It is hardly surprising that hard pressed GPs have reacted angrily to unjustified criticisms by the secretary of state for health that they are to blame for faults within the NHS. It is a gross simplification to suggest that removing responsibility for out of hours care from GPs is the main cause of increasing attendances at A & E. Apart from anything else, prior to the changes in the GP contract in 2004 most GP practices used “deputising services” to cover their practice obligations out of hours. For many practices, the only real change in 2004 was that responsibility for managing the out of hours contract moved from individual practices to the primary care trust.
But the pressure on individual GPs brings to the fore the difficult question as to whether general practice services are best delivered within businesses where the GP is both the provider of professional services and part owner of the business. My anecdotal impression is that some GPs move to management because they want control over how their services are delivered or want to ensure that the practice is managed in a way which delivers the best services to patients, beyond what they can deliver in a series of individual consultations. Many GPs play their part in management in order to maximise their incomes. Being a GP is not a purely philanthropic activity and there is nothing wrong with making sure that services are set up in order to deliver the maximum available income to the practice. After all, that is why the Department of Health introduced mechanisms into the contract because they believed that extra payment was the route to achieving better services for patients.
But there are many GPs who have looked at the trade off between additional income and the added stress of management responsibilities and have decided that they have no interest in becoming “partners.” As one friend (and I have lots of GP friends as well as clients) explained “the financial benefits of taking on management responsibilities don’t work for me.” GPs get a salary for delivering professional medical services and get extra payments if—in one way or another—they take an active part in the medical services business in which their services are delivered.
However it may be worth reflecting that being a medical professional running a medical services business is fairly unusual for working doctors in other areas of practice. In hospital trusts, most consultants have a measure of departmental management responsibility but are not concerned with the overall running of the Trust. There is an interesting parallel here with other professions, including lawyers. Until recently restrictive practice rules prevented anyone other than a lawyer running a legal services business. That is why law firms were all run by partners. That monopoly has been broken and the legal services market is in a considerable state of flux. The Cooperative now has a legal services business employing hundreds of lawyers and delivering legal services to Cooperative customers. A large number of lawyers now have no interest in aspiring to a part share in the ownership of the business within which they work.
And I finally come to my own position as a barrister. I am self employed in chambers. I do a measure of “management” to support the running chambers but, as we all work on a “eat what you kill” basis, that is delightfully limited. Most of the time I deliver the professional services that I was trained to deliver—not attempt to be a legal services manager for which I am untrained. I previously worked in a law firm (as a barrister) managing a department of 90 lawyers. Eventually the management responsibilities drove me back to the Bar. I accept the business needed to be managed but (a) I did not want to do this, and (b) most of it did not need to be done by a lawyer. Interestingly, my own experience and that of many lawyers may have echoes in the approach taken by many newly qualified (and not so newly qualified) GPs.
There is an interesting debate as to whether salaried professionals genuinely deliver the same level of commitment to their clients/patients as those who own a share in the business. There are some who complain that salaried professionals “watch the clock” and do not have the same commitment to providing holistic services to clients/patients, regardless of the terms of their contract. I have heard this complaint levied to salaried GPs, but also to salaried solicitors.
However there is another way of looking at this issue. I recall a conversation a few years ago with a Criminal Defence Lawyer working for the Public Defender in Los Angeles. He was an eloquent, committed, and client focused lawyer. He explained to me that he had no interest whatsoever in running the business side of his organisation and did not want to be responsible for hiring and firing staff, doing performance reviews, negotiating leases, or “buying paperclips.” He just wanted to be focused upon doing the best job he could as a cruel defence lawyer for his clients, leaving the “management crap” to somebody else. As far as his clients were concerned he was 100% committed professional; he said this was because his focus was not diverted by attempting to be a legal businessman and as well as a criminal defence lawyer.
Translating that approach into the NHS, one answer to the present dilemma about intolerable pressures on GPs could be to recognise that GPs are trained medical professionals whose expertise and focus is best directed to their patients, and that we should encourage the role of the professional GP who wants to stay a doctor and does not want to become a manager. This has echoes of the debate about teachers – where often the only way for talented teachers to progress was to get promoted out of the classroom. Now many teachers are paid extra to stay in the classroom and pass on their genius to the children, and to other teachers.
Perhaps the world of GP does not value the work of those who are brilliant doctors, but do not want to be diverted from doctoring by responsibilities of management. My anecdotal impression (formed in part by living with a GP) is that many of the “pressures” which keep GPs awake at nights have little if anything to do with patients but often arise from management responsibilities or worries about the running of the practice business. I learned yesterday of a GP who was finally driven out of the profession by attempting to “manage” a practice manager and the pressures from a VAT inspection which showed up the faults of the practice manager (and produced a horrendous bill which he, as part owner of the business, had to fund). What a waste for medicine—because the GP was a great GP for patients, but was driven out of practice by things that had nothing to do with the service that he delivered to his patients.
Passing management responsibilities onto others, who do not report back to the GPs, means, of course, that the GP becomes a salaried professional who has to surrender a measure of control to others concerning the circumstances in which his or her professional services are delivered. It thus puts the GP in a situation which is more analogous to a hospital consultant. This can have its own frustrations, but releasing more GPs from being responsible for the management of a medical services business might lead to the more effective delivery of professional medical services.
It may be that the most effective way to relieve the intolerable pressure on GPs is to pass total responsibility for “management crap,” as my American lawyer friend characterised it, to those who have training in dealing with management crap, see their professional career as delivering the most effective solutions to what others see as management crap and who may even enjoy sorting out the type of management problems that cause so much anguish to other professionals.
That leaves the question “Who should own and/or run the GP medical services business if not partnerships of GPs?” which is a whole different discussion.
David Lock is a barrister and QC, No5 chambers. He is a board member of Brook Sexual Health, a member of the BMA Ethics Committee, and a Honorary Professor at University of Birmingham.
Competing interests: I am a member of the Labour Party and Chair the West Midlands Branch of the Labour Finance and Industry Group. I am due to become a non-executive Board Member of Heart of England NHS Foundation Trust which is due to commence on 1 June 2013. My wife is a doctor who is employed by Worcestershire Partnership NHS Trust.