Passing the contractual buck

Negotiations for a new contract for British general practitioners have begun. Following an announcement in July by Alan Milburn, the secretary of state for health, ministers and civil servants of the department of health no longer negotiate the terms of the national contract directly with general practitioners.¹ NHS managers, represented by the NHS Confederation, now have this role.

This change took everyone in the general practice community by surprise, but it might just break the longstanding stalemate between the government and the medical profession. Currently, general practitioners are plumbing new depths of despair with their workload, with New Labour's consumerist vision for the NHS, and with the constant references to medical failures from Shipman to Bristol. While politicians assert sympathy with the position of health professionals, they have set up a host of new mechanisms to increase their control over doctors in the NHS. The lay press alternately paints a picture of special pleading by greedy doctors and exhausted caring professionals struggling to keep afloat in a system stretched to breaking point. In a pre-election ballot, over 80% of general practitioners who voted said they would be prepared to consider resigning from the NHS should the government fail to agree contractual changes with their leaders.²

Reform of primary care is linked intimately to general practitioners' terms and conditions of service. The debate between general practitioners and the government is part of a continuous negotiation whereby the contractual obligations of doctors are agreed by both sides. The BMA, as a trade union, is seeking the best possible deal for its members. The trouble is that this combative relationship between the BMA and the government gets in the way of addressing the real issues—the problems experienced by users of the NHS and the difficulties of doctors' working lives. Patient surveys show high levels of satisfaction with primary care services, but changes are needed.³,⁴ Patients should have shorter waits for appointments and be seen in decent premises by a competent professional who has time to listen to them and who can arrange timely access to specialist care if needed. These aspirations are shared by doctors and the government. Both sides agree a new contract is necessary but inevitably disagree about the details. The government is increasing general practitioner numbers by 2000⁵; their leaders say 10 000 extra are needed.⁶

Despite complaints of low morale from general practitioners, surveys show that their job satisfaction is on a par with other professionals.⁷ Though not among the highest earners in society, general practitioners earn more than their counterparts in many other western countries. Financial remuneration, however, is only part of the mosaic of factors which contributes to job satisfaction. Historically, dissatisfaction among general practitioners has increased whenever changes in policy have been imposed on them—as in 1990.⁸ This is despite the fact that the working lives and earnings of most general practitioners improved after the revision of their contracts in 1990. Satisfaction at work requires a degree of control over events and ownership of change.⁹ In their absence the central relationship between doctors and patients can suffer; doctors feel increasingly overwhelmed by patients' expectations.

Central to the conflict between the government and general practitioners are the issues of workload and patient demand. Politicians promise ever easier access at patients' convenience (NHS Direct, walk in centres, a 48 hour maximum wait to see a doctor). General practitioners fear that this will fuel inappropriate demands in a system that does not have the capacity to meet them. While there may be some substance in the view that patients will seek medical help simply because it is there, it also reflects the lack of control which general practitioners feel over their working lives.

Interestingly, there is no clear evidence that the workload of general practitioners has increased recently.⁷ However a new BMA survey shows that general practitioners feel more burdened.¹⁰ Two thirds of those replying report low morale and consider general practice to be excessively stressful. Consequently nearly half are planning to retire before the age of 60. The content of work of general practitioners has become more complex, but in other respects workload has decreased, for instance out of hours work. What is clear is that general practitioners feel more burdened. An important reason for this is the collusion between doctors and patients in the fiction that medical care can resolve most human ills. To maintain this illusion is ultimately stressful for doctors and damaging for patients. Few health problems are amenable to purely technical answers.¹¹

So what will improve the relationship between doctors and government and doctors and patients, and, most importantly, people's experience of health care? While it takes a brave minister or civil servant to resist further reorganisation (reform in the NHS is needed), changes should be made with the medical profession, not despite them. As long as the principal relationship between the government and general practitioners is primarily in the arena of contract negotiation, combat rather than cooperation will be the norm. But Mr Milburn's move remains astute. Placing NHS managers in the front line of negotiation should give ministers and civil servants more contract free space with doctors in which to formulate policy. Contract negotiations cannot easily be depoliticised and ministers still pull the strings.¹² This may foreshadow a legislative framework, which detaches the secretary of state from micromanagement of the service.

Questions remain of course—how does passing the negotiator's role to the NHS Confederation, a national body, allow greater local control as claimed by Mr Milburn? If negotiations flounder, relations between general practitioners and managers may suffer, affecting primary care trusts at local level. There is now a bizarre disparity between general practitioners and consultants, since consultants' contracts are still being negotiated with civil servants and ministers. The contract for general practitioners on “personal medical services contracts,” projected to form over half of the workforce by 2004, remains a thorny issue.⁵ The general practitioners committee insists that the national elements of these should be negotiated centrally, as for all other general practitioners, but the government wants these contracts to encourage local variation. This may include the provision of general practice by professionals other than general practitioners. But whoever the negotiators are, the central issue of the workload of general practitioners and expectations of patients will not be reconciled until there is a more mature acceptance of the limits to medical solutions by all.