Thirty-Five Years of General Practice Payment and Administration in England

Abstract

Rationale

Fee-for-service payment is commonly blamed for problems in the US healthcare system, including the current and projected shortage of primary care physicians. Britain's National Health Service (NHS) general practitioner (GP) workforce has been paid mostly by capitation since the creation of the NHS, which leads many US observers to conclude that capitation will solve many primary care problems.

Aims and Objectives

To compile and synthesize information about GP payment and administration from publicly-avalailable sources.

Methods

This was a compilation of 30+ years of articles I accumulated about GPs and the NHS supplemented by Google Scholar, NHS websites, and similar searches to close information gaps; as well as two trips to directly observe UK GPs care for their patients.

Results

Thirty five years of cycles of scarce resources have impacted the GP workforce and scope of practice. There has never been a golden age of support for GPs. GPs have worked under a series of unfunded or under-funded mandates and have been tasked with responsibilities that more appropriately should have been handled by policy makers. The net result is that the scope of practice of GPs has gradually eroded. The years 2002–2009 were probably the most GP-friendly with the best population outcomes, when GPs were given additional resources and were empowered to positively affect other aspects of their local healthcare system.

Conclusions

The British GP experience shows that it is too easy for politicians to add more work responsibilities to physicians paid by capitation without seriously examining and supporting the GP workforce to achieve the desired goals, which has led some UK GPs to recently propose fee-for-service payment. Administering and paying for GP services through the lens of complex adaptive systems management, with adequate resources, will likely result in a more effective and sustainable GP workforce.