Will we all become GPs?

Laura sent me an interesting link to a blog.

To summarise, it explains how there is a shortage of primary health physicians in the US. The main contributing factor is money, family practitioners get paid on average 55% less than non-primary care specialties and when you are trying to pay off loans of about $180,000, its not unreasonable to go for the job that is paid 55% more. The reasons for the differences, which underpins a fundemental difference between the US and the UK, is the market.

The health sector in the US operates in a market driven system, capitalism. Whereby the price is never static, its whatever someone is willing to pay for it. Thus, radiologist 5 years after residency can be expected to earn $325,00 nearly double that of a family practitioner because the customer is willing to pay more for the services of the radiologist than the family practitioner.

Here in the UK the opposite is happening, more trained medics are becoming GPs. This, unlike in the US, is not about money because we have a socialist approach in the NHS. There is no market, which is the main problem that opponents have of the NHS. Salaries for consultant and GPs are fairly similar and are equally bellow that of other stressful jobs that require far less training. This is because stressful jobs such as banking and law are market driven, so they will get paid what ever the market will pay them, there success should represent there payment. However this is not the case in the NHS, you can be a very average doctor and get paid the same as a very good one that reach targets and pushes the boundaries because there is no monetary incentive to be better. It goes on through out the NHS, from drugs to toilet roll, they all get procured inefficiently because there is no real incentive to do it differently.

So if it is not about money, what is it about? Well lifestyle and decreased training time play a big part  but a big problem is that there aren’t enough consultant positions and because there is no market there is little incentive to slave away to become a consultant. I have a friend who has wanted to be a hospital physician for a long time, he is a very clever chap and has tried, many times in vain, to bolster his CV in anticipation. However, he may soon be faced with the prospect of becoming a GP because of the lack of consultant post. I am not saying this is bad but this wasn’t what fits his skill set.

One would have thought that being market driven, the US would be more efficient but it spend more per capita on health care than we do. However, the NHS is deeply inefficient and there are things to be done about it. Maybe as the NHS becomes more efficient more consultantships will be created but until that happens I am afraid it seems that we will become GPs.

Josh

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16 Comments on “Will we all become GPs?”

  1. laurz09 Says:

    Was quite an interesting article wasn’t it?
    I also head from someone this week – that part of a state in America is actually paying its students to stay and work for them upon graduation in attempt to avoid the mass exodus that occurs each year when newly qualified doctors all head off else where to find the money pots in plastics.

  2. Joel Schneider Says:

    Very interesting Josh and Laura.

    I do however have a minor quibble or two: firstly, markets. Maybe it’s more so in England, but, as far as I can see, “Foundations Trusts” have been invented to act as businesses. Take for example, the Chief Exec’s bulletin for the “Trust” I work(ed) for. The second item is ‘finance and workload’ – it’s all about surplus, shortfalls, “Cost Reduction Planning”, “financial targets”. When I was working there, they spent quite a lot of time on lean, kanban, 5S… all about cutting costs, removing business inefficiencies. It’s managed like a business, except we’re expected to provide an NHS service. In my experience of working in pathology, there was a lot of markets, competition, whatever you want to call it, going on. For example, with Choose and Book. Similar idea with GP sample processing. On example: bloods would go from a GP surgery sited next door to another hospital, to ours for processing – talk about inefficiency! The reason? We provided a better service (electronic results, faster). So rather than improve the service everywhere, it’s the survival of the fittest. Instead of co-operation with the NHS, it’s competition. That’s not to say there are no benefits to this business-mindedness.

    Sorry if I’ve painted a gloomy picture, there’s an awful lot that is excellent about the NHS! We can get treatment when we need it, and the first concern is not do we have insurance. There’s often a genuine care.

    Also, on the pay thing: I heard the other day that there’s the normal consultant scale, but beyond that there’s what’s effectively performance-related-pay. And of course private work on the side.

    Of course to say that market-driven will be more efficient is probably too simplistic – it can lead to short-termism (like we’re told of the banks) and inefficiency when a rich monopoly or oligopolies can charge whatever they like. But so can a system like the NHS, without incentive to provide value-for-money (whatever that is). Wait long enough and patients will die, and thus treatment cost is nil for those patients, or the sceptics might say so anyway! Basically, whatever system you go for, it will never be perfect – it’s full of imperfect people. However, the advantage of the NHS fixed salary is that there’s no personal incentive to do a particular procedure: you’re less likely to be biased.

    I’ll stop now!

  3. Josh Scales Says:

    The NHS is still not a market.
    You are right, its not perfect but thats a static view, why don’t we try and improve it?
    Somewhere in between the two, I have plans but I am on strictly small steps at the moment

  4. laurz09 Says:

    I liked what you said at the end of that comment Joel – the advantage over the NHS fixed salary being ( I hope? ) that there is no personal incentive to carry out a particular operation for example.
    The ‘in your best interests’ or ‘not in your best interests’ argument r.e. treatment is surely far more reliable in a system where patients can trust in the non biased judgement of the medical team and not worry over whether they’re treatment will be decided upon the pay-packet to be received at the end?

    See you guys tomorrow

  5. Josh Scales Says:

    Upon reflection my reply to Joel’s engaging reply was a bit off hand, sorry. I think you are completely right on that kind of level, GP and assoc services but I still think on a national level is not very efficient, a contributing factor to the national debt. You are right that the fixed salary does aleviate bias but it also allows for complacency.
    See you tomorrow

  6. dundeechest Says:

    Crikey, I leave the blog alone for 1 day, and oligarchial collectivism breaks out.

    Hard to know where to start, really.

    Consultant salaries. Joel, you are correct, there are extra monies to be had in the way of discretionary points, and merit awards. These are awarded to consultants who carry out extra duties usually considered beyond the normal job description, or for excellent work in the way of service development. They are peer reviewed and peer awarded. They can be lucrative, and not everyone gets them, but most consultants will have some – by the time we get to consultancy, we have ideas of how to make changes, improve services, and it is expected that we will do more than just see a patient or three in a morning clinic.

    There will be fewer jobs in the future, there’s no doubt. But I think you’re missing a vital point – there will be fewer ‘everythings’. Fewer consultants, fewer GPs both. We train too many doctors, the government is reducing the numbers of doctors in training, and thus the numbers of senior doctors will fall also. The predicament your generation finds itself in is how to make sure that you are in the top xx % of your peers, to ensure that you are the one that gets the job – be it in General Practice, or Secondary care.

    Health care cannot be made efficient – we spend squillions on it by rationing our services as best we can, and offering everyone as equal a service as we can. The US charge what they fancy, insurance is essential, and if you don’t have it, you go to hospital anyway, and when you can’t pay, the hospitals write it off. Squillions of dollars written off every year. And by offering any treatment to any person, rather than rationing it, their survival is….? Just the same as over here.

    Every health board in Scotland has to make a 2 % saving in costs this year – how would you do it? For example – how would you save £2M in the medical department this year. What changes would you make, if you were in charge, to make a £2M saving, just in the medicine department???

    • Josh Scales Says:

      You said “health care cannot be made efficient” I thought it was “impossible is nothing”
      If I had to save 2m I would start be review the role and efficiency of management.
      What about a central procurement fund to maximise the buying power of the NHS?

      • dundeechest Says:

        Impossible is only nothing in the confines of East Block!

      • dundeechest Says:

        But *how* are you going to save that 2 mil? Cut the number of managers? Stop giving out statins? Close a ward? Sack a few consultants? Only clean the toilets every other day? switch all the lights off?

        We already have national procurement systems, and we have bulk buying power, even just the “little” NHS Tayside!

  7. esoneil Says:

    I agree about the non-biased point too, patients are more likely to trust our advice if they relise this is not benifiting us personally. Does it make the NHS more or less efficient not to order a complete raft of investigations for every patient who comes through the doors? It certainly makes less trouble for the patient and eases what would be an enormous, (unsustainable?) burden off the finances. If I needed investigation I think I would prefer my doctors to tailor their thought process to my individual case and not look at lists of numbers (not suggesting US etc. medicine works like this, but it is a distinct risk).

    Also relating to Joels comment on “performance-related-pay” have a look at this –
    http://www.dh.gov.uk/ab/ACCEA/index.htm
    Anyone see any issues here?
    I’m not suggesting that doctors get graded according to how they do their job and paid accordingly but surely the care they are giving their patients in the job they are doing is the most important aspect of their clnical practice. Who, when faced with a points scheme would be able to resist ticky-box-syndrome and planning (allbeit sub-consciously)how to spend their time to get the most points. Eg. should I really be putting so much effort into this particular research project if it only covers one section of the criteria? That being said, it is a great blessing to be faced with a system which is (comparitively) well balanced, so people will hopefully specialise where they are most suited and not for other reasons, etc.

    Harking back to Josh’s original post, and his friend finding a lack of consultant posts, I’m not very up to speed on this aspect but what about the arguments that we will soon need more consultants to do more as junior doctor hours are cut back (another issue – leading to less training time)? Someone once told me –
    GPs know a little and do a little
    House officers know a little and do a lot
    Consultants know a lot and do a little
    Pathologists know it all but its too late.

    Somewhat unfair on GPs but you get the idea I hope.

    • dundeechest Says:

      Couple of points

      1. This document only applies in England and Wales, not Scotland. But it’s pretty much the same process in Scotland, to be honest.
      2. Fewer training jobs will mean fewer consultant posts – it has to. Who will fill the consultant posts if we don’t train enough junior doctors? The proposed solution to doing the work is getting the current consultants to work (even) harder.
      3. The rhyme is upside unfair, and untrue. I would challenge you to follow me around for a day, never mind a week, and tell me I “know a lot, and do a little” – I’m not sure I can actually fit much more into my 8 – 5:30 day. You can follow a GP for a day too, see how “little” they know about pretty much everything.

      We all are paid handsomely for what we do, and none of us, from FY1 to consultant, have cause to cry poverty. And, we get to do the most fascinating job in the world. Never forget, it’s a privilege to be a doctor; a privilege too many of us are quick to ignore.

      • Joel Schneider Says:

        1. Is there a Scottish equivalent document? Or do we not waste as much time writing documents? Like nicking NICE guidelines instead of rewriting a SIGN one?
        2. I thought that’s what moving everything to primary care was about – saving money. And of course getting the lowest paid person competent to do the job to do it: Phlebotomists instead of JHOs, HCAs nursing, nurses prescribing, treating…? Although good staff of any job title are still better that bad, grandly-titled staff.
        3. Wasn’t it the case a while back (maybe in England) that the powers that be thought consultants basically played golf all day, so rewrote the contract, then found that they worked a lot harder than the powers thought, so they had to have a huge rise? Something like that.

        Totally agree with that last bit. People are naturally greedy, but doctors in this country are paid a lot (unless of course http://www.jobs.scot.nhs.uk is complete lies). People get complacent too, and used to a particular standard. Medicine’s definitely a privilege too. And sometimes people (not just doctors!) think they are owed exactly the health they demand, at a whim, and are so ungrateful for what we have.

        • dundeechest Says:

          The government’s grand plan is to do as you say – re-organise the staff so non-doctors can do the more “menial” doctor work. Physicians’ Assistants, H@N nurses, that sort of thing.

          The great thing about a doctor, though, is that we will do anything, fill in any gap; we don’t ever say “I’ve not been on that course” or “that’s not in my job description”; we start early and finish late, and never claim flexi-time; we care about doing a job well; we’re well trained; and we’re capable, in the main.

          Doctors are a valuable commodity – Josh suggests cutting consultant salaries, which means cutting consultant job plans, and sessions. Most consultants would probably jump at that – work 10 sessions over 4 days rather than 12 sessions over 5 (don’t forget that there are actually only 10 sessions in a week); get a day off a week; come home on the dot of 4:30 EVERY day? Most consultants I know put in their worth two times over. Replacing one consultant with non-doctor staff requires a clinician, a manager, an educator, a researcher, and someone to take forward service development (Not to mention webmaster). Not an easy task to find one person to do all that, and particularly *only* pay them £75000 p.a.

          I’m not trying to justify my own existence here, I’m just saying, there’s a lot more to being a doctor than seeing patients, and although the easy way to save money is to cut salaries, one has to think hard about the ramification of cutting doctor salaries….

  8. Josh Scales Says:

    well if no one is crying for poverty then we could start the saving of 2m by cutting the doctors salary, it shouldn’t make a difference because its the privilege lets not forget.

  9. dundeechest Says:

    Exactly – which doctors, how much, and to how many people? Do we cut 10 % from every consultant wage? Do we cut 10 % of the doctors from the payroll?

    Some doctors do a lot more than others for their 10, 11, or 12 sessions – do we cut the wages of the ones that do less, and keep the money for the ones who do more? Who assess that? And how much time will it take? If you pull the sessions, which sessions do you pull? The only session the board could pull from my contract currently is my session to teach medical students. Should we pull that?

    Or do we do what the government have already done and cut junior doctor numbers?

    The biggest percentage of NHS Tayside’s budget is nursing wages. Should we cut nurses wages????


  10. […] made in response to a post made by one of our second year students on the DundeeChest blog ‘Will we all become GPs?‘ There will be fewer jobs in the future, there’s no doubt. But I think you’re missing a […]


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