Is doctors' self interest undermining the National Health Service?

Abstract

Recent newspaper headlines have suggested that doctors' pay is responsible for the financial crisis in the NHS. Alan Maynard argues that financial and other self interest is endangering the service, but Laurence Buckman believes the remuneration is justified

The NHS is its staff. Europe's largest employer spends the bulk of its money on those who deliver health care to UK patients. The small amount that is doctors' pay could not undermine the NHS, when the total number of workers is so large.

Without adequate pay there is no morale. Demanding and receiving proper pay and conditions is everyone's right, even in the public sector. This is not self interest. Self interested doctors would go and work elsewhere. Reward, including non-cash benefits, in the NHS is less than that in the private sector for equivalently weighted jobs, and NHS professional pay was less than that of almost all other Western health services for many years until 2004.

Doctors' pay has been maintained irregularly since the Doctors' and Dentists Pay Review Body was created to advise governments 46 years ago. Periods of very small pay rises have been followed by sudden large catch up increases. The review body's reports have repeatedly been interfered with by the Treasury and the government because they did not like the results. Effectively, doctors' pay is being used as a partial regulator of inflation, which is specifically forbidden in the review body's rules.

Today's general practitioners, like their predecessors, have to fund their practices from their income. Until 2003, there was a “cost plus” contract that supported business expenses, but it had become inflexible and complicated. General practitioners were working very long hours, including nights and weekends. Out of hours pay was very low, and general practitioners were willing to give up £6000 each to pass the responsibility to someone else. That out of hours care has proved much more expensive to reprovide is no surprise to doctors.

General practitioners' morale was very low in 2000. The new contract was an attempt to correct that by placing contracts with practices rather than general practitioners, setting limits to what a practice could be asked to do, and creating a total budget for staff and expenses. General practitioners' pay became the profit that was left after expenses. Despite dishonest government taunts to the contrary, practices must continually invest in their staff and premises and provide high quality service or else patients will leave.

Performance and pay

The main source of extra income into practices from the new contract is the quality and outcomes framework, which accounts for 40% of practice income. During the development of the framework, civil servants and ministers repeatedly taunted that general practitioners were rubbish and could never deliver any quality. We replied that practices were doing much of what was in the framework already and that we regarded this as pay for work already done hitherto unrewarded. We told the government exactly what the profession would achieve if given performance related pay—it would perform. The government believed that general practitioners would score only 350 points (out of 1000) and took much persuasion that practices would do better than 750 points as this could be reached by data cleaning alone. When we asked what would happen if the NHS did not have enough money to pay for this improved quality, we were told that “the NHS bank” would bear the cost. Ultimately, the evidence based practice defined by the framework will save lives by preventing and limiting disease, although it is too early to show this.

In 2004 framework pay rose sharply, but that was an agreed part of the 2003 deal. Since then practice resources have increased by very small amounts, if at all. Increases are paid only if the practice undertakes a variety of government inspired activities. This money has proved hard to earn, and most practices have seen profit fall in real terms as expenses have risen. In order to limit losses, many have regrettably resorted to replacing general practitioners with non-medical staff.

The government claims that general practitioners' pay has risen unexpectedly, but this is not so. The BMA predicted the rise quite accurately. Despite the frequently quoted £300m overpayment,¹ the sum is actually only £140m as the rest was given to other primary care staff.² The £140m was the amount that general practitioners earned by doing better than the government thought they would. Total pay has been deliberately misquoted by adding the employers' pension contribution that general practitioners have to pay for themselves—which makes pay seem 14% higher than it is.

If patients want a health service round the clock delivered to a high standard by sufficient doctors of acceptable calibre then they will have to pay for it, preferably through their taxes. Government figures show there is a shortage of general practitioners. If self interest had been pandered to there would be a glut of doctors. That there isn't is due to the dreadful way that the NHS is managed by a government bereft of ideas and the honesty and wit to tackle the problems that deter young people from joining us. Doctors are fed up with being told that the very small percentage of the NHS that they cost is the reason why the NHS is in financial trouble. Most patients see us as part of the solution and are willing to pay.