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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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  • A payment by appointment number system will lead to more follow up appt's/strategic callback systems to keep the appointment rate up to maximise income. A new patient appt waiting time criteria will need to be implemented to less than a week to ensure clog-up does not occur with the same old patients coming in for a renumerated chat.

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  • One of the CCG director ask GPs - What is the biggest challenge GPs are facing now? I replied 'Unfair GP contract'. Understandably GP cum manager was not happy with my answer.
    We have the most unfair contract in the NHS. Even when you have unlimited mobile contract - there is a small print - tells you that you are subject to fair usage. Unfortunately we have a bottomless contract. As a result Daily mail/ Hunt Co smearing GPs saying 2 weeks to get an appointment. I warn you public distrust is growing, NHS choice website is now becoming the indicator of quality - at least this is what CQC is quoting this to the practices !
    Before it is too late, backbone of the NHS needs to be sorted and i am 100% in agreement that payment needs be by activity (time/ consultation/ visits).

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  • Drachula

    I have long thought that if GPs were paid on a similar basis to the hospitals then it would quickly become apparent how much we do and how much we can manage in the real world.
    I wonder if we really would abuse the system if we really were paid per interaction? It would certainly get us to code our consultations better! There would be a trade off between earning money for a consultation (based on codes, I am afraid - be realistic) and probably still some kind of capitation. It may be that it quickly becomes apparent that there is a balance to be reached.

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  • 8:41 you are wrong high conusltation rates can indicate poor management, too high a follow up, poor encouragement for self management, poor prescribing for minor illness, weak practice administration, low confidence and 100 hundred other things.
    The are lots of ways to fund primary care but consultation rates are a million miles from the answer. Weighted lists taking a true reflection of disease prevalence & deprivation & other risk issues are the only way to do this without privatising services.

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  • How do general dental practitioners get paid? Is it per consultation or per item dependent on how it is coded? If we were counted as employees of the NHS (we are for pension purposes) then the EWTD would apply and we would have a maximum number of hours to work whether in front of a patient or not?

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  • I think it is about time we did start looking outside of the box (or current GP contract) as Clare is doing. There are obviously lots of issues around justice, gaming etc but this is small print. The fact of the matter is, working in an inner city, deprived, multicultural, multi-lingual practice like mine means that our consultations are frequent and longer. We have introduced lots of self care and access strategies to manage demand but we still have patients consulting more frequently than average. This issue needs to be addressed before falling recruitment squeezes practices like ours and then there is even more health inequality in populations such as ours.

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  • As a UK GP working in Australia the govt (medicare) pays me 36-45 dollars for a standard 15 minute consult. This equates to around 25 to 30 pounds. Many GPs charge a co-payment or 'gap' which can nearly double the fee. There is also extra money for chronic disease management, ECGs, spiro, suturing, zoladex, implanon, skin lesions, fracture management etc etc A full-time GP can earn 300000 dollars a year - around 180000 pounds. You really get paid for the work you do - see an extra patient? You get paid for it. It really is a no-brainer.

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  • To 4.46
    I agree. Payment per consult with co-payment top up PRN, if the rate gets too low, happens everywhere else in the world. What makes some GPs disagree, other than having to get used to a new payment system? What makes the UK different to everywhere else in the western world? How else are we going to stop General Practice completely falling apart?

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  • Most of the contributors keep referring to hospitals but the trends is now to move away from tariff to fixed budgets. Also community services have always worked under a fixed budget just like primary care.

    The NHS has made it clear they are not going to give more money to primary care as it is set-up at the moment

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  • I find Clare's language really interesting.
    Not " let's pay per consultation" but let's pay per 1000 consultations"
    Comes to the same thing ( divided by 1000) but smells of pile em high and sell em cheap and suggests that our value is only measured in volume.

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  • Ps. If a practice did 999 consultations, how would that be paid?

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  • Good idea but the money should be paid directly to the GP doing those consultations

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  • Hahahaha!
    The comment above is laughable.
    Who would pay the nurses, rent, rates, bills, management costs, CQC, water, heating, medical supplies, accountancy costs, ....
    You clearly have absolutely no idea and should stay as a salaried GP!,,,

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  • As normal there are issues both for and against this idea. The overarching need is for HMG to properly fund PC! If they need the current service to survive they need to commence dialogue with those at grassroot as a matter of urgency. We all have our ideas but most of us too busy/tired to write a formal business plan - perhaps a roadshow with grassroot GP's from each CCG. Excluding the political, protfoilio, part-time (we know how it is) GP's

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  • Seems unlikely to work as we just call everyone back! My first patient this am had a list of 4-under this system I would have brought him back 4 times (or more)!!
    As it is I have the shortest surgeries in the city, 2-3 day wait for routine appointments and same day emergencies-all because I have spent the last 14 years promoting self care!
    Am I now to be impoverished by this new system??
    I hope not!

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  • Una Coales

    This is the fundamental flaw with US and Australia's medicaid/medicare government schemes. The GPs can just keep calling pts on medicare/medicaid back for appointments, reviews, etc as the government reimburses based on bulk, the more patient consultations, the more GPs get paid.

    Akin to NHS trusts encouraging GPs to refer patients so they can charge the government tariff per patient seen and treated.

    The US government is tackling this with rac attacks, ie random audits of the medicaid/medicare charges made by US hospitals and imposing fines for overcharging.

    This is also the flaw behind dispensing surgeries in Hong Kong where GPs have a financial incentive to prescribe more expensive meds that get filled in the on site pharmacy.

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  • Why get hung up on the complexity issue? In terms of winning the PR battle with the press and the public, surely most people would consider £20 per consultation in a GP surgery as extremely reasonable - and this simple formula would immediately DOUBLE the baseline income in my practice. Plus no more fighting with the powers that be about increasing workload, we'll all be fighting to do it!

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  • DEFINE consultation. when gp ring lots of patients on advising on lab results is a consultation. one can do follow up for everyone. no repeats rx without consultation.
    i certainly can make as much money as i want. not a good idea i think.

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  • High consultation rates are only a marker of poor practice if they are outliers. Nationally there is no point pretending that GPs are not bursting at the seams, such an approach will lead to disorderly failure of the NHS. A consultation is either a face to face appointment or a request for a phone call (which should cost less) It is fairly easy to prevent abuse of the system by capping and auditing reimbursement. There is no new tax money available. Ultimately funding has to recognise that demand for GP services has increased and we need to bring in new forms of income or face implosion of the current model - the voters will notice eventually.

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  • So Gerada doesn't call for more money, just a different way of distributing it. And since the DoH would need to cap it otherwise it would rise out of control, each practice or CCG would be given a finite budget roughly similar to what they make now. So what would we do when we have done enough consultations to reach our financial limit? Stop working and turn patients away? Or carry on and work for "free" Tell me oh great and wise Clare, what the heck would be different to now?

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  • Azeem Majeed

    All methods of funding primary care providers - whether based on capitation, workload or performance - have strengths and limitations which are debated endlessly in health policy journals. Countries that have payment systems based on fee for service also have problems and some are considering changing to give capitation-based funding a bigger role. However, as we have seen in the UK, capitation-based funding also has problems when the payments that primary care providers receive are not sufficient for them to meet all the demands placed on them by their health system.

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  • Payment per task is the way forward. Nhs pays for items bought from pharmacy. We don't have a price per random thousand items from pharma . The technology already exists to make it possible for the payments to be directly proportionate to the work done. We also need to have payments up front so that additional clinical hours can be purchased by the practice without harming cash flow

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  • Contrasting appointments with services given by pharmacists or dentists is not appropriate..they don't generally spend much time 'talking' something which is difficult to cost and would be pretty unacceptable .how would it go.....10mins with person gfeeling suicidal....say £mega dosh on top of ordinary appointment due to saving the nhs potential hospital cost...........ugh it's getting rather grotesque .

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  • This idea was mooted at the LMC conference as a simple maths model and lost.
    The problem as shown was that if patient list size is the criteria it leads to increasing workloads as the population ages with no increase in pay. It was also shown that the fee per consult has halved in 10 years and will continue to fall.
    It leads to MPIG and such bizarre arcane calculations that bankrupt GPs who are still doing 12-13 hours a day seeing 40+ patients.
    The system is clearly broken as GPs are leaving abd recruitment is down.
    The list size system is at fault as proposed at LMC.
    But, sadly, the motion lost.
    Ultimately, we have to move away from an unremitting demand led patient list. Otherwise, there will be no GPs.

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  • ha ha 29/5/14 11.04pm GP partner. You miss the point - you WILL all be salaried GPs..

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  • A good method of recognising workload, but there has to be some recognition for time spent as well as raw numbers. A system based on raw consultation numbers would even more favour your area 1 only , 1 problem per consultation doctor. As a patient, I want to deal with all my problems at once. I hope for enough time to answer my concerns and to understand the logic behind treatments recommended for me. This will improve my compliance and allow me to make the best health decisions. I like to do this for my patients too.--
    Now: what about hourly pay for GPs - what an innovation?

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  • Bob Hodges

    Currently, if my practice were paid 'per 1000 appointment' we'd need a tariff of about £17-20k to maintain out funding. Out of that we'd pay all our costs, pensions and taxes, then take some home at the end.

    We'd spend 45% of the day doing appointments to ear money, then spend 55% of the day doing everything else for free.

    The main danger is that when one starts to put a 'price' on a consultation (the maths is easy) then it makes it painfully obvious that 'the taxpayer' is getting the deal of the century and GPs are being mugged.

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  • We need to increase the percentage of the NHS budget that goes to general practice - anything else is pointless and just shuffling paper. If the total amount of funding remains unchanged this is pointless. Infact it's missing the point and confusing the issue. It's about total funding - not pretending the problem can be fixed by yet another 'clever' reorganisation promoted the latest wizz in the spot light. We need to argue in a clear united voice..'increase the proportion of the NHS budget going to primary care' ..clever ideas to shuffle money from one pot to another might feed the ego of the person proposing it but it's basically empty unless there's more cash...simple

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  • I think many practice could be better organised and even better educated on what practice nurses can and should be doing.

    I find it odd that some GP practices with 5+ GPs have one nurse and some single GPs have 2 yet mine with 3 cannot "afford" a HCA, nor can they "afford" to allow their reception staff to have a lunch break.

    Everyone could benefit, more job satisfaction, respect and motivation if skill mix were better utilised. I work for GPs who do not seem to be interested in my ability to do more, after all, they sent me on the "course" but keep trying to do it all themselves and missing QOF. Well, things I could do like minor illness, chronic disease etc.

    A well trained HCA at around £8 an hour can do half of what your nurse does i.e. smoking cessation, BPs, ECGs, sometimes ear irrigation and flu's, B12's...
    ...then the nurse is freed up at around £18 an hour to do all the GP routine stuff. I have a special interest in mental health and have had more training that most GPs...
    ...then the GPs could have longer appointments to deal with the complicated stuff at how much an hour?

    Include your nurse/s in the team and find out what they are capable of and reorganise instead of staying on the Arc and seeing only GPs as the solution.

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  • i could generate 20 a year for each patient but then my other patients would not see me. as pointed out the difficult ones take long -so we cut the easy to the old spanish or portuguese or chinese style ..
    print rx as talking and out 3 mins

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