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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)

  • 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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