Gp in Europe

United Kingdom


The National Health Service (NHS) is comprehensive and largely free at the point of use. Charges are, however, made for pharmaceutical and dental services and the NHS no longer provides general ophthalmic services to the majority of the population. NHS expenditure totalled almost 44 billion in 1997 or 1 3.7 per cent of total public expenditure. The bulk (84 per cent) of NHS expenditure is financed from general taxation.

Primary care
Primary care is the area of the patient's first contact with thehealth service. As such it includes not only medical care provided under the general medical services (GMS), but also the community health services and treatment in accident and emergency departments of hospitals as well as dental and ophthalmic care. Using this broad definition, primary care accounts for some 33 per cent of NHS expenditure in the United Kingdom (UK).Prior to April 1996, primary care was administered principally by family health services authorities (FHSA) in England andWales, health boards in Scotland and health and social services boards in Northern Ireland. Since that date however, changes in England and Wales have made it the responsibility of new unified health authorities which combine this role with their other functions assessing the health needs of their resident populations and purchasing appropriate healthcare from providers, usually NHS Trusts. All four countries within the UK now therefore have a unified system. The move to devolution of government within the UK is, however, going to lead to increased diversification in the healthcare systems of the four countries.Primary care services are provided for the most part by independent contractors. Dental, and where appropriate, ophthalmic practitioners are paid by fee-for-service and general medical practitioners by a complex system of fees and allowances, described in greater detail below.Pharmaceutical services are provided by chemists and appliance suppliers who are also independent contractors to the NHS, as well as by doctors, particularly those in rural areas. Drugs and appliances are supplied under the NHS upon receipt of a prescription provided by a general practitioner, with the exception of certain 'over the counter' preparations. The pharmaceutical services account for around ten percent of total NHS gross expenditure. A charge is levied (currently 5.80 per item supplied) for prescribed drugs, but an elaborate exemption mechanism for groups such as the' elderly, the indigent and the young, as well as for some patients with chronic, mainly endocrine diseases, means that some 80 per cent of prescriptions are dispensed free.

General medical services

General medical services are those services provided by general practitioners to patients on their lists (and in certain circumstances to those on the list of other practitioners) for which no remuneration is received other than from the health authority. General medical services absorb around 30 per cent of gross expenditure on primary care. The definition of GMS is crucial to understanding the range of services provided. Although the remuneration system for general practitioners specifically recognises certain activities, others are undertaken at the total discretion of the practitioner with no explicit remuneration. There is currently much debate about the content of GMS, and about the possibility of a more specific definition of core services to be provided by all GPs.The general medical services are funded entirely from general taxation and no charge is made to the patient for the service rendered by the general practitioner under the NHS. There is thus no financial barrier between patients and their first point of contact with the health service.The importance of the general medical services sector can be judged by the proportion of medical care it deals with. Of nearly 300 million initial doctor contacts, 95 per cent are with general medical practitioners. Of these latter some 12 percent will lie referred by the general practitioner to hospital for tests, x-rays or further treatment, whilst nearly 90 per cent will be treated from start to finish by the general practitioner. On average each person in the UK contacts their general practitioner about five times per year. Of these consultations, approximately 12.b per cent take place at the patient's home and the remainder at the surgery or by telephone. The number of patients per unrestricted principal in general practice is around 1,850 and each general practitioner will therefore be involved in around 9,000 consultations per year. Some 1,150 of these will be in the patient's home. However, UK general practice is increasingly focused on premises-based care, both in hours and out of-hours, and increasing attention is being given to ways of getting vulnerable patients to surgery premises for the delivery of high quality clinical care.Over the course of the year each general practitioner issues approximately 1 7,400 items or an average of 9.4 per patient.The regulations governing the general medical services, the terms of service of general medical practitioners and the current organisation of the discipline combine to provide the consumer, ie, the patient, with substantial freedom of access to general medical services. Each person may choose their general practitioner. Equally, the individual practitioner is free to decide whether or not to accept an applicant onto his or her list as a patient. Under certain circumstances a patient may be assigned to the general practitioner. A doctor's patients are not only those as recorded by the health authority, but also those accepted as temporary residents, those to whom certain specified services (contraceptive, maternity, child health surveillance or minor surgery services) are provided, and those to whom the doctor may be requested to give treatment which is immediately necessary, for example, after an accident or in an emergency.General practitioners are obliged to render to their patients all necessary and appropriate personal medical services of the type usually provided by general practitioners. They can fulfil their obligation at their practice premises, the patient's home or elsewhere in their practice area. They are under no obligation to give treatment personally, provided that they take all reasonable steps to ensure continuity of treatment. Notwithstanding this, they are responsible ultimately for any treatment given by those to whom they delegate, unless that person is also a general practitioner principal.Access to general practice is made as easy as possible by a combination of organisational factors. Firstly, the Medical Practices Committee is charged with the efficient distribution of general practitioners across the country. This Committee categorises areas as 'designated', 'open', 'intermediate' or 'restricted'. Designated areas and, to a lesser extent, open areas are thought to be under-doctored. Intermediate areas are deemed balanced and restricted areas are deemed over-doctored. The success of distributing general practitioners (the direction of labour in this respect being negative rather than positive) can be gauged by the fact that no general practitioners now practice in designated areas, compared with 20 per cent 20 years ago.Two other features of the organisation of general practice lend themselves to easier access by patients. The first of these is the progressive reduction in average list size, which has taken place over the period since 1969. The second is the emergence of group practices.Group practices include partnerships and also groups of doctors that have no business relationship but rather one of organisation. A single-handed general practitioner can combine with others to form a group practice, provided that they spend a certain amount of time at common practice premises. Eighty per cent of all general practices in the UK are group practices, and the great majority of those are also partnerships. The average size of a group practice is four 'principals in general practice'. There has also been a significant increase in the employment of ancillary staff in general practice and in the attachment to practice of staff paid by health authorities, such as health visitors, nurses and midwives.


Remuneration of the general practitioner
General practitioners are remunerated by means of a number of fees and allowances. Over half are related to list size (capitation-based) and others to recognised item of service work. General practitioners are also paid various allowances, and are eligible for bonus or target payments for the achievement of certain levels of childhood immunisation and cervical cytology coverage. These four elements for a general practitioner's income currently, or average, account for 53 per cent, 1 9 per cent, 21 per cent anr seven per cent respectively. These fees are recommended each yeai by the Review Body on Doctors' and Dentists' Remuneratior (DDRB). They are set so as to provide the average general practitionei with the recommended net income felt appropriate by the DDRR after practice expenses have been met, and a recommended gros;-income sufficient to reimburse indirectly all the average general practitioner's practice expenses which are not reimbursed directly. Those practice expenses are calculated through an annual survey of general practitioners' tax returns.Other payments are also made to general practitioners as direct reimbursements of expenses. Such payments cover premises, staff, computer expenses and drugs in varying proportions, all othel expenses are met by general practitioners from their gross fees and allowances. In cases where the general practitioner practises in partnership, remuneration may not be in direct proportion to personal list size or indeed, the personal service provided. Rather, it will be dictated by an agreed partnership share. This share reflects, amongst other factors, the individual general practitioner's contribution 1<;the practice capital, seniority in the practice and share of total practice workload.During the financial year 1997/98 payments under the general medical services totalled some 130,418 per unrestricted principal. Of this total, 44 percent were direct reimbursement of expenses. Of the 56 per cent remaining, 34 per cent was capitation based. Average intended net income for 1997/98 was 46,450.


Beyond the internal market
Since 1991, the NHS has been organised as an internal market with purchasers or commissioners, on the one hand, and providers ol health services, on the other. Providers are mostly hospitals o( groups of hospitals now reconstituted as free standing NHS trusts, the remainder largely being community trusts providing community health services. Purchasers are the health authorities described above. The relationship between purchasers and individual providers takes the form of contracts and purchasers receive the necessary funds by way of a weighted capitation formula. This takes' into account the age structure and socioeconomic characteristics of the authority's resident population.Eligible general practitioners are allowed to opt for what is termed fundholder status. If they have more than 5,000 patients (3,000 foi community services fundholding) on their practice lists they can be allocated resources to enable them to act as purchasers in place of the health authority for their own patients in respect of a defined range of services. These may include outpatient services, diagnostic tests, the provision of medicines and certain inpatient and day case treatments mostly elective surgery. A number of total purchasing pilots, in which general practices or groups of practices either purchase or provide the full range of services required by thc'ii patients, are currently being evaluated. To continue with fundholding status, the fundholders must demonstrate that their contracts foi purchasing are well-managed within their allocated budgets.The UK government is currently embarking on a series of reforms of the health service which will abolish the internal market in it1 current form and will group all general practitioners in geographically-based groups. These groups, primary care groups in England, will have functions which will include the development of primary care, focusing on improving standards through a process called clinical governance, commissioning of secondary care services and improving the health of their local populations. There will be significani differences in the systems as they apply to the different countries of the UK as devolution progressively takes effect.



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