When we look at the development of the income of the GPs between 2000 and 2010, several conclusions can be drawn. Firstly, the incomes of GPs in all countries except Denmark have increased (corrected for inflation), and increased more than the average income in the population. The largest relative increase was found in the Netherlands and Belgium. Secondly, the gap between the countries where GPs have a relatively lower income (Belgium, Sweden, France and Finland) and the countries where GPs have a higher income (Netherlands, Germany and the UK) continues to exist over time. Thirdly, the countries with comprehensive reforms are the countries where GPs received the highest payments already. The result of the comprehensive change seems to be that GP income increased substantially in the two or three years after the change. After that, the income decreased somewhat. In the UK, an increase in income was intended [
27,
28], but the increase was higher than foreseen [
27]. In Belgium, the increase in income was also intended to make the profession more attractive in comparison with other medical specialties [
16]. In the Netherlands, the change was intended to be budget neutral, as in Germany.
Fourthly, on average, GPs working in countries with a strong primary care sector in terms of governance, workforce development, access, and coordination of care appear to have a substantial higher income than GPs working in countries with a medium or weak primary care sector. We found no association between income development and the continuity of primary care. Perhaps this can be explained by the fact that having a long-term relationship with patients, keeping medical records, and creating a feeling of trust is a universal feature of primary care and inherent to the profession of GPs, irrespective of their income level, while governance, workforce development, access, and coordination of care are largely influenced by policies and financial incentives. It is unclear why GPs in countries with a comprehensive service delivery earn less compared to their colleagues in countries with a less comprehensive service delivery. The dimension of comprehensiveness was mainly based on expert opinion, whereas the other dimensions are based on more robust data [
10]. Maybe experts tend to overestimate the comprehensiveness in their country. All in all, the results seem to suggest that in countries with a better organized primary health care system, GPs have a relatively stronger position in the system and are also able to use this position to their own benefit, i.e. by ensuring a higher income.
Policy makers have tried to curb the unintended increases in income in the UK and the Netherlands. In the UK, the GMS contract of 2004 was valid for three years. So the first year of possible measures to curb the increase in income was 2007. In the following years, net remuneration of GPs was either frozen or increased with only a (partial) compensation for inflation [
27,
33]. The quality and outcomes framework was adjusted several times. The idea behind the changes was to continuously improve the quality of the general practice. The effect was that income of GPs in real terms decreased after the initial GMS contract had ended, but remained higher than the level before the reform. In the Netherlands, where a budget neural transition was envisaged, the unforeseen increase led to a claim on GPs to repay the excess, which is currently under discussion between representatives of the GPs and the Ministry of Health.
Limitations of the study
An important limitation of this study is that we only present average incomes of GPs. The variation in income within countries in the case of non-salaried GPs are large. Evidence for this is found in Belgium [
35], the Netherlands [
36], Germany [
37] and the UK [
38].
A problem in calculating GP income from the total revenue is the increasing complexity of the financing of GP practices. The emergence of new payment systems, such as the integrated care fees and new health professionals working for GPs, such as nurse practitioners, make it difficult to establish the expenditure of GPs, since for instance health care consumption of specialist care of patients on the GP’s list have to be paid by the GP(−practice). There is no longer a relationship between workload (in number of patients or number of services) and remuneration. This will make it difficult to monitor GP-expenditure in the future.
We have tried to relate the development in GP income to the context of primary care. However, we are aware of the fact that we only have eight countries in our study. Therefore, the results should be seen as a first indication of the association between income development and primary care context.
Further limitations concern the calculation of practice costs, the method of calculating GP income before and after a drastic reform, the information on number of active (fulltime) GPs, and the income derived from services for private patients.
The most important problems in calculating GP income in countries where GPs are self-employed entrepreneurs are to calculate practice costs and to define what is a full-time GP. Practice costs include salaries for practice personnel, housing, medical equipment, transportation etc.. The most reliable data on practice costs come from tax data. However, this implies that the tax office knows who are GPs and how many GPs are actively working as GP. Since this information is not always available, in some countries dedicated studies have been carried out into this matter (as for instance in Denmark, the Netherlands and Germany [
39‐
41]. These studies are usually not repeated on a yearly basis, thus estimation methods have to be used to calculate practice costs for the years where no data were available. Besides, the outcome of the studies into practice costs are related to the organization that initiates the study. Parties that represent the interest of GPs often have a systematically higher estimate compared to paying parties, such as governments and health insurers [
8]. The definition of what is a full-time GP may change over time, leading to different income figures. In Belgium, for instance, a continuous effort to improve the estimation of the GP’s context lead to different methods of calculation and thus to different figures of GP income.
For the comparisons within countries, as a result of changing remuneration methods, the calculation of the income may contain different income components before and after the reform. In the Netherlands, for instance, this may underestimate the income of GPs before 2006, since GPs may receive some extra remuneration through extra allowance for practice management and from extra activities such as pap smears, health checks for drivers’ licences, making an ECG etc. These income components (besides influenza vaccination) are not included in the calculations. However, the underestimation will not be so large, that the difference between 2005 and 2006 can be explained from this artefact. For the comparison between countries, we have to note that there is an underestimation of the income of GPs in Denmark, because the income is based on head counts of GPs in stead of full-time equivalents. There is a difference of around 20% for the three years that data are available for both full-time GP and income based on head count. However, since the number of GPs has not changed substantially over the years, we assume that the underestimation is constant over time. In the data for Belgium, Denmark and France, income from out-of-hours activities are included, whereas this is excluded in the other countries, leading to a slight overestimation of the income of Belgium, Danish and French GPs compared to the other countries.
Finally, changes in GP remuneration may not be the only cause of changes in income. Other developments, such as increasing demand for GP services, ageing of the population and substitution of hospital care to primary care may also affect GP income. In the Netherlands, for instance, there is evidence that part of the increase is due to an increase in primary care use [
42].