PI Brief Update

Why is Primary Care 100 times more Effective than Hospitals? - Dr Mark Burgin

25/03/25. Dr Mark Burgin challenges assumptions and explains why prevention is better than cure and health anxiety is creating an ill health industry.

The mathematics is simple enough , one in ten patient contacts is with hospitals each day and they use 9 out of 10 of the pounds put into the health service. GPs see ten times more patients for a tenth of the budget. Times ten by ten and you reach one hundred in the cost per consultation difference between GPs and consultants.

This number is huge. The difference between most choices is less than two, one fizzy drink is usually 1.5 times better than the other. One taxi company is 3 times better than its competitors. It is rare outside of genius to have 100 times difference although perhaps Picasso was 100 times better than the average artist.

Of course, the consultants might have much higher productivity than GPs, they might be able to cure a patient in one consultation that a GP takes ten. The evidence however does not support this view and the evidence is that most consultants spend their time in endless follow-up clinics. GPs are productive because they can prevent problems so will always be at an advantage.

Funding of GPs has fallen from 11% to 8% of the budget expanding the theoretical difference in effectiveness. There has been a small increase in the GP’s team but this is dwarfed by the non-consultant senior clinicians. These SAS doctors have increased in numbers faster than any other groups. Add on the specialist nurses and hospitals have beaten GPs hands down in every area.

What do GPs do?

The best GPs appear to do nothing, their patients are all well and attend follow up for to manage their risk factors whilst continuing to work and holiday and enjoy their lives. It takes a decade or two to stabilise a population’s health so they do not need to attend A and E for emergencies. The magic of primary care is the biopsychosocial model which looks at the person holistically.

The GP makes small steps with the patient called psychosocial progress, for a diabetic this might be getting stable housing, taking their antidepressant regularly, getting back together with their parents before they start to address their blood sugar. After this they can have access to their child, get a part time job and start to study for a different career.

Medical interventions in primary care are directed at helping the person live a better life. The GP is less concerned about the exact diagnosis and more about the next step to recovery. Over years GPs make small imperceptible changes to their patients’ lives which combine to transform their trajectory. This can make it difficult to recognise the value of the GP.

Managers are unable to measure what good GPs achieve, they will often favour the busy chaos of a bad GP. This GP has lots of activity but little progress, it is easy to measure and set targets. Despite these targets being inappropriate and possibly harmful for patients, failure to understand what a GP does leads to micromanaged waste.

Why hospitals cannot help patients

Most conditions have long prodrome, heart disease for instance will often start in childhood. This gives a large window of opportunity before they die in their 50s for the GP to change their path. The cardiologist is limited in what they can offer at an early stage. Invasive tests are dangerous and likely to be normal, the specialist cannot offer what is required – 35 years plus follow up providing support to avoid or treat risk factors.

Only when the GPs efforts have failed and at 73 years the cardiovascular disease becomes too severe is it worth making that referral. The specialist can arrange an angiogram to confirm and treat the problem before sending them back to the GP. The outcome of that treatment will depend heavily on the work of the GP and patient over the years.

Patients with treatable disease often fail to get the best results despite hospital care that is excellent. If the patient’s anxiety is out of control, if they have other problems that have not been addressed and if they are referred too early or too late things will not go well. Hospitals cannot do prevention any more than a GP can do brain surgery. Most patients don’t need brain surgery but they do need prevention.

Hospitals have excellent staff, highly skilled in their areas and although a few might be struggling overall they deliver an excellent service. The problem is that what patients need is not what the hospital can deliver. This mismatch between supply and demand causes high levels of waste and increased supply does not fix the problem.

Money, money, money

Political argument is often loud and any sensible comments are drowned out by the rhetoric and polarisation. This shouting does not change the fact that hospitals offer treatment for illnesses. If patients’ main issues are social problems and behaviour problems then the hospital will not be the best option.

A small increase in funding for GPs would undoubtedly lead to some GPs enjoying a better lifestyle. The sight of a few more GPs sending their chid to the same posh schools as other professionals may be tolerable if access to those GPs was to improve. In the last 20 years extra funding in secondary care has led to worsened performance.

A roughly doubling of NHS funding from £75 to 150 billion has been associated with removal of services such as varicose veins, hernias, ear wax etc. It cost more, much more to do the same as 20 years ago. The explanation is that even a small transfer such as 1% of primary care causes an increase of 10% in hospital workload. Costs to hospital of this transfer can be 100 times the savings in primary care.

Hospitals are not to blame for the increasing mismatch between what they are able to deliver and what is required. Much of the transfer from primary care has been those social and behavioural problems rather than medical illness. Hospitals with their large complex organisations cannot compete in terms of cost per patient with the GP.

Conclusions.

Imagine a medical system made up of two parts, one 100 times more effective than the other. Any rational government would fund the effective part and decrease funding for the other part. Medical leaders would shout loudly about effectiveness and urge funding to prevent cost rises in the other part. Patients would call out for tax reductions and cuts to waste.

Patients often prefer the drama of seeing the consultant to the quiet efficiency of the GP. When GPs gave 2 thirds of all the Covid jabs it was the private companies that took the glory (and all the money). When a GP prevents a patient from dying in 30 years time they do not thank the GP and buy them a bottle of brandy.

In the real world large industrial organisations ensure that rather than manufacturing health, the NHS manufactures health anxiety. People waste money on ineffective healthcare and begrudge their GP getting £50 per patient per year. Patients are terrified about cancer but forget to have a flu jab. They will see a specialist for expensive tests but not work with their GP to manage their mental health.

My message is to remind those in power that primary care is 100 times more effective than hospitals. That for every pound spent in a hospital 99% is being wasted leading to increased taxes and debt. I urge those who are concerned about their own health to consider what psychosocial progress they could make. What small thing could make a difference to their health?

Doctor Mark Burgin, BM BCh (oxon) MRCGP is a Disability Analyst and is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 websites drmarkburgin.co.uk and gecko-alligator-babx.squarespace.com

This is part of a series of articles by Dr. Mark Burgin. The opinions expressed in this article are the author's own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand.

Image ©iStockphoto.com/andrei_r