I wonder how many people really understand how the NHS works?

I ask this because I’ve noticed that over at Non-trivial Solutions, Andrew has managed to get a little too carried away with Tory rhetoric over a BBC story about opposition amongst doctors to proposals to give specially trained nurse and pharmacists greater powers to prescribe drugs.

Andrew’s right to offer up criticism of what amounts to a bit of blatant protectionism by doctors, but where he goes completely off the deep end and into surreality is with statement:

Just one of the many reasons… why the healthcare unions and the NHS monopoly have to be broken:

First of all, its a hell of a reach describing the British Medical Association as a ‘healthcare union’ – it’s certainly not affiliated to the TUC, nor indeed is the Law Society, the Bar Council or any one of numerous other professional associations which operate as independent regulatory bodies.

Then there’s the business of the “NHS monopoly” as well.

What’s being proposed here is an extending the ability of pharmacists and nurse practitioners to prescribe drug treatments for more serious medical conditions such as diabetes and heart disease, a measure which, if it goes through, will leave only controlled substances like diamorphine as the exclusive preserve of doctors and, therefore, something which will effect, almost exclusively, General Practitioners working in Primary Care.

Now this is something I know a fair bit about, both from having worked in the NHS a few years ago and also because a very good friend and occasional visitor to the comments box here just happens to be a non-Executive Director of a local Primary Care Trust.

And what most people don’t realise about Primary Care is that the vast majority of NHS funds which go into providing GP services are actually paid to private sector businesses.

You see, the vast majority of GP’s don’t actually work directly for the NHS and they are not public sector employees. The vast majority of GP practices and health centres in the UK that hold NHS contracts are private sector businesses – more and more of them being limited companies.

And this is nothing new at all. In fact it’s the way its always been since the founding of the NHS by the Atlee government. GPs are not public sector employees, they’re self-employed sub-contractors who hold NHS contracts.

Now, the whole system of NHS contracts for GP services is a long way from being perfect, starting right from basic contract payments which are based on the number of patients on a GPs list irrespective of how many of those patients a GP sees during the year. This is one of the main reasons why recruiting GPs to work in inner city areas is so problematic – a general practice with a 5,000 patient list based in a nice leafy suburb full of healthy middle-class fitness freaks gets paid the same basic contract payment as one with the same size list in inner city slumsville but does far less work for their money as their patients don’t get sick quite anywhere near so often.

General practice, in terms of what doctors actually do, has barely changed over whole 60 year life of the NHS and, in fact, is little different from how it ran before WWII; not because the NHS don’t want things to change, for services to be delivered more flexibly and efficiently at times which fit in better with the changing patterns of work over the last 20-30 years and for payments to be geared to actual performance but because GPs don’t want to change arrangements which, for many, provide a high basic income without eating too dramatically into their other interest – not least amongst which can be private consultations and other nice little earners.

It’s not the NHS monopoly that the problem here, the real problem is the power of what is effectively a cartel of private sector businesses which uses its privileged professional status to rig ‘the market’ in its own favour.

This is an issue I’m more than happy to debate – it so happens we’d almost certainly get better services all around were the NHS better able to direct GP services to meet local needs and not the convenience of doctors – but let’s at least get the language right here. This is isn’t about unions, the NHS monopoly and state corporatism, its about curbing the power of a privileged professional association which operates as a cartel in the absence of independent regulation and scrutiny.