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GP

by John Knox

I don’t mean to be unkind, but we could probably take £20,000 a year out of doctors’ salaries without it having much effect. In Scotland, that would save the NHS around £200m a year which could be used to meet other rising costs or even employ more doctors.

According to the OECD, Britain has fewer doctors per thousand people than any other European country. It also pays its doctors more than any other European country. On average, GPs earn around £80,000 a year. Senior consultants in our hospitals may earn as much as £110,000. Partners in a GP practice may earn up to £103,000 – but that includes the costs of running the practice. Salaried GPs, employed directly by the NHS, earn anything between £53,000 and £81,000.

These numbers defy economic logic. How can the UK have so few doctors and at the same time pay them so much ? In a normal market you would expect high wages to attract a large number of workers, the supply would then exceed demand and the wage rate would fall. But of course we are not dealing with a normal market. Medicine, very largely, is a state-controlled business and the powers that be – politicians and the professional bodies – determine the salaries paid and the numbers of doctors.

There are always plenty of applicants for the UK’s 32 medical schools (5 of them in Scotland) – 16 applicants for every place at the last count. And the number of specialised training places, after basic qualification, is again restricted. The system is so tightly controlled that it has left Britain, and Scotland, with a chronic shortage of doctors – so much so that a third of our doctors are from overseas – 10 per cent qualified elsewhere in Europe and 28 per cent qualified outside Europe, mainly in Asia and Africa.

It seems to me that it would make more sense to loosen the stranglehold on entry to the profession and pay those in it a little less in order to balance the books. Individual doctors would then be under less time-pressure and we might then see a fall in the number of complaints against doctors which the General Medical Council says have risen 23 per cent in the last year.

Now you might say doctors have a very responsible job, they are all clever men and women, they have worked long and hard through university and training, they have not been paid high wages while junior doctors, so they are entitled to a substantial salary. Indeed it’s a sign that society places a high value on their work and that they are among the most respected professions. All this is true. All I am saying is that £80,000 a year is excessive and unnecessary.

It is a throw-back to the old days when old boys dominated the profession and were able to restrict membership of their club in order to keep their rewards artificially high. It was also a wage designed to provide for two people, doctors’ wives often serving as unpaid receptionists and secretaries. Nowadays woman make up half the profession and a lot live in a two-income households.

A salary of £80,000 or more is also unfair when compared to other professions. Experienced nurses are paid around £30,000, teachers £40,000 and the average wage is around £26,000. Not much wonder there was considerable public anger when doctors took industrial action in June over their generous pension arrangements….an average annual pension of £68,000 a year. They had lost touch with the fact that the whole country is having to take a 10 per cent cut in our living standards as a result of the bankers’ recession.

So what can the Scottish government do about it all ? Well it can start moving towards a doctor’s salary of £60,000. Next time the contracts with our 5,000 GPs come up for renewal, that lower salary should be the basis for working out the practice payments. Health Boards – who employ the other 5,000 doctors directly in their hospitals – could advertise all new doctors’ posts at the reduced rate.

Of course there would be outrage from the leaders of the medical profession but I think that would soon die away – as it did over the introduction of the NHS in the first place. And, in any case, the change would have to be introduced slowly to allow the universities time to train more doctors. But I don’t believe it would lead to any great exodus from the profession. Medicine is, after all, a vocation and £60,000 a year is a comfortable living.

Rannoch Moor: Is there a doctor in the house? <em>Picture: <a href=

Rannoch Moor: Is there a doctor in the house? Picture: Pip Rolls

I hope that members of the Scottish Parliament’s Health Committee enjoyed their wee trip to Rannoch yesterday; it’s a lovely part of the world and the weather wasn’t as bad as it could have been in January.

So I trust they enjoyed the scenery, because I’m not sure what else the trip would have done.

The committee is investigating the issue of out-of-hours GP cover in rural areas, and Kinloch Rannoch has, in a sense, become the “poster” village for campaigners who think the service has gone down the pan.

Kinloch Rannoch, a small village in Highland Perthshire with approximately 300 inhabitants, used to have its own resident GP who was on-call 24-hours-a-day. When the new GP contract allowed every other practice in Tayside to opt out of responsibility for care out-of-hours, that GP didn’t see why he couldn’t do the same.

Eventually, an appeals panel agreed with him, and the health board had to put in other arrangements. Although this caused local outrage at the time, the village ire was upped when the original GP decided to retire, and, instead of being replaced a doctor resident in the village, the nearby Aberfeldy practice was awarded the contract and now looks after the area’s patients.

Rannoch was now without a resident GP, dashing the hopes of residents who had hoped things would go back to the way they were before, so they kicked up even more of a stink.

But let’s look at it logically. Rannoch is a rural area and is relatively remote. But it’s not as if it’s stuck on an island miles away from the shore. It’s just 20 miles – albeit by slow roads – from Aberfeldy and Pitlochry. That’s roughly the same distance, by the way, which Rannoch Station is from Kinloch Rannoch. Nobody seriously thought, however, that Rannoch Station with its handful of houses (and rather lovely hotel) deserved its own resident GP.

NHS Tayside, presumably aware that the situation would be under scrutiny, has made exceptional efforts to sort out the out-of-hours care. Like the rest of the region, it is now covered by the Tayside Out of Hours service. Calls are triaged and a decision taken about whether a GP visit is required, or whether the patient should be seen at minor injury units. According to NHS Tayside, there are approximately two requests per month for GPs out-of-hours, and these are routinely met within the required timescales.

Gerry Marr, NHS Tayside’s chief operating officer, told the BBC yesterday that cost per head of having a dedicated GP in Kinloch Rannoch would be £900 per year, compared with £15 under the current arrangements. While cost isn’t the “determining factor”, he said, obviously it has to be taken into account. Which it does. We all might like a GP available all the time, but it just isn’t sustainable, just as it isn’t possible to have an acute hospital in every small town.

People who live in rural areas, by and large (and I am one of them), know they have to make compromises. It can take a bit longer to get deliveries, the village shop won’t have as much choice as Sainsbury’s, chances are your children will have to get a bus to the nearest town for secondary schooling. But there are tremendous upsides too, which is why so many people who have spent their working lives in cities decide to retire to beautiful places like Kinloch Rannoch.

GP services aren’t going back to the way they were when Dr Finlay was around (although, ironically, there is a Dr Finlay in the Rannoch practice). The world has moved on. Doctors are people with families and lives outside work – most will not stand for being on-call all the time, particularly as today’s consumers (patients) are a lot more demanding than they were in the 1950s.

And that’s the other point. The NHS is trying to move from a system where it is responding to emergencies and trying to anticipate and prevent them instead. Good “in-hours” GP care is the key to that, and this certainly seems to be provided by the new Rannoch practice. For goodness sake, you can see a GP there any day of the week, Monday to Friday, including Wednesday afternoons, and you don’t generally have to wait for appointments. How many inner city GP practices can say the same?

The health board has also been criticised for putting in other measures, such as the Community First Responders scheme, run by the Scottish Ambulance Service and supported by NHS Tayside. These volunteers aren’t a substitute for GPs, say critics. No, they’re not, but they were never intended to be. The campaigners are missing the point.

So that’s why I’m saying that yesterday’s meeting probably didn’t take the issue on: the critics will not be convinced and the health board probably can’t bend any further.

As for me – I’m tempted to move to Kinloch Rannoch. The healthcare seems quite amazing.