Euan Lawson is editor of the BJGP.
When I wrote the May Briefing I had recently finished Chris Thomas’ book: The Five Health Frontiers: A New Radical Blueprint. I was much taken with his initial description of the problem of ‘buy-out’ and it merits close attention. I had to summarise this in a sentence or two but Thomas explores it in much more detail and points out this was understood by the founders of the NHS:
“What Bevan recognised was that anything less than the most comprehensive health service provides those who can afford it with an incentive to ‘buy-out’. That is, it gives them a reason to supplement or replace their public entitlement to healthcare with private health services and insurance – to skip long waiting lists, access novel treatments, receive better technology and digital tools, become eligible for clinical trials, or even to travel to other countries to receive their treatment.”
Much of Thomas’ book is directed at the political left and the need for them to re-assert themselves around the NHS. The typical narrative in the media around the NHS is often most inflamed when privatisation is raised.
“A crucial difference between the buy-out and the sell-off is that the former does not need the NHS to be sold, or its budget to be cut. It simply needs public health investment to lag behind the sum of growing need and advancing innovation – that is, to remain in stasis. It is a method of transitioning from comprehensive service to a string-bare safety net that requires little to no expenditure of political capital by the right.”
We may think we are still a long way off from this and there is no real need for concern. That looks to be very wrong. An article in the FT last week [paywall] presented some alarming figures for anyone concerned that buy-out is well-established and growing. The graph on household out-of-pocket health care payments, shown in the tweet below, is clear that there is now little difference between the US and the UK.
30 years ago, US out-of-pocket spending on healthcare — costs that cannot be reimbursed through insurance, but are borne by the individual — was more than double that of the UK.
Today, the two are virtually indistinguishable. pic.twitter.com/pf7ZrCvTVE
— John Burn-Murdoch (@jburnmurdoch) April 28, 2022
Thomas’ book is excellent. As is clear from the title it is a blueprint and some of the technical public health policy suggestions later in the book are very detailed. He doesn’t get it all perfectly correct either when it comes to general practice though I think this is related to the relative brevity of the coverage around primary care rather than anything else.
There is some wishful thinking around digital technologies and I writhed in irritation when told more GPs are working part-time — it might be true, but if we actually counted patient contacts rather than sessions I suspect that narrative would look rather more shaky. Either way, it doesn’t change the underlying workforce crisis and it is a hint, though I think unintentional here, of the GP-blaming agenda.
The main point to my Briefing is that I fear we are trapped in a world of short-termism. Re-booting the stuffing-mouth-gold approach of the 2004 contract certainly isn’t the answer and we need a longer term strategy for general practice without the lamentable adverse consequences of that contract. Of course, the future of NHS general practice is intimately bound up with wider NHS policy and funding decisions but it would be helpful if general practice knew where we were headed.
May 2022 Editor’s Briefing links
Here are the relevant links/references that were mentioned in the May 2022 Briefing.
“In his book The Five Health Frontiers: A New Radical Blueprint, Christopher Thomas describes one of the main threats to the NHS. ”
Available here: https://www.plutobooks.com/9780745343921/the-five-health-frontiers/
“Phil Whitaker has written wonderfully on the GP crisis in the New Statesman, and in March 2022 he noted that a new GP contract was needed.”
The article mentioning the contract at the end is here: https://www.newstatesman.com/health-science/2022/03/were-told-apps-ai-and-video-calls-will-transform-the-nhs-what-about-gps. He also wrote about the contract for a submission to the Health and Social Care Select Committee in December 2021 – it should be noted that Phil also wrote about loss of continuity, amongst other things, in this report and how the 2004 contract “created the conditions for it by decoupling an individual GP from their specific list of patients”. It’s an excellent read about the challenges faced by general practice.
“As Gerald Gill reported in an excellent article in the BJGP in 2020, An Australian reflects on the Collings report 70 years on…”: https://bjgp.org/content/70/696/356