn them into salaried servants of the monolithic state? GP practices account for a bit under a tenth of the NHS spend so are not huge in comparison with secondary or tertiary health care but they are independent businesses, operating within the NHS and, as such, must be pure anathema to the private sector hating likes of Nicola Sturgeon, Leanne Wood and Natalie Bennett.