Is general practice in trouble?
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6814 (Published 27 November 2014) Cite this as: BMJ 2014;349:g6814
- John Appleby, chief economist, King’s Fund, London, UK
- j.appleby{at}kingsfund.org.uk
Like other parts of the healthcare system over the past four years, general practice has been under pressure financially. But is it, as the Royal College of General Practitioners’ current campaign suggests, in need of saving1 or, as a recent Nuffield Trust review reports, “in crisis”?2 And, if general practice is in trouble, why do three quarters of the public remain satisfied with it?3
In terms of funding, general practice accounted for around £8.8bn (8%) of total NHS spending in 2013-14. This share has reduced by about 0.7% since 2008-09. It has also reduced in real terms. Between 2005-06 and 2013-14 total investment in general practice fell by 6% in real terms—equivalent to nearly £560m (€710m; $880m, fig 1⇓). Over the period of the current parliament (since 2010-11), it fell by 2.5%. This is in contrast to a real rise in total NHS spending of 4.4% since 2010-11.4 5 6
A slightly longer view provides a somewhat different perspective, however. As figure 1⇑ also shows, in the two years following the introduction of a new contract for GPs (2004-05 and 2005-06) there was a substantial real increase in total investment of over 27%. And over the whole decade from 2003, this meant that there was a real increase of nearly 20%.
Figure 2⇓ gives another view of spending on general practice, with the change in spending from 2005-06 to 2013-14 broken down by the many different elements of general practice funding—from payments for practice premises to the performance related funding element of the Quality and Outcomes Framework. GP-NHS contractual arrangements are anything but straightforward, and there is no room here to explain all the details. However, it is worth noting that one item that accounts for just over half the 6% total real reduction—“dispensing”—does not affect patient care itself but rather the income some GPs make in their role as dispensing practices. The fall in this payment item is largely due to reductions in the discount paid by the Department of Health to offset part of the cost of drugs that dispensing practices purchase. Similarly, reductions in some other items do not necessarily adversely affect patients if there are compensating service provisions elsewhere in the NHS (such as payment for out of hours services organised by clinical commissioning groups rather than GPs).
Fig 2 Break down of change in total investment in general practice (2013-14 prices) in England, 2005-06 to 2013-144 5 6 (APMS=alternative provider medical services, DES=directly enhanced service, GIG=gross investment guarantee, IM&T=information management technology, IT=information technology, LA=local authority, MPIG= minimum practice income guarantee, NPFiT=National Programme for IT, PCO=primary care organisation, PCTMS=primary care trust medical services, PMS=personal medical services)
Around a third of all spending on general practice ends up as personal income for GPs—after the expenses of running a practice are deducted from gross earnings. Following a 42% real rise over the three years to 2005-06 (from around £95 000 to over £134 000), GPs’ mean real income before tax has reduced each year to 2012-13 and now stands at just over £105 000—a combination of a small real cut in gross income and rising real expenses (fig 3⇓).7
Fig 3 Mean earnings, practice expenses, and income before tax for general practitioners (2012-13 prices), England 2002-03 to 2012-137
While changes in income have a direct effect on GPs, the knock-on effect for patients and their care is more complicated and will in part depend on how GPs react and the effect real pay cuts have on, for example, GP numbers. Data on the number of full time equivalent GPs (fig 4⇓) show an increase from around 30 000 in 2003 to 36 300 in 2013—equivalent to a rise per 100 000 population of nearly 12% (but with a much smaller rise over the second half of this decade).8
Fig 4 Full time equivalent general practitioners per 100 000 population, England, 2003-138
Given all this, is general practice in trouble? It’s hard to say. Although the data on inputs—spending and staffing—provide part of the picture about the state of general practice, it remains partial (and not easy to interpret). Crucially, there remains a dearth of information about outputs—activity and outcomes—in general practice. This is exemplified by the fact that the most up to date data on the number of consultations in general practice is from a sample of around 500 practices in 2008.9
Notes
Cite this as: BMJ 2014;349:g6814
Footnotes
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; externally peer reviewed.