I want to address the elephant in the room. The massive, looming elephant that is GP pay. You have probably seen the reports in the right wing press, and noticed progressive governments' steady drip of negative spin about doctors. Every one of these articles feels like a personal attack on me. Every GP around the country loses that bit more morale when they see those headlines, when another patient comes in carrying one of the tabloids that publicise that viewpoint, steadily undermining the hard-working core of the NHS. The bright young graduates from medical school watch this, and choose other careers. Sometimes I feel embarrassed to say I'm a GP when I meet people. I hope to change the minds of a few people who might read this, but also represent my hard working colleagues.
I have worked damn hard to be a doctor. I do not claim to be better than any other doctor who works for the NHS in this country. I also do not claim that my nursing, midwifery, or healthcare support colleagues get paid enough - they don't. But I can't speak for them. I worked hard at school. I did my GCSE's, my four A-levels. I did all the extras required to get shortlisted for a medical school interview; my exam results got me the place. I had a part-time job from the age of 16, alongside my studying. Saving up to go to university. Like most students, I had to take out the maximum student loans to pay for my rent and my tuition fees. I worked each university holiday to make ends meet. In my first three years, I got my first degree. I sat on average 20 exams a year, as well as writing a 20,000 word dissertation. On full-time clinical placements, the long university holidays vanished, so in the 4th and 5th years of medical school, I focused on exams. I got my second and third degrees. I worked as a junior doctor, doing on-calls and nights. I sat extra exams to give me a chance of getting the most competitive job.
Every doctor you meet has done all this and more. I applied to join the GP training scheme when doctors still wanted to be GP's. I trained for another three years in junior posts, sitting more exams - extra qualifications in child health, women's health, family planning. I sat exams to gain membership of the Royal College of GP's - a mark of excellence. You want to talk about money? It cost me £530 to sit the written paper for this membership. It cost me £1780 to sit the clinical exam. The certificate for these cost me £390. I started work as a GP with over £70,000 of debt. I have a family, a mortgage, a hard-working spouse in another public service.
I undertake continuing professional development each year - I study and attend courses to meet a target for hours spent learning, I have to provide evidence of this and show that I am continuing to improve as a doctor. I must audit my work, analyse and show I have learnt from any complaints, report any significant events in my practice and target my learning to these. I must survey staff, clinical colleagues, and my patients to get their honest feedback on if I am a good doctor or not. If I do not complete this every year, I face having my license to practice removed. Every 5 years I must present a summary of these annual appraisals to the GMC. They have the power to decide if I am fit to practice, to remain as a GP in the NHS. All the courses I go on, the online modules I do, the textbooks I read, I pay for myself. Each year I pay £390 to stay on the GMC's register of doctors. I pay £6900 a year to cover me against being sued for negligence. If I have a bad day, if I am stressed and tired from the increasing demands on me, and I make a mistake - I can be sued, I can lose my livelihood, but most importantly, I could kill you. So how much is this worth to you? How much should I earn given it has taken me 10 years of training after leaving school to get to where I am today, and I continue to work hard to be the best I can be.
Both Labour and Conservative governments have made huge changes to GP contracts, sometimes unilaterally imposing them. In 2004, targets were introduced to General Practice, called the Quality and Outcomes Framework (QoF). Each point on the new QoF framework was worth a set amount of money. As points make prizes, GP's suddenly found that in order to continue to earn their previous wage, they had to hit a certain percent of these targets. The more they hit, the higher the income.
Allow me to labour this point with a simplistic analogy, as this is usually where the "high earning GP" headlines originate from. You're a self-employed businessman. You own a factory making pottery. You have a staff, premises, a family to support. There is only one shop that sells plates, and they buy all your products. Normally, they pay £10 for every plate you make. But one day, there's a call. They've changed their mind. The new price is £5 per plate.
"£5?? But what am I supposed to do? That's not enough to pay my staff! I can't work for that!"
But hang on, there's more. The shop says that if you make some coloured plates, they'll pay you the usual £10. But if you make them coloured and decorated, you'll get £15. What would you do? If that was you, would you settled for a massive drop in your income, lay off staff, potentially close down. Would you work that bit harder, taking on the extra work of painting everything you produce to keep the same money? Or would you employ a talented painter, buy the special equipment they need, and make every single plate a work of art? But wait - there's even more. The shop want to cut costs. They've changed the pricing system because they think they can get better value for money, get you working harder but pay less. Even if they end up paying the same as they do now, they're getting a better product for the price. And they know you'll never employ that painter, spend all that money getting new systems set up to hit the maximum...... will you?
And that is exactly what happened in General Practice. Income was slashed; to get the same amount as the day before, we had to work harder, with the carrot of higher income for more work. What would you have done? So we, as a profession of intelligent individuals, played the game. We employed extra staff, we bought new computer systems, we created new roles - at least one person in each practice whose only job every day of the year was to make sure we hit every single one of those targets. 12 months later the first QoF was published. And to the Government's horror, GP's across the country had jumped through all the hoops, and earned 95%, 99%, 100% of the targets they were given. Incomes leapt, we celebrated, and the government cursed. They were now tied into a contract that was costing them more than before, and the rot started to set in. It is this point I wish I could shout in the face of the writers in the right wing excuse for the press - if it was your job, your income, what would YOU have done? Risen above it all? Said, "No, I became a doctor to save people's lives. When I qualified I instantly became a saint. I don't do it to earn any money at all. I scorn your offer of more pay, and will take my pay cut on the chin, in the interests of saving my soul from trial by tabloid."
No. You wouldn't, would you? And I hazard a guess, almost every user of the NHS wouldn't have either. Would you turn down a £20,000 Golden Hello to move to a part of the country that was recruiting for your job? If it were a newspaper that were short of journalists, I wonder would the writers of these articles stand on their high morals and ignore such an offer? I often want to ask the people who complain about our pay, what they think a GP should earn? What is an acceptable income to them? After all, I'm frequently reminded they pay my wages. Patients feel entitled to question my pay, and have done so in consultations. I am so taken aback by this, I am never able to answer them properly. Perhaps at the end of the consultation I should ask if they feel I have earned my pay for that particular 10 minutes? Did they get the antibiotics they wanted for their cold? Or if not, should I hand them a cheque as they leave?
Every year the government moves the goal posts with changes in QoF targets. Every year it becomes harder and harder to meet them all and still provide basic services. Many of these targets are highly controversial amongst doctors, often drawn from consensus opinion, not evidence based facts which have been shown to improve patient care. GP incomes drop as the government push harder and harder, and the doctors take home less each month to keep the practice running. GP's are the only part of the NHS that is personally cushioning it from the current situation. GP partners earnings have fallen by 20% in the last five years, as they try to sustain the feasibility of the small businesses they run. Despite this practices are closing or being taken over by private companies. Is this your ultimate aim? To deride the nation's doctors until we fail, and the alternative of private General Practice appears? Does the current situation of NHS dentistry teach you nothing? We will never succeed in pleading poverty as doctors. We are highly trained, intelligent professionals. Doctors should be challenged. We should be asked to show we are up to date. That we do the best possible job. That we treat our patients to the absolute best of our ability. But don't tell me I earn too much. Tell me I earn what I deserve, and judge me on how good a doctor I am.Suggest a correction