What is a GP worth? There is no answer in this gold-rush decade when the government shies away from even thinking about worth. The public sector is nailed to 1.5% pay increases, boardrooms soar by 30% and the Pay Commission is rowing about whether to defy the Confederation of British Industry and raise the minimum wage a measly 25p.
No wonder this year's GP negotiations have run into the mud, suspended in anger. In a value void, how should we think about GPs earning an average £106,000, and many a lot more? Are they worth it? That's roughly the same as a director of social services running a whole county's complex children's services, including all schools, children in care and children's health. But that director is a hated "bureaucrat": just see the bloggers' bile when I described their jobs this week.
GPs are visible frontline public heroes. They need four As at A-level and five years' hard training. They are greatly respected: patients are attached to them with the loyalty of limpets. They top every poll for trust, so would presumably top public approval for generous rewards compared with, say, lawyers, let alone journalists. About 90% of NHS work happens in the community, via their clinics. As effective NHS gatekeepers they are the envy of many less efficient EU health services. Politicians love to "reform" hospitals with cunning market devices, but what matters most is the tricky business of micro-managing what GPs do.
Bevan's great failure was to leave GPs as small businesses, so the NHS never controlled its key service. Alan Milburn strutting his stuff about "reform" draws nothing but snorts of disbelief from NHS experts: he is remembered as the health secretary who turned Bevan's error into a monumental blunder.
Here is what his new GP contract did, intending to encourage more preventative work: GP earnings rose 63% in three years. They gave up out-of-hours work, home visits are rare, and they work 44 hours a week - low for top professionals. Clinics stay resolutely shut on evenings and at weekends. The Healthcare Commission says that a third take no bookings more than two days ahead and 12% can't offer appointments within two days. (About this there is public outrage, though curiously not at GPs.)
They earn more than the lord chancellor and circuit judges, which may be fine with the public. But while their pay soared, they took more NHS money into their own pockets and spent a lower proportion on their practices. They used to keep 40% for themselves, but in the past year that has crept up to 45%. As they're private businesses, no mechanism fixes how much they keep and what they invest in their clinics. Patients are supposed to be the "market" that tests their quality, though patients neither feel nor behave like "customers" - and most don't know their GP is a business.
This is rum commerce with a no-risk contract that any ordinary business would die for. The contract has a guaranteed minimum income: they can make as much profit as they like, with no risk of failure. Is there any comeback against less good GPs? No, say the NHS negotiators. Only the very worst are terminated as a danger to the public. There is no comeback against perhaps a third who are a bit lazy, weak, bad managers or have simply lost interest.
Why can't the primary care trust (PCT) withdraw their contracts? No, can't be done, say the NHS negotiators. You'd have 3,000 of their loyal patients up in arms defending even bad practices. Surely an NHS that dares to close local hospitals could brave that? No, can't be done with GPs. Instead, the NHS will soon publish GP results, hoping better informed patients will shop around. But as no one expects that to happen, these private businesses have the NHS over a barrel.
The Milburn golden contract paid GPs for performing new tasks under a "quality framework". For example, they got extra points to identify chronic patients with kidney disease, diabetes or heart problems, so good early treatment might keep "frequent fliers" out of repeat hospital visits. The result? Last year, 850,000 extra chronic cases were diagnosed, 100 more per practice, most with high blood pressure. This paid out some £70,000 extra to practices with maximum scores.
Is that good or bad? No one knows. Some suspect gross over-diagnosis, others say it shows the system works. Either way, no one predicted a sudden increase: unexpected GP pay rises added £300m to NHS deficits. This illuminates all that is wrong with the way GPs are employed. Either they are cheating on payments or they admit they never bothered to check enough blood pressures until bribed to do it. (If the BMA writes its usual reply, please answer that conundrum.) Now GPs demand extra to open their doors at times when the working public can actually visit.
The ministerial response is more private competition: in Derbyshire, with one weak GP area, the PCT offered a GP contract to a genuinely private company - and there was uproar and a court challenge. GPs want to have it both ways, to be businesses when it suits but to be a loved and protected part of the NHS when that suits even better.
In the deadlock over this year's pay, the GPs have appealed to the doctors' and nurses' pay review body. This is odd. The review body doesn't cover GPs because they are private contractors not NHS employees, yet suddenly it suits GPs to pretend they are. So perhaps it's time they were paid a salary like consultants, with a normal job specification and the cash for their clinics safely ring-fenced.
Others conclude the opposite - that they should become genuinely competing private contractors in a real market. But that would end up costing more, with spare capacity, lacunae in some areas and too little NHS control. Patients just don't make good enough choosers to guarantee a real market. They want to trust their doctors (as I do mine of 35 years absolutely, but with no real information). It's a trust relationship, it's not buying iPods.
The chief NHS negotiator (eager to say she wasn't there for the Milburn car-crash), Dr Barbara Hakin, is an ex-GP, now head of a strategic health authority. She muses over the way GPs are employed. She says the best GPs are all the better for being private entrepreneurs, free from NHS bureaucracy, innovative at squeezing better service out of their money. I know the kind, inspirational, idealistic practices, often in inner cities where they work all hours. Ironically, she says they make most money through good management, alongside the worst doctors who make most by doing least.
But then Dr Hakin says there would be strong advantages too in taking many GP practices into direct NHS employment. Doctors are not always good business managers. "We need more flexibility, with different models to deal with those - maybe a third - quite good, but not very good practices." There need to be more levers to improve the sub-standard without exorbitant bribery.
In this era of mega-pay, it is unfair to begrudge the GPs their professional salary: there is a shortage of them. But it's also time to reopen the old Bevan settlement and bring the under-performers back in-house to be better managed as the NHS's most vital resource and key gatekeeper.
· Polly Toynbee will be away until March