Robbie Coull

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Monopoly handover puts us on Skid Row

Doctor Magazine, 11th January 2005

I’m never been a fan of the new GMS contract. Of course, one can argue quite successfully that anything is better than the old Red Book, but I think new GMS transforms a profession of (relatively) independent patient advocates, into a gaggle of tickbox-monkey technicians.

However, there are two areas in the new contract that I initially welcomed as long overdue. The first is the ability (in theory, at least) to say no to new work. GPs have been an unpaid NHS dumping ground for far too long, and although many of us have still to learn how to pronounce the word ‘no’, at least the new contract acknowledges that it’s in the dictionary.

The second area of the new contract that I welcome – and I suspect this is the sole reason that many GPs voted ‘yes’ – is the out of hours opt out. GPs have traditionally provided 24hr cover essentially for free; or even subsidized it themselves. However, much as I laud the fact that we are finally going to get to be paid to do OOH (after a fashion – far too many GPs still place far too little monetary value on their time), I cannot help but be suspicious of this NHS ‘gift’.

In fact, I am beginning to wonder if the entire OOH opt out is not the bait for some fiendish trap – either that or my Depixol depot is overdue. Basically, up until April 2004, GPs had a monopoly on primary care. Ok, it was a rubbish monopoly in that we didn’t get paid properly (if at all) for providing the service. But it was still a monopoly. The new contact effectively breaks up that monopoly. One of my brothers-in-law (I have a wife of many sisters) is a self-made multi-millionaire from starting and selling businesses, and at a recent family get together he told me: 'Robbie, never, ever, ever, give up a monopoly - even if they gouge your eyes out with pokers and drag you over hot coals, monopolies are rare as hens teeth and of priceless value'. Actually, he may just have said ‘GPs are idiots to give up their monopoly’, but I was struggling to locate the last can of Diet Coke in the kitchen and was not paying as much attention to his words of wisdom as perhaps I should.

However, this did start me thinking about things:

1. The GMC colluding in the 'luring' of thousands of third world doctors to this country with little hope of work (as they lack the specialist qualifications required). Said doctors are now heavily in debt and working in petrol stations across the UK with no hope of getting themselves out of debt.

2. GP entry rules are changed. So now these doctors are flocking to GP training. They don’t want to be GPs, but are desperate for work and ‘any port in a storm’.

3. GP monopoly is broken in primary care via OOH opt out and enhanced services contracts, destroying the ‘GP as Sole Gatekeeper’ role.

4. EU enlargement opens up markets for doctors in Eastern Europe (not the great surge of Polish dentists and doctors that John Reid was hoping for, but still....).

5. Private companies, for the first time, are allowed to bid for fragmented segments of the broken primary care monopoly. GPs have the key medical skills, but lack the business skills necessary to apply their leverage in an open market. So contacts are going to private firms because GPs don’t know how to write business plans.

So, in five to ten years time it is perfectly possible that general practice as we know it will have ceased to exist. There could be Chronic Disease Clinics in Tescos, Smear Clinics in Boots, and Minor Illness Clinics next to Specsavers. GPs may be fighting each other for salaried jobs with private firms. GPs with partnerships could see their profits fall as they are left with rump core services for which remuneration is falling, while the GPs outside of partnerships might need to accept terrible pay and conditions simply to get work.

Now I know what you are going to say (‘I don’t care, so long as I don’t need to do 24hr cover any more’), but this just shows how demoralized we have become as a profession. We could have negotiated a contact where we retained the control over Out of Hours, but that it was funded properly so we also were paid properly for running the service. It was never the responsibility that was the problem – it was the lack of funding.

As it is, I plan to make as much money as possible from OOH sessions over the next two or three years, because I’m really not sure what state the profession will be in after that, and I’d rather have paid off my (rather modest) mortgage by then. Just in case.

Robbie Coull

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