The NHS specifies what GPs, as independent contractors, are expected to do and provides funding for this work through arrangements known as the General Medical Services Contract.
There was a clause which stated "a doctor is responsible for ensuring the provision for his patients of the services referred to … throughout each day during which his name is included in the … medical list".
[9] The College of General Practitioners was founded in November 1952, and became an increasingly important player in negotiations about the GP contract.
It demanded: "To give the best service to his patients, the family doctor must: The resulting 1966 contract addressed major grievances of GPs and provided for better equipped and better staffed premises (subsidised by the state), greater practitioner autonomy, a basic practice allowance for any GP principal with a list of more than 1000 patients, and pension provisions.
There was considerable pressure from doctors for the introduction of charges to patients but the Minister, Kenneth Robinson and the leadership of the BMA resisted this.
[11] In 1976 parliament approved legislation requiring doctors who wanted to become principals in general practice to complete vocational training.
[9] The Conservative government under Margaret Thatcher from 1979 onwards looked for ways of changing the NHS, with a greater role of the private sector, and for limiting health spending and it was not afraid to take on the doctor's trade union, the British Medical Association (BMA).
The government also introduced a new locally negotiated personal services contract for general practitioners in 1997, permitting them to be salaried, paid by the session, or work as locums.
The new GMS contract came into force in April 2004, abolished the "Red Book" and led to a significant but temporary increase in some practices' income.
This share is determined by the practice's list size, adjusted for age and sex of the patients (children, women and the elderly have higher weights than young men because they cause a greater workload).
Furthermore, the practice gets an adjustment for rurality (greater rurality causes greater expenses), for the cost of employing staff (the "Market Forces Factor"), which captures differences in pay rates between areas, (e.g., it is more expensive to hire a nurse in London than in Perth), the rate of "churn" of the patient list and for morbidity as measured by the Health Survey for England.
[12][13][14] The Working in Partnership Programme (WiPP) was launched under the 2004 contract to support doctors in general practice by providing them with innovative ideas on how to improve services for the public.
The inevitable consequences of systematic underfunding of primary care OOH services and their provision by the cheapest bidder came to a head with the Dr Ubani case, although there have been many others.
It should perhaps stand as a warning of the risks inherent in the "lowest bid cheapest provider" model of medical care.
A series of amendments have followed each year – each time reducing income for the current workload, and tying existing pay to new targets (adding new QoF indicators, making them harder to meet, extending working hours).
Main changes included a named, accountable GP for all patients, publication of GPs' average net earnings and expansion and improvement of online services.
[15] All practices were required to have a patient participation group[16] According to Jeremy Hunt the right to a named GP turned into a tick-box exercise as there were not enough GPs.
Babylon Health complained that this penalised their GP at Hand operation which had invested in technology in order to serve patients over a wide geographic area.
[20] Capitation payments, which make up about 60% of a typical practice's income,[1] are calculated using a formula developed by Professor Roy Carr-Hill.
Richard Vautrey said "Some of these will be people that have recently died, or left the country, others may be homeless or simply unaccounted for in government statistics, and we would be concerned at any suggestion that any discrepancies are down to wilful deception by hard-working GPs.
A study, published by the Journal of the Royal Society of Medicine in 2015 found that 347 of the 8,300 general practices in England were run by under 'alternative provider medical service' contracts.