I’ve heard a lot of shocking things since arriving in England five months ago on my sabbatical. But nothing has had me more gobsmacked than when, earlier this month, I was chatting with James Morrow, a Cambridge-area general practitioner. We were talking about physicians’ salaries in the UK and he casually mentioned that he was the primary breadwinner in his family.
His wife, you see, is a surgeon.
This more than any other factoid captures the Alice in Wonderland world of GPs here in England. Yes—and it’s a good thing you’re sitting down—the average GP makes about 20% more than the average subspecialist (though the specialists sometimes earn more through private practice—more on this in a later blog). This is important in and of itself, but the pay is also a metaphor for a well-considered decision by the National Health Service (NHS) nearly a decade ago to nurture a contented, surprisingly independent primary care workforce with strong incentives to improve quality.
Appreciating the enormity of this decision and its relevance to the US healthcare system requires a little historical perspective.
As I mentioned in a previous blog, the British system cleaves the world of primary care and everything else much more starkly than we do in the States. All the specialists (the “ologists,” as they like to call them) are based in hospitals, where they have their outpatient practices, perform their procedures, and staff their specialty wards. Primary care in the community is delivered by GPs, who resemble our family practitioners in training and disposition, but also differ from them in many ways.
GP training is the only pathway to primary care here—there isn’t the mixed bag of general internists, pediatricians, family practitioners, and scattered community-based subspecialists one finds in the States. (An important side effect of this is that the primary care community speaks in a single voice, not the cacophony you often hear from our primary care fields.) Training to become a GP takes five years: a three-year GP residency following the two foundational years (similar to our old rotating internships) that everyone does.
Prior to 2004, GPs were poorly paid, and had very low status and little incentive for improvement. Most practices were organized in groups of one to three physicians, and very few had a sophisticated information technology or management infrastructure. Most people—physicians and patients—saw primary care as a relatively weak link in the NHS system, and few top students became GPs. The primary care world was a demoralized mess.
In other words, just like the current state of American primary care.
In the US, when we talk about the need to increase compensation for primary care doctors, we are constrained by the political realities of a shrinking healthcare budget and the knowledge that any bump in PCP pay would almost certainly have to come from cuts to specialists. In this environment, talk of anything beyond a 5-10% raise is rapidly dismissed as being as real as the tooth fairy.
Around 2000, the NHS saw what had happened to the GP world, and decided it was absolutely vital to reinvigorate primary care. Having a strong GP workforce is the cornerstone of universal access to care, and 80% of all MD visits here are to GPs (vs. 58% to PCPs in the US). Moreover, keeping costs down depends on population management and limiting the use of expensive hospital-based consultants and technology.
Wisely, the NHS did not simply throw money at the problem. Rather, it chose to link a pay raise with a new program to promote improvement. In 2004, the NHS negotiated a new contract with GPs, which included a “Quality and Outcomes Framework” (QOF), an unprecedentedly far-reaching pay-for-performance system in which GP practices could earn substantial sums based on performance on over 100 quality measures. The NHS underestimated the degree to which the QOF would transform practice: before the program was launched, it estimated that GPs would hit 75% of the targets; the actual number proved to be 90%.
The new GP contract did have its intended effect of bumping GPs’ salaries and improving their lifestyle. Many GPs saw their salaries go up by 20, 30, even 50%! Moreover, the NHS limited GP practice hours to 8 am-6:30 pm, weekdays only, creating alternative ways (mostly through a series of urgent care clinics and, of course, through emergency rooms) for patients to receive after-hours care. The lives of GPs improved overnight, and the field immediately saw an uptick in its status and desirability.
In previous posts, I’ve discussed my perception that many UK hospital-based physicians, after years of working in the NHS bureaucracy, have developed a kind of learned helplessness. Life as a GP is somewhat different. While they have to work under NHS policies (and, in this regard, they too recognize that resistance is largely futile), they aren’t employed by the NHS the way the specialists are. Rather, they are in private practice, and they generally own their own practices (the difference from the US is that in the UK there is only one payer—the NHS). This makes them more entrepreneurial than their specialist colleagues.
Dr. James Morrow is a very bright, articulate and sophisticated GP who is both an empathic physician and a savvy businessman. He has an undergraduate degree from Cambridge (where he lived in Oliver Cromwell’s dorm room as a freshman) and a medical degree from Oxford. Along the way, he also picked up a law degree, mostly for fun. In other words, he is not your average bloke. Nevertheless, the day I spent with him earlier this month did tell me a lot about the world of the British GP, and the lessons this holds for the US as we struggle to reinvent our dysfunctional system of primary care.
James works with seven MD partners (along with a few other physicians and a couple of NPs) in Sawston, a small town about 10 miles south of Cambridge. The practice is housed in a pleasant and nicely appointed office building. There is plenty of bustle in the patient and provider areas and in the full-service pharmacy, which is owned and managed by the practice. Fading photographs of Cambridge-area GPs from eras past grace the walls of the hallways.
But the most prominent wall decoration is a large white board, located in the practice’s main thoroughfare, its grids filled with data on the group’s performance on the QOF measures. All the doctors, nurses and staff track these numbers daily because their livelihood, literally, depends on them. In addition to tracking process and outcome data via the white board, the practice’s sophisticated computer system allows caregivers to track their adherence to evidence-based quality measures and to see how the practice is doing against benchmarks and bonus thresholds.
The practice’s peer review process is also robust, more so than in most US outpatient practices. James’s partners meet for about three hours each week to review not only business and scheduling matters, but also clinical performance data. They sometimes bring in a specialist for a mini-lecture on a key topic. In addition to measures in areas like hypertension control and asthma management, they review every case in which a patient goes to the ED, is admitted to the hospital, and is referred to a subspecialist.
Yes, the decision to refer even a single patient to a cardiologist or nephrologist needs to be defended. As far as I could tell, this is not because the costs of subspecialty consultation come out of the practice’s resources (although this may soon change, as the Cameron government’s plans to turn over most of the healthcare budget to GPs, called “commissioning,” are rolled out over the next few years). Rather, it seemed to me to be an issue of professional pride.
Can you imagine a US primary care practice reviewing every one of its subspecialty consults? They wouldn’t have any time left over to see any patients.
These reviews flow from the UK’s overall care model, which requires that all patients go through their GP in order to access subspecialty care and most sophisticated tests (one vivid example: a GP cannot order a CT scan or MRI—they need to be ordered by subspecialists). They don’t call this “gatekeeping” here, but that’s precisely what we would call it in the US. While American patients want to be able to see the toenail specialist without having to see their PCP, this is one of many areas in which the British (both patients and providers) seem to accept this type of control as the price one pays for the benefits of universal access and remarkably low cost.
The GPs have a reasonably wide array of skills, and they are encouraged to become local practice experts in a given domain. James, for example, had some additional training in surgery and neurology, and so he sometimes sees curbside consults from his partners in these areas. One of his partners trained initially in pediatrics but later decided she wanted to retrain to be a GP (note that there is no office-based general pediatrics in the UK—you bring your kids to the GP; pediatricians are hospital-based specialists). So she’s the go-to person for tough kid-related problems in the Sawston practice.
The practice has a state-of-the-art computer system, one of six endorsed by the NHS and capable of data sharing between ambulatory practices and labs. As I discussed previously, the NHS completely bollixed up IT implementation in the hospitals through a ham handed top-down process. Conversely, IT implementation in the GP world—which involved NHS subsidies but bottom-up decision-making and implementation, has gone well. The result is that a British GP is more likely than an American PCP to have a robust computer system in his or her office. Sadly, these outpatient systems don’t talk to the (relatively few) inpatient systems, so there is a lot of paper, faxing, and scanning still, which surprised me in a unified system. This will need to be addressed.
James’s office runs efficiently, and there is a powerful sense of ownership and hands-on management. The office is run by Gerard Newnham, a sophisticated former Department of Justice administrator who walks around with a lanyard that says “LEAN” (referring to the quality improvement technique, not the body habitus.) By way of contrast, most of the space on the second floor of the Sawston office building is leased to the NHS, which is the sole provider of certain outpatient services such as physical therapy, nutrition counseling, and audiology. Looking at these two floors tells you all you need to know about government vs. market-driven efficiency: while every inch of the first floor is used optimally, the upstairs offices are often used by these NHS-employed staffers perhaps one or two days a week, though rent is being paid for full-time use.
I asked James about his billing department and he told me it consisted of one person whose job is to deal with “insurance companies.” I told him that an eight-physician practice in the US would probably have two or three staff members to handle insurance issues. “What does your insurance person do?” I asked, since his practice (like most GP practices here) does not accept private insurance. “Oh, her job is to fill out forms for our patients applying for life insurance.” In other words, they have zero FTEs dedicated to billing. Wow.
While the GPs I’ve met (about half-a-dozen) were all far more content than their US PCP counterparts, they do complain about silly NHS rules, just as their hospital-based comrades do. But the vibe is different: by virtue of owning their practices and having some independence from the NHS, there is less resignation, a greater sense of innovation, and a greater culture of ownership.
James Morrow is an unusual guy, and his office is a model practice. The overall picture of general practice in the UK is less rosy than what I saw in Sawston. I’ve heard from specialists who deride the banker’s hours and begrudge the GPs their 
higher pay. As in this headline from the Daily Express, some believe the QOF pays doctors extra for simply doing what they should be doing anyway. The evidence that the QOF has resulted in improved quality is positive but not overwhelming, and—as with most pay-for-performance schemes—there have been unintended consequences such as declining performance in non-compensated measures.
And then there are the usual complaints that we hear about family physicians (“jack of all trades…” and inappropriate consults are ones I’ve heard from some specialists). GPs’ practice volumes are high, and visits tend to be relatively short (partly because of the capitated payments and the small number of malpractice suits, the documentation load is lower than ours, which improves efficiency). GP training programs are too haphazard; for example, by the luck of the draw, some trainees will get little pediatrics experience despite this being an important part of their later jobs. Finally, there is a general belief that the quality of GPs is not uniformly high, and many practices remain poorly organized and continue to operate without the level of peer scrutiny and skill development that one sees in larger GP or hospital-based practices. Some of this is the lingering effect of the pre-2004 era, when few doctors who had any choice in the matter entered general practice.
But the British GP’s life today seems to be a relatively happy one. The NHS has decided that its ability to provide universal access and a decent level of care at a manageable cost depends completely on the presence of a robust primary care system, staffed with good and contented physicians. This, it seems to me, is a very wise decision.
The Republicans’ main beef against Don Berwick—which led to his decision this week to step down as Medicare chief— was that he once said that he “loved” the National Health Service. As I’ve made clear in my posts from Britain, there is much about the NHS that I don’t love—it is too bureaucratic, and its top-down tendencies stifle innovation. But if the US could emulate the UK’s system for delivering primary care and supporting outpatient generalists, I am certain we’d improve the effectiveness and sustainability of our own healthcare system very quickly.
Just to clarify, GPs in the UK definitely do call this practice “gatekeeping”. http://www.rcgp.org.uk/brjgenpract/recent_issues/free_content/previous_free_content_aug11.aspx
A pretty accurate article except the assertion that pre 2004 ” few doctors who had any choice in the matter entered general practice.”
this is an insult to the very many of us who have spent an entire career in genereal practice through choice and i started in 1972 eventually building up a practice very simialr to the one described.
thre was a recrutiment crisis in the late 90s and early 2000s largely because of problems with nd funding and a contract which gave the idividual GP responsibility 24 hours aday and 365 days a year > but please don’t belittle the many o0f us who made a career choice to be General Practitoners and helped to develop it as a specialty in its own right.
Great article. There are a few errors or misunderstandings about the NHS, which is probably related to taking to only one GP about the services in his area, and the NHS is far from being homogenous. The first is the myth that NHS GPs earn more than NHS specialists. In fact, the average NHS income for NHS Consultants is £117,900 (http://www.ic.nhs.uk/cmsincludes/_process_document.asp?sPublicationID=1316529419323&sDocID=6982), and the total NHS AND Private earnings for GPs is £105,700 (http://www.ic.nhs.uk/webfiles/publications/010_Workforce/gpearnex0910/GP_Earnings_and_Expenses_200910.pdf). Once private income for consultants in taken iton account (which for many can double their income), there is a significant higher income for specialists than GPs. Finally the NHS Consultant Pension scheme is much more advantageous that the GP Pension scheme.
Access to diagnostics varies considerably across the UK I work in the city of Coventry and I have direct access to refer for MRI and CT Scans. Many hospital letters (although not all) are electronically transferred to our IT Systems already, and all referrals to our main hospitals are made electronically.
There are still problems in the NHS – mainly too much variation in quality, and too much micro-management and beaurocracy. The current NHS reforms are very costly, will not improve services, but are likely to decrease provision of health care for patients from socio-economic classes whilst incaresing transactional costs.
Finally although there has been additonal investment in GP services, the investment in GP premises (which funded through a separate system) has decreased.
Grant Ingrams
The Crossley Practice
Coventry
Thanks to Jamie and Drs. Rose and Ingrams for their thoughtful comments.
Re: gatekeepers, I’ve not heard the term used a lot here in the UK, though it clearly is a familiar one — I appreciate your citation. The term was introduced to the US by Dr. John Eisenberg, one of my mentors, in 1985. Fourteen years later, Laine and Turner, reflecting on the experience of primary care physicians who assumed the gatekeeper role in the context of managed care, wrote,
“More than a decade ago, Eisenberg warned that gatekeeping would be a challenging role for primary care physicians. Since then we have had ample opportunity to experience firsthand just how thankless a role this can be. Current studies of gatekeeping focus on utilization and costs. But gatekeepers are still searching for the research that will help them decide how to use specialty resources to the patient’s best advantage. Without solid evidence to guide us in how often and easily we should open the referral gate, someone will always be berating us for opening it too much or too little.”
Today in the US, the word “gatekeeper” has a negative connotation among PCPs and patients, partly because patients never came to appreciate the positive elements of primary care coordination and often saw it as a economically-driven model designed to block them from receiving the specialty care they wanted and needed. The degree to which patients seem to accept the model in the UK is one of the great differences between our two countries. I’m always impressed by how much our healthcare systems are shaped by the dominant cultures of our populations.
To Dr. Rose, my goal was to highlight the difficulties experienced by many GPs prior to the new contract. Fewer students were choosing to pursue GP careers, which was leading to substantial challenges in keeping up with the GP workforce needs. But I didn’t mean to imply that no good students pursued the pathway, and I apologize if that seemed to be my message. The situation is akin to the one in the US today — we have some extraordinary students and residents choosing to pursue primary care despite the obstacles (many because of their passion for the field or their commitment to serve), but the numbers have gone down substantially over the past decade. And top students are less likely to pursue careers as outpatient generalists. Instead, the fields that have become more attractive over time are those that are very well compensated and are judged to have easier lifestyles, such as the “ROAD” specialties of Radiology, Ophthalmology, Anesthesia, and Dermatology. We simply need to come up with a system that makes outpatient generalism sufficiently attractive that students who would enjoy primary care and do it well are not repelled by the field’s lifestyle, income, hassles, and status. The UK appears to have done that; in the US, we most definitely have not.
Re: Dr. Ingram’s comments, I appreciate the data. As I mentioned, I was accounting only for the NHS portion of the specialists’ salaries; many (though not all) specialists augment this income with work in the private sector.
But even if the ultimate outcome is that the average salaries of specialists (including their non-NHS work) are a little higher than those of GPs (11% higher, according to your figures), this is still a different planet from that of the US, where the average primary care physician (internist, family physician, or pediatrician) earns about $200,000 per year, while the average dermatologist and radiologist makes slightly more than twice that (approximately $400,000). If one was designing a sensible system from scratch, few would see that degree of salary disparity as the desired outcome.
Bob – could you comment or point me toward a link that would explain how the US came to its current system where specialist pay is so much higher than primary care? My understanding is that there is some very secretive government agency that sets the relative reimbursement rates for medicare and then the insurance companies tend to follow suit. Is this correct? My father started working as a dermatologist in the 1960s and his recollection is that his salary was only 10-20% more than primary care at that time. Though I am not sure I trust my father’s recollection about his salary 50 years ago.
Derek,
Check out my recent post on the RUC to learn about the committee sanctioned by CMS to advise on work value of different specialties. This committee (along with other poor government workforce planning) has contributed to the broadening income discrepancy between specialty (scopes and scalpels) physicians compared to general internal medicine, pediatrics and family medicine (aka: primary care).
http://www.healthwise-everythinghealth.blogspot.com/2013/08/some-doctors-set-their-own-pay.html
Your dad’s recollections are probably right. The RUC basically reflects the status quo. This situation was mostly brought about by insurance company fee-setting policy. Remember that insurance companies’ profit is typically a percentage of total charges, so they have a huge incentive for total costs to increase year over year. Starting with BCBS back in the 1950’s, the pricing mechanism for Medicare and virtually all fee-for-service insurers has been to set the ‘allowed payment amount’ (called the UCR=’Usual, Customary and Reasonable’ fee, though it’s anything but) at the 75th %ile of the charges received for each service the year before.
Since the individual services providers are not told what the UCR charges are, they naturally set the price they bill to insurance (for covered services) high enough to be sure it’s at least equal to the UCR. But there’s no penalty for submitting a higher charge, nor any cost to the insurer; the insurance still pays only its usual 80% of UCR, secure in the knowledge they’re paying the market rate. (Wink, wink.) Anyone familiar with positive-feedback systems can see where this will go.
Observationally, services covered by insurance-(surgery, hospital, lab, imaging) all went up by 10-15+%/year from the 1950’s to the 80’s, while out-of-pocket expenses like primary care and medications went up at approximately the rate of general inflation. This resulted in a huge incentive for physicians and others to prefer the higher priced specialties and avoid primary care.
Since increasing primary care reduces costs, if you think the insurance companies are Machiavellian, they’ve deliberately kept primary care prices down to reduce supply and prevent cost savings. If not, then primary care started being covered about the time that ‘cost containment’ became popular.
The period of 10-15% price increases for covered services made that “The Golden Age of Medicine” for the specialties providing them.
At one time in America we relied on General Practioners as the Doc who could diagnose many ills just from experience and innovative thinking. Technology is a good thing but it is no replacement for a mind that can be on the nose with most diagnosis. The day we started using technology as a crutch and being a Doctor meant becoming very wealthy is the day that our healthcare system became inefficent and control was surrendered to for profit insurance companies. When it is all about the money we end up with Bankers that loan you money to open your business and Insurance companies that take there pound of flesh to protect you from the unforseen; between the two they pretty much run the whole show. America always does things better than other countries and I would bet as a country we could implement a system run by the people for the people that would be envied. The problem we have though is that as long as caring for others is always about the money we cant get by the Bank and Insurance lobyists that own our government. It would probably cost less to have the Mafia run our Healthcare System.
Robert, I too often refer to the golden days of medicine when GPs could make the diagnosis with accuracy purely by talking to the patient and completing an adequate physical exam. Unfortunately, as a radiologist, I am reminded daily the limitations of imaging free medicine. I cannot count the number of times I have diagnosed benign self-limited inflammatory processes such as omental infarct and epiploic appendagitis that would have surely gone to surgery for appendicitis without a CT scan (and a well trained radiologist to read it).
I would love to know imaging volumes for UK radiologists. I would happily accept 150, 000 US for doing half my current volume of work. I imagine if medical school loans were paid off, many specialists would accept a decrease in pay for decreased referral volumes. The problem I see is patient expectation. At this point patients expect to see a specialist whenever they want and get the best imaging test whenever they want it. How do we fix this problem?
Dr. Wachter,
I am curios about the actual patient volume seen by GP’s and NP’s -and how many days per year they work. Can you elaborate or point me to a reference?
Bill Light
An overview of the GP contract is here, Bill. Their work hours are approximately 8-6, Monday-Friday. If they choose to cover their own patients on nights and weekends, they can, but most feel that the extra pay isn’t worth it, so the vast majority do not cover these hours. Patients who need care seek it either through ED or urgent care centers, many of which were set up specifically to offer out-of-hours care when GPs were allowed to give up nights and weekends. I don’t know about NP schedules.
[…] most patients seem relatively satisfied with their publicly funded general practitioners (whom I described here) and most GPs make enough money that they don’t seek more work. The action in the private world […]
Just stumbled across your interesting article.
Firstly, i am a bit picky, and would like to point out that Sawston, is in fact a village,
not a town.
Secondly, at Sawston health centre, there are extremely long waiting times to see a GP.
An appointment may take 6 weeks+ if you’d like to see the same Dr twice in a row.
Then when you get in, you are limited to just 10 minutes to discuss one problem.
I (along with a majority of the public) don’t think the mainstream of Dr’s/GP’S in this country
give a damn about their patients, and it’s all about money.
Trying to get a GP to listen to a problem, and do something about it is extremely difficult.
Try living here before praising the service.
[…] for patients with pneumonia, acute myocardial infarction, and heart failure. In other studies, substantial bonuses to British GPs (up to 30%) have been shown to be associated with improved adherence to process measures and […]
Nice post. I’d really like to see a discussion about how primary care is delivered in Australia and New Zealand. Seems like whenever the US looks to compare themselves on anything (gun policy, health care etc) they look to England. I’m sure our southern mates have some interesting perspectives on healthcare delivery also, but they always seem to be forgotten.
Thank you indeed for such a relevant article, expressing pretty much the facts of the UK GP service.
Patients here, would (I think) however wish to point out a serious flaw that leads to poor health care at the bottle-neck primary care end of the matter.
The (political) simplistic use of the target culture to characterize the effectiveness of “care” misses the widely experienced tendency for patients to give up, waiting perhaps for symptoms “strong” enough to trigger some science, or a visit to A&E!
The tendency for patients to reach first for A&E is not just a matter of personal dis-ingenuity!
Again that much vaulted skill of “~ feeling for the patients issues” instead of jumping to tests (the white coats) looked at from a different perspective is rather like “those good ‘ol boys getting together in smoke filled rooms”; the intrusion of science is – possibly – resented, as taking away a certain kind of a dimension.
The costs and development of testing/ technology are, like everything else, (here US may have an edge at the moment) connected seriously to Volume; less demand – less development, and the engendering of niche areas.
Yes, the term Gatekeeper (also a butterfly) is an exact, increasingly used epithet describing the UK scheme as directed by tick-box and directives dreamed up by 1990’s UK politicians.
Take care with “enthusiasms” in this vital area.
As a passing shot…. contrary to the common view among GPs – and Politicians for whom scant care with facts is acceptable – the guys sitting in the waiting room do not want to be there.
Hi
I’ve just across this article.
I worked in that foul place for 2 very long years.
It’s very much a tick box and uncaring environment.
The management are a bunch of bullies and I’ve never come across such a scum bag crew of big headed, overpaid nobody’s -with the exception of a handful of the employed GP’s who were just normal caring people doing their job.
Gerard Newman is not sophisticated by the way! And his LEAN programme is hysterical.
What a bunch of morons.
I feel much better for that, thank you!! ??