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A faulty production line

GPs should be paid per 1,000 consultations, says Gerada

GP practices should be paid based on the number of patient consultations rather than the number of registered patients, former RCGP chair Professor Clare Gerada has said.

Professor Gerada, who now advises NHS England on its London primary care strategy, said the current contractual model has failed to recognise the increase in consultation rates and needs to change.

Speaking to Pulse, she said: ‘I think the problem we have got at the moment is that we are paid per patients and I think we should maybe look at a different formula and be paid per consultation – or per thousands of consultations, or paid something that takes into account that the consultation work has doubled in [recent] years.’

‘I think it would be much more honest if we were paid by consultation rates than by numbers on our lists because I think what is going on at the moment is that there is no account being taken whatsoever for the increased consultation rate, which has doubled, and we just can’t keep absorbing all of this work.’

Her suggestion comes after delegates at the LMCs Conference voted against a motion suggesting a move to a payment-by-results system only last week.

But Professor Gerada said the ‘desperate’ times meant the profession has to explore contracting options.

She said: ‘My morning surgery, sometimes I just don’t know where to start. We need to completely re-look at the ways that GPs are remunerated. We need to open up a debate… about whether the way that GPs are contracted is the right way. It has served us well, but things are so desperate now that I think we have got to look at all options.’

Last year, while still in her RCGP role, Professor Gerada caused a debate within the profession with her suggestion that all GPs should become salaried.

The RCGP’s 2022 GP evidence pack published last year claimed GP consultation rates increased from three to six per patient over the last decade.

Readers' comments (54)

  • Absolutely, there needs to be a change! What that is, we need to look at all options.
    Payment per consultation/per 1,000 consultations is one idea, but also need to look at caveats - what is the limit in terms of number of problems per consultation (some come in with 3-5 problems, which is unfair on the GP trying to deal with this), how many medical problems is it safe to manage in one consultation, how long should a consultation be etc?

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  • Vinci Ho

    Fine
    Please give a quotation at what rate/price GPs should be paid per 1000 consultation . Otherwise , the debate will be meaningless....:.:

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  • I have always felt that we should be paid by consultation as that is the bread and butter of gp land. We cannot always show a result when a patient comes in for counselling,advice or just a chat. If we are paid for the time spent consulting then that works. Why not be paid per consultation and allow so May consultations per patient?

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  • Fantastic idea, implement asap

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  • Sadly if it makes sense it is destined not to be considered appropriate by any politician. Grrrrrrr

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  • Great idea. Cure GP access problems overnight. Grant GPs licence to print money. Just employ more salaried doctors and make them pay for themselves by offering loads of appts.
    You haven't thought this through Dr Gerada.

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  • Excellent idea. Hospital services and Dentists are already paid like this. It is the only way to prevent unfunded work being pushed into primary care. The devil will be in the details e.g £3 per consultation will not win support. The ability to pick and choose whether to provide this on the NHS or privately, as Dentists do, would also help

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  • Took Early Retirement

    Clare is spot-on, IMHO, as she so often is. I agree, it COULD be open to abuse. Difficult one to sort out. I suppose it could be implemented and then CQC could be made to do something useful, like look at outliers. I bet the government would be very unhappy when they have to start paying for currently unfunded consultations, like the "GANFYD".

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  • I think systems could be put in place to stop gaming - such as ceiling to rate or rates adjusted for deprivation & complexity. But the current system is not fair to GPs who are reeling under the work.

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  • Dr Gerada, this is by far and away your best idea yet. Fundamentally no business model can endure without some relationship between work done and resources gained. I'd have thought it would be fairly straightforward to construct barriers to excessive claims and promote productivity, perhaps we have finally found a role for Monitor? This model would also translate very well to the private sector that the government seem so obsessed with so everyone is a winner!

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  • In the interests of competition and stimulating the market perhaps a suite of options could be offered just like mortgages such as 2y fixed rates, variable and capped so practices can suit incomes that match their finances and appetite for risk?

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  • this seems diametrically opposed to Clare's previous "we should all just be salaried" idea??

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  • Some sense in this suggestion, but many procedures, complex disease management and other appointments need to be provided in 20 minute 'double slots', rather than 10 minute appointments. Paying per consultation will only work if all consultations are 'worth' the same money! A quick 'please could you check the mole on my back' taking a couple of minutes, is not necessarily 'worth' the same as a review of an elderly patient with multiple co-morbidities and polypharmacy attending for a medication and chronic disease review! Paying 'per consultation' might only incentivise GPs to set limits on 'one problem = one consultation', which could have the knock on effect of making appointments even more scarce, and risking even more dissatisfied patients who do not want to keep taking time off work, or another bus from 5 miles away, to return for 'another 10 minute appointment'. I frequently run late in my surgery, because I am aware how difficult it is for a patient to get an appointment in the current climate we are all experiencing, so I DO try to deal with all of their problems in one consultation to save them having to come back - this idea would penalise and not reward me for doing what the patients generally prefer! Perhaps extrapolating the idea to payment by hours of appointment time offered might be fairer, but even that wouldn't pay us for all of the extra work done outside of appointment time! We all spend a lot of time doing things for patients outside of the time they spend in our rooms - how will be remunerated for this? Or will we just stop doing it?! Of course not, because patient care is the fundamental role of a GP, regardless of whether they are with us when we provide it. I can appreciate the idea and sentiment behind it, but fundamentally don't agree that paying GPs on an 'hourly-rate' basis can work (or be costed for, as we'd probably be too expensive!)

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  • The biggest positive is that it moves the onus of capping demand away from GPs.

    It will immediately become obvious how much hidden work we do.

    But there will be very strict limits on how many appointments we are paid for (just like hospital admissions) and we all know it will be used as a tool to limit costs /activity first.

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  • My issue is't money. I'm absolutely knackered by doing 40+ a day consultations and the additional admin.We should have an hours worked and maximum consultations per GP guide -- pilots and HGV drivers have their work limited. It's not safe but there aren't enough trained GPs to do the current workload. The only thing payment by consultation will do is value us a stupidly low per consultation rate.

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  • This is the most strange an odd suggestion by a supposedly educated leader. Consultation numbers is by no way a sign of quality or workload. It also will create significant gaming & prevent innovative use of alternative clinicans etc. The is no such thing as a standard consultation or length. Weighted lists remain the only logical answer it is getting the weighting correct that will always be the challenge.

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  • 19.45 I agree, health and safety legislation is conspicuously absent from the consultation room. The open ended GP contract is unsafe by design but the government are covering this up with their current smear campaign against GPs. It is inevitable that things will go wrong if you are doing excessive consultations but the unfortunate doctor usually gets hung out to dry by the GMC. Compare this to the airline industry where flying time is restricted to prevent disasters and it looks like we are working under conditions usually associated with the Victorian era. Sadly it is almost impossible to speak out against this in public due to our endemic culture of fear. Ultimately the patients pay the price for such a lax attitude.

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  • 8.26 You are plain wrong. It is self evident that consultation rates have some impact on workload and should be taken into consideration when weighting resources. Overall higher consultations will average out into more work whatever your demographic bearing in mind that patients are getting older and more complex whilst the hospitals dump work on GPs. Its fairly obvious that gaming can be controlled by appropriate regulation and audit as happens in every other area of finance.

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  • Aus seems to manage on a system like this. Get paid for problems and consultations.

    You can put a limit on contracts to stop gaming

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  • what about associated blood results, referrals, prescription?

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