The government shows its misunderstanding of GPs – scapegoating the resentful and disengaged may lead to unintended consequences.

Perverse incentives abound in all health care systems. The job of public health consultants and strategic advisers to government is to anticipate the possible actions of all the stakeholders. They need to see that new perverse incentives do not result in unintended consequences and outcomes.


GPs are self employed. They work in partnerships, some very large and able to cope with extra hours, and change, and some very small, unable to cope with their current workload. The latter are equivalent to Mrs May’s “Just about coping” cohort of the population at large, but this time with workload rather than money.

The government shows its misunderstanding of GPs – scapegoating the already resentful and disengaged will lead to unintended consequences.

Many GPs are at or near retirement. They can afford to  leave and become locums or salaried doctors working within less stressful contracts. This is the choice for many with young children. It is only the ongoing partners who will have a duty to provide 12 hours cover, as they will hold the contract with the .commissioning group.

Since there in an undercapacity provision of a sufficiently skilled and experienced workforce, and successive administrations have failed in their manpower planning, locums will be able to demand and receive high payments. Whilst stronger partnerships who use internal cover for leave might tolerate this situation, smaller partnership may disintegrate.  The first step would be to hand back the contract giving 3 months notice.

Partnerships that own property would be wise to move it into a company if they have not already done so.

The civil service administration would recruit from overseas.

So to summarise the possible unintended consequences:

  1. Fewer GPs and GP hours consulting (especially those with families) .
  2. Higher locum pay.
  3. Disintegrating – smaller practices in particular.
  4. Emigration from the English Health Service
  5. Reduced access for patients.
  6. More demand for Private Practice
  7. Increasing inequality
  8. Public unrest starting in peripheral and less affluent areas
  9. More employment of immigrant doctors with poorer language and cultural appreciation. (these doctors, mainly from outside of the EU, will then block places for future doctors when we get the manpower planning right, thus repeating the cycle started in the 1950s whereby we take doctors from countries that can least afford to lose them)

No wonder many GPs think there is a conspiracy to undermine and destroy the former NHS. What is left is not National, is in poor health, and is becoming such a poor service that private care seems a reasonable option to those who can afford it. Anger and resentment mean the insult seems even worse..

BBC News 13th Jan 2017 reports: GPs urged to commit to seven day service or lose funding

Chris Smyth reports in The Times 13th Jan 2017:  May demands 7-day GPs

PM blames early-closing doctors for fuelling A&E crisis

Theresa May has ordered GPs to stay open seven days a week as she blamed doctors who close early for fuelling the A&E crisis. The prime minister said that surgeries should provide appointments at times convenient for patients rather than themselves. Cash allocated for longer opening hours…

Image result for unintended outcome cartoon

Update 14th Jan 2017:

Damien Gayle reports in the Guardian: May’s scapegoat attempt could spark mass resignations, says top GP – Dr Kailash Chand says GPs are rightly angry at government effort to shift blame for NHS crisis on to them with seven-day threat

BBC letters: The NHS is making people sick, GP tells BBC

Update 16th Jan 2017 – Times letters

Sir, The final blow to general practice has been dealt by Theresa May’s seven-day-a-week plan (News, Jan 14). It sounds eminently sensible, but where are the GPs to run this service? In the past two decades there has been a ten-fold increase in the number of hospital specialists — doctors who would otherwise have entered general practice — as well as a significant change in the workforce. Sixty per cent of medical graduates are now women, which offers many advantages but only a small number are full-time. General practice is dying on its feet as there are so few who wish to become partners and keep the profession going. This latest gambit will see all those close to retirement resigning from partnerships and taking the softer option of working as assistants and locums, leaving precious few to even attempt to provide extended hours.

Dr Duncan Hall Sid Valley Practice, Sidmouth, Devon

Sir, To read that the current crisis in the NHS is the fault of GPs is yet another kick in the teeth to a primary care service that is on its knees. I and my GP colleagues around the country routinely work 12-plus hours a day and are struggling with low morale, a lack of resources and chronic recruitment problems. To lay the blame at the door of general practice when the real cause is a serious lack of NHS funding, and in particular significantly under-resourced social care, just emphasises further that the government has no clue what is going on in the NHS and no plan to resolve this crisis.

Dr Catherine Sherwin (GP) Tiverton, Devon

Sir, Theresa May’s demand for seven-day opening by GP surgeries will not increase access to a GP. Moving a surgery or two into the weekend will reduce weekday access; similarly, moving the morning surgery to the evening will not alleviate the GP crisis. Moving surgery times will not by itself create extra appointments over the whole week. We need more working GPs, not just surgery buildings being open all hours.

Dr Steve Norman Milton Keynes

Sir, Perhaps the prime minister could set an example to GPs by making parliament sit seven days a week in order to debate all matters that need resolving for the impending Brexit.

Alistair Lenczner London SW4

Sir, There seems no doubt that if GP surgeries were funded to “open all hours” and treat people not registered with them, far fewer people would need to visit A&E. In the past few years I have felt I had no choice but to take relatives to A&E with: a badly cut hand, a painful knee infection, a ripped-off toenail (the football injury of a pupil at my school), plus a few others that could have been treated locally but but for “we cannot treat a person not registered here”, “the surgery is closed” or “no appointments available”. I now do not hesitate to drive the 15 miles to A&E.

Linda Miller Dereham, Norfolk

Sir, Angus Hanton (letter, Jan 14) agrees with Simon Stevens that older people who use the health service more should pay more towards health costs. They are both missing one important point: that older people have been paying all their working lives, therefore longer than young people towards health costs. It is unfair to pick on the elderly to raise an £2 billion a year when they have already paid into the system when they were young and fit.

John Mitchell Lincoln

Sir, I read with interest Professor Joy’s letter bemoaning the number of reorganisations there have been that have undermined the health service.

He then proposes another.

Charles Dewhurst London W4






This entry was posted in A Personal View, Commissioning, Perverse Incentives, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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