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Gold, incentives and meh

GP leaders to vote on whether to support patient charges for appointments

Exclusive GP leaders are set to vote on whether the GPC should ‘explore national charging for GP services’ at the LMCs Conference later this month.

The motion, put to conference by the agenda committee and set to be proposed by Wiltshire LMC on the day, suggests general practice is ‘unsustainable in its current format’ and that ‘it is no longer viable for general practice to provide all patients with all NHS services free at the point of delivery’.

The motion concludes: ‘That conference… calls on GPC to explore national charging for general practice services with the UK governments.’

A Pulse survey of 440 GPs last July showed that just over half of GPs are in favour of the NHS charging a small fee for routine appointments, with many believing it is the only way of managing their workload and curbing rising patient demand.

Other topics scheduled for debate at the annual policy meeting, set to be held 22-23 May in York, include whether or not CCGs should commission primary care, with several LMCs arguing that this will ‘fatally damage relations between CCGs and their constituents’.

However, in a counter motion, Merton, Sutton and Wandsworth LMCs will argue in favour of CCGs commissioning primary care. This comes as NHS England invited CCGs to bid to commission primary care last week.

GP leaders will also be voting on a motion to ‘reject the concept of routine general practice care 8-8 seven days a week’, a concept that has been heavily pushed by Prime Minister David Cameron over the past six months and which is likely to form part of Conservative policy ahead of next year’s general election.

The agenda document also highlighted LMC concerns over the Government’s scheme, which is now set for a delayed rollout in the autumn. An agenda committee motion, to be proposed by Bedfordshire LMC will say that ‘the introduction of has been nothing short of a disaster’ and call for a patient ‘opt-in’ system to replace the current process of patients having to opt out if they disapprove of their records being shared.

The motion says: ‘That conference believes the introduction of has been nothing short of a disaster and.. asserts that extraction should only take place with the explicit and informed consent of patients opting-in.’

The conference will also see LMCs debating the ‘unsustainable workload in general practice’; deplore ‘the CQC’s plans for a simplistic rating system for practices’; and condemn the ‘disorganised mess’ resulting from the NHS reorganisation, including delayed payments to GP practices.

Highlights from the 2014 LMC conference agenda

AGENDA COMMITTEE to be proposed by WILTSHIRE That conference:
(i) believes that general practice is unsustainable in its current format
(ii) believes that it is no longer viable for general practice to provide all patients with all NHS services free at the point of delivery
(iii) urges the UK governments to define the services that can and cannot be accessed in the NHS
(iv) calls on GPC to consider alternative funding mechanisms for general practice
(v) calls on GPC to explore national charging for general practice services with the UK governments.

AGENDA COMMITTEE to be proposed by NOTTINGHAMSHIRE: That conference views with alarm proposals contained in NHS England’s (NHSE) interim response to the ‘call for action for general practice’ to make CCGs co-commissioners of GP contracts and
(i) believes that this will fatally damage relations between CCGs and their constituents
(ii) warns that this will undermine CCGs’ chances of success in other areas of commissioning
(iii) predicts this will undermine the credibility of CCGs
(iv) asserts that conflicts of interests would be unacceptable
(v) insists that GP core contracts should not be held by CCGs.

AGENDA COMMITTEE to be proposed by WIRRAL That conference:
(i) rejects the concept of routine general practice care 8-8 seven days a week
(ii) believes that GPs will only provide routine planned care 8-8 seven days a week if resources are provided to the satisfaction of the profession
(iii) commends GPs for already providing unscheduled general practice care for 24 hours every day, seven days every week.

Source: BMA

Readers' comments (57)

  • I can see the Daily Mail having a field day with this!

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  • let the Daily Mail have a field day - at the end of the day we want to maintain good quality patient care, and this can only be done by putting brakes on the demand.

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  • Screw the Daily Mail

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  • So A+E will become overburdened and the government will throw more precious resources at it. Give this money to general practice to employ more nurses and pharmacists following a set triage reducing the burden on declining GP numbers

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  • Wouldn't it be great if we actually got 8 to 6:30 Primary Care Monday to Friday right before we try to tackle the weekend and longer days? Politically no one will hold their heads up and confirm consultation/patient ratios (or pay appropriately for them). There is also no political appetite to educate patients for appropriate use of GP appointments as we encourage a demand and be given society regardless of how reasonable it is/isn't.
    If charges are applied for Primary Care what impact will this have on A&E if its free to turn up there?

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  • This could be a trap - a dangerous move- potentially doing Government's bidding for them.

    They wish to destroy the NHS, but aren't willing to come out and say it for fear of the public backlash.

    So instead their plan may be to achieve this indirectly by withhold funding to such a degree, that GPs clamour for patient charges - and then they will sit back as the baying public rip GPs to pieces. The government will then issue press releases blaming 'greedy' GPs for the destruction of the 'free at the point of use NHS'.

    Be careful.

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  • Medical student thanks for your advice but we have had enough with being careful and if we all have to go private so be it....about time we did a dentist

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  • Easy on the student! They have a point. But totally agree. Now is the time to charge patients + government for our worth. Happy GP = sustainable NHS. Simpli

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  • Of course this is a lot of hot air given that the people debating it have no power or authority to bring it about even though they sound very self important.

    Does anyone who has their feet on the ground really think that any political party will entertain this in the year before a general election?

    There must be nothing else to put on the agenda for the meeting if this has room.

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  • I've been against patient charging because of one reason.

    It will not reflect the true value of the consultation, (which is of course is about 4 or 5 pounds take home, should a simple income/consultation number be believed.)
    We are cheap per consultation.
    What is a consultation worth?
    To the rich it'll be a joke and the poor a barrier.
    I only wish the BMA and their leaders spent a bit on advertising the reality rather than letting the red tops andn DH spin machine continue to destroy us.
    And to the medical student- you are 100% correct, choose where in the world you want to practice medicine because you cannot do it in 10 minutes. Go somewhere where you are valued as a professional in the quality of medicine you practice and you get paid to reflect it. Good Luck.

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  • I would:
    Vote for a connection between practice income and practice appointments per 1000 patients and each year adjust the recommended number of appointments based on the pay increment (chuckling inside), inflation and expenses. The adjusted number should be made by the BMA (not the government), Any extras forwarded to A+E.

    If you really want attach a caveat that charging for appointments might be a way to help the situation.

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  • It is not up to us to decide if we need to start charging patients. Government has got to come up with a plan on how to do this as we do not legally have the right to do this.
    If we decide we want to do this, what the government's response will be is- ' We gave the GPs the budget, they misused it and now they want to charge you. We will protect you from them and pass a law strictly prohibiting any GP from charging.'
    I agree with charging patients but it is not up to us to initiate.

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  • Let GPs charge whatever the market will bear yet retain the right to refer to NHS services and NHS scripts:

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  • I have worked in systems where the patient pays for a consultation. And no it was not not somewhere like Australia or Europe, but a mission hospital in St Lucia where people would pay a week's wages to see a dr. It didn't reduce work load, but it did did change the dynamics of the consultation. It led to increased investigations, longer consultations, more demand as a right by patients, and people would continue bringing their children even if you had seen them only a day or so earlier for the same self limiting conditions that you had tried to educate them to self treat.
    So no, not a good idea, not a safe idea, and not a cost effective idea.

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  • I don't understand how a GP CAN charge for a consultation - don't you provide the consultation as part of your contract with the NHS? In which case, you are simple the service provider and not the author of the service ergo if the government says free at point of delivery, then it will stay free - the only thing a GP can do is refuse to provide the service - and so lose their contract for all GP services. It seems someone has spent a lot of time and effort on something you can't actually implement without government support - and, I would hazard, a change in the statutes

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  • @ Mr Eggleston : just to say obvious that GPs are asking for contract change! Is there any problem doing that? what do you mean by 'simple service provider'? Like in your contract you charge by every prescription you dispense, similarly GPs are asking for fairness, if they see more patients they will be paid more (per patient or slot basis) , simple ! At the moment this is being paid as block payment, in other word bottomless contract where it is unlimited minutes for fixed bill (by the way - phone company is clever enough to put small print as 'fair usage' but not our negotiator colleagues) !

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  • If you charge patients, then would you also be eligible for MPIG or NHS money, surely you cann't get paid twice for same service

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  • 06 May 2014 5:35pm

    Have read suggested link - good stuff !

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  • I think we are talking about NHS getting the money, not individual GP practice.

    I quite agree with the medical student this is a double edged sword and our hapless leaders are yet again being out maneuvered into voting for unpopular move which will direct the wrath of the nation at our feet. They should have had the intelligence and the tenacity to force government into starting this debate but alas no - they are too naive to be paying a political game.

    We should be paid per consultation now - all secondary care are, why can we not have the same?

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  • The important message is that the debate on different care models has started whether or not it is fair to charge or not it is worth exploring the issue.

    Hopefully we will end up with a better and more sustainable health care model in the end.

    What is clear is that the current NHS model is not sustainable and doing nothing or hoping for government funding is not an option.

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  • In reply to some of the above:
    To stop A+E becoming overburdened A+E minors should attract a higher charge than a GP. A properly funded GP could take on much more minor injury work.
    GPs are reaching a point where the option is to close shop or introduce realistic funding. It doesn't matter at this stage what the public think because we have a moral responsibility to ensure the system is stabilized unlike the politicians who are just trying to get voted back in.
    Of douse GPs currently have no authority to bring in charges, but as a group we could force the end of the GMS contract. The government would be left with no choice but to allow us to operate in a real market rather than the present abusive monopoly employer situation.
    The cost of a consultation needs to be set at what encourages those on median incomes to consider if their use of the service is sensible. We should offer concessionary rates and reduce the cost of medicines for long term conditions which cost more if not managed appropriately.
    It is absolutely up to the doctors to have some input into the process of their payment because they are the ones offering their skills and labor, this is the same way the rest of the workforce operates.
    You cannot compare St Lucia to the UK as they are chalk and cheese. A fair comparison would be any European or Antiopdean nation and they all have some up front charges.
    It is fairly obvious that GPs could bring in charges even if this requires a change in the law - the dentists have already provided the model for this.
    We have to start the funding debate somewhere in a country with £1trillion debt and a demographic crisis. The LMC are getting the ball rolling. The current politicians refusal to consider alternatives is dishonest and likely to hurt more people if the NHS collapses into a disorderly mess.

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  • Charging the taxpayer without allowing him to set it against tax is not a good political move.It effectively amounts to double taxation and plays into the hands of those who wish to portray all GPs as lazy greedy money grabbers

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  • The politicos are terrified of bad press . The worst scenario for them is one of overcrowded A+E departments in winter . We have 9 months to plan their demise . Withdraw any work for OOH in February . It will not take the whole month 2 weeks will be enough . Then we can make a deal . No deal loses them the election.

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  • 8:18 Charging for appointments is not double taxation. We already pay surcharges for a whole range of government services. The tax system is not like a savings account, you cannot simply withdraw what you put in. GPs have already been portrayed as greedy money grabbers so it is too late for that argument, besides this does not happen in countries where there is an up front charge for access. In fact if primary care was funded in a sustainable manner then we would probably have to plead for resources less often and money would become less of an issue - we could then get on with the business of looking after the sick.

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  • Despite the attempt that the GPC made, it seemed with initial success, with the 2004 contract to change the method of funding of primary care and deliver increasing resources for increasing work, the politicians have deviously undermined that agreement by portraying us as greedy, overpaid and incompetent ever since. The 'John Wayne' contract lives and breathes, despite rumours of its demise in 2004.

    As a result of political bullying, with the full cooperation of the media, our leaders have been cowed into accepting worsening contractual obligations for GPs every year since 2004. The main problem being ever increasing workload, fuelled by the fantasy propagated by politicians that unlike any other field of human endeavour, an ever increasing, supposedly unlimited in fact, supply of high-quality produce is available within a strictly constrained budget.

    It seems to me that the strategy of shifting the public debate as to how a realistic and sustainable method of funding for primary care can be delivered is now entirely correct.

    On the contrary, the existing strategy of fighting for a reasonable contract without questioning the basic system within which that is delivered (the NHS free at point of delivery etc) has proven disastrous.

    Unfortunately we have played into the hands of politicians by letting them choose their battleground -- the danger being that GPs will now be portrayed as even more greedy because they are asking for payment for item of work done (or at least top up funding per consultation) and thereby undermining the principles of the NHS.

    The 2012 BMA strike to protest against changes to the NHS pension was not just ineffectual and misconceived (it seems that even the legal position had not been clarified in advance) but further undermined our standing in the eyes of the public, rather than engendering their sympathy -- because of what we chose to protest against.

    It must be clear to the public that, if we choose to protest in future, we are not campaigning simply for more money, rather we are campaigning for terms and conditions which permit us to deliver the service to the required standards in a sustainable way.

    Ultimately, the public have to realise that they cannot receive high-quality readily accessible care without the system being adequately funded. The question as to how that system is designed and funded should be opened to democratic debate.

    It seems to me at the moment we have politicians acting like an elected autocracy, certainly with regard to the design of the NHS -- remember the election pledge 'no top down changes' anyone? Maybe the politicians wish to stifle debate, whilst they implement a policy of privatisation by stealth?

    In conclusion, the political leaders of the medical profession in my opinion should advance the argument that the interests of the public and GP's, in securing a system adequately funded to deliver ready accessible and high-quality care, are aligned -- and not necessarily identical to the interests of their political lords and masters, who aspire mainly for their own reelection and quite possibly the piecemeal privatisation of the NHS.

    Privatisation may be inevitable but it should be subjected to public scrutiny and debate before it becomes irreversible.

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  • Please doctors do not vote for this - as this would be the end of the NHS free at the point of delivery - which is the whole ethos of the NHS = Patients currently value their GP more than any other establishment - you will destroy this cherrished place as the patients will never forgive you

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  • Of course, the NHS is not all free at the point of delivery. We pay when we attend a dentist or an optician, for example. We accept having to pay for check-ups, and paying extra for additional services.
    At present, GP practices cannot charge their own patients for any treatment provided. Enabling practices to charge for some extra services - think weekend and evening appointments, minor surgery, acupuncture - would be an incentive to introduce additional services and promote patient choice

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  • There was similar reservations re: dentists - yet they managed it and there hasn't been a collapse of care for vulnerable groups. Can any one recall a negative story about dentists in the last 5 years? or some report stating how uk dental care compares to the rest of the planet? No, neither can I.

    Time to leave the contract.

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  • Yes - and that's why we get dental problems coming through to primary care from time to time. I often decline to treat this but still, it shows the dynamics between money and access.

    I think Germany had a trial a few years ago of introducing 10EUR surcharge for primary care appointments. I understand it didn't curve the demand and increased demand else where in the system so it has now stopped.

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  • The cost and infrastructure for money handling, the effect on the doctor patient relationship, patients wanting their money's worth, no thanks
    Charging for home visits- that would be different, especially the Green argument!

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  • The focus should be on how demand can be controlled, especially looking at inappropriate attendances. Tis should be government led, not primary care led as it is a public health issue not each local practice problem.

    The government will only do this if a political or financial pressure is applied. As we know bma is pants at applying political pressure, the only way is to put financial pressure without involving patients.

    I quite agree we should be paid per time spent on appointment (10 min tariff, 15 min tariff etc). That way government will have to cough up the money if they don't address the demand, patients are not charged and we get paid fair amount and able to spend decent time with patients!

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  • problems with the proposed charging system -

    1. the very group of patients who cause high demand will be exempt from charging i.e. it won't curtail demand.
    2. those patients who are already working and paying tax who may only use the service occasionally will be unfairly penalized.
    3. the public will assume that the money will be going into the GPs pocket and resent GPs even more.

    a better method would be

    1. leave the NHS contract
    2. set up independent private practices
    3. only see patients who are part of a health plan (work based, government 'nhs', employer, private) or as an emergency encounter or who are willing to pay directly. The health plan will specify what patients are entitled to i.e. it will not be unlimited.
    4, have a doctor patient contract which sets outs rights and responsibilities for both parties
    5. charge per activity / encounter / time

    Each GP can then decide what ratio of private to government work they will do. Demand will be curtailed as patients will have to pay or will have to justify their attendance to their plan provider. This will put an end to abuse of the system and will ensure 'vulnerable' groups are represented as they will be covered by the government plan.

    The days of unlimited care are over.

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  • I fail to see what is so great about the NHS ethos of 'free at the point of delivery' when ultimately someone pays(usually the middle class) and the quality of the service is being degraded because we insist on hiding the true costs of excellent care. The poor will be offered concessionary rates and the wealthy will go privately as they do now. The idea that patients will never forgive us if we bring charges in is utter nonsense, you don't get all the GP bashing stories in New Zealand or Australia. I believe that charging might paradoxically make us more popular because we would have the resources available to manage people in a time effective appropriate manner. Papering over the cracks of the NHS as 'gatekeepers' makes patients resent us because we are lumbered with the politicians dirty work of how to ration care fairly. The German experiment did not work well because they weren't charging enough to cover the costs of the changes, we need to charge at least £30/consultation to sustain primary care and £100 for A+E attendance to prevent a flood into other parts of the system. This is still less than the cost of taxing your car and is unlikely to bankrupt those on middle incomes whereas the collapse of the NHS could easily lead to financial hardship for he majority of the population.

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  • We all pay the tube... even if you don't use it...
    We all pay for rail... even if you don't use it...
    We all pay for the police... even if you are able to use them.. ( i.e. they wont come)
    We all pay for bus service.. despite not using it.
    We all pay for benefits all 210 billion of it... despite not using it. (btw the NHS budge is 110 billion)
    9 billion used by GPs although we see 1 million patients every 36 hours... or the entire population every 86 days...

    Don't compare Gp's to dentists look at peoples teeth in england!

    Point being... national insurance pays for the service to exist... if you need a 46000£ you get it for your effort... if you need 100000£ in chemo you get it...

    it should be universal... just like a script... pay per use.. 10 pounds a visit... is 2 billion a year for improvements on patient care... at the same time reducing demand.

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  • 1.43 We can still curtail excessive demand from people who are exempt from the full charge by putting in concessionary rates at an appropriate level say £5. People who are working and paying tax may feel penalized but such is the nature of taxation. It is likely they will need the NHS to be there for them one day no matter how fit they are at present and I suspect their children are already using it anyway. The public won't resent GPs for collecting fees because it is human nature to value that which you pay for - you don't hate your hairdresser or local garage! The mixed health economy model is undoubtedly the best which is why the rest of the western world use it! No tax system will ever be able to support infinite demand for healthcare in an ageing world.

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  • GP registrar | 07 May 2014 2:33pm

    the bottom line is this - how to we create a sustainable healthcare model in the face of rising demand and falling funding/supply whilst increasing the quality of care?

    many think it is impossible to do and something will have to give i.e. funding/supply will have to increase, demand will have to curtailed (?loss of universal care or unlimited care), or expectations on quality will have to change.

    no conscientious doctor wants the NHS to fail or for us to lose universal free at the point of use care but sadly it may come to it if these issues are not addressed and looking at different options may help focus the public/politicians into action i.e. if we don't raise the issue don't expect politicians to.

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  • Absolutely don't charge the patient they will all just rock up at A&E total chaos - what a disaster!!

    If you pay at a GPs then you need balance with charging at A&E and that will never happen - political suicide for any government! Let's take the NHS out of the hands of the politicians then maybe just maybe something good might happen!!!

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  • There is no reason that charges for A+E minors should not be introduced if a better value alternative in primary care is made available. There are of course a lot of GPs who would like to walk away from GMS so we can be in control of our own destiny rather than jumping through the hoop of the week at the whim of politicians. Ultimately patients still trust their GP more than their MP and if we make it clear that the current arrangements will end in chaos then the penny will finally drop.

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  • I feel charging patients for an appointment will make patients expect and demand more.
    I have worked all my life and paid my dues so I have already paid my share.

    What will happen when someone dies because they couldn't afford an appointment, however small the cost?

    what about script costs, £8 for a bottle of 75 mg aspirins than cost pence?

    When things go wrong, it will be the GP that is blamed!
    DNA's should be fined and barred from pre booking, that would make more appointments available for those that really need them.

    NHS equipment should demand a deposit as many items end up in boot sales!

    There are plenty of ways of saving money without charging patients for appointments, but whatever happens, it will be the overworked GP that sits in the firing line!

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  • So ashamed of Wiltshire for proposing this. It will backfire.

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  • Everyone has a right to propose what they like, but I agree it is shameful to suggest this in a supposedly civilised society with a welfare state. Consumerism gone mad. This will be a very sad day for the profession and the beginning of the end for one of the best healthcare systems in the world.

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  • Being free at the point of delivery is crucial. Some conditions are hard to spot and patients attend on several occasions until conditions are diagnosed. Do they keep paying until diagnosis? Does this encourage non-diagnosis to encourage patients to return (ie increase money coming in)? The poor, those with poor health and those with difficult to diagnose conditions will suffer.

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  • Can the do-gooders please switch off the GP practice lights on their way to an early grave? Shocking that many of you have so little self worth that you are prepared to flog yourselves to death. Do you really crave attention from you patients that much? Neither the government or your patients respect any of you anyway. They might if you charge them have more respect for the profession.

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  • totally agree with 9.01pm comments. Have GPs so little self respect now that they worry about what others think rather than what is right for them and their colleagues in terms of acceptable working conditions. As a GP trainer, I can assure you things do not look pretty for the state of primary care at this time. Just today I have had a conversation with an ST3 GP reg (who is excellent by the way, and passed all exams with easy) coming to the end of training. They are adamant that GP in its current form is not for them and is already looking at ways to exit the profession even before its started!! Even more worrying is the fact that she reports a lot of other GP trainees on her VTS feel them same way and are planning to locum before either emigrating or changing career.
    So all those who feel self flagellation is the only way to get to heaven and capture the hearts of our leaders, patients and the media, really need to answer one question. What happens when the well runs dry and there are insufficient GPs to service the UK population? And believe me it will if drastic action is not take to change the current trajectory that the GP workforce is on.

    Disillusioned GP Partner (1yr)

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  • It isnt sad, it is just matter of fact, the NHS is unsustainable. All you do gooders how do you propose the funding is acheived.
    I have worked in the system down-under, and patients made a co-payment for services. It did get rid of lots of the trial questions, and patients came in with more of a defined question. If they wanted a longer consultation, they got double charged. Home visits got double charged too (due to the time it take to do them).
    Overall it worked well. Alas family ties brought us back.

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  • Una Coales

    If you allow the government carte blanche, not only will they privatise healthcare but insist everyone pays 100% copayments. Please listen to your NHS GP who wants to ensure the poor and elderly are not overlooked. Semi private Irish/Canadian/Australian healthcare systems are the best modern way of treating both those who cannnot afford to pay and those who can and it keeps doctors from self flagellating themselves as @9:47 so aptly described. I lost an overworked dear GP partner colleague to suicide this year. I will do everything in my power to ensure GPs are safe too!

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  • Patient dictate terms to us now and if they start paying for consultations we will be virtually at their mercy; do that, do this,

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  • Just to be clear- having worked in Canada almost 5 years- it is not semi-private- in fact in theory "private " medicine is supposed to be "illegal" but in practice happens but not frequently and mainly for occupational medicine issues or cosmetic procedures.
    It is more honest I would say though.In most Provinces/territories each person or family says a monthly premium for their medical care- in BC we pay $69.25 for a single person, $125.50 for a family of 2 and $138.50 for 3 or more in a family- all per month. In Alberta, I believe its free ( lots of oil!!) This gets you your card which you must show when joining a GP, and every time you go to a lab, for an X-ray, into ER etc. We soon know if fraudulent as we can't bill for that patient. NO-ONE expects free care if they can't produce the card and I have no problem being "gatekeeper" as it were. I also have no issues billing patients if they no show and "firing" them if they won't pay
    I bill BC gov per visit- it's a set amount per patient dependent on age/length of visit etc. I have to say reading all this on Pulse I can honestly say I feel I am paid fairly for the work I do. I chose to have see about 30-35 a day- mostly 15 mins a time- a few "fit ins", have a "closed" list, do very rare home visits and chose my days/hours .Patients in general ( but not all) are appreciative and pleasant.
    Patients ( all ages) pay for their medication though which can be expensive but some have extended benefits via work, and there is a means tested scheme for those on low pay, if on disability etc- its free. Also a palliative care scheme etc. Ambulances also have to be paid for, unless urgent people seem to be able to make their own way to hospital!!

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  • Bob Hodges

    ". I lost an overworked dear GP partner colleague to suicide this year. I will do everything in my power to ensure GPs are safe too!"

    That explains the new zeal we are witnessing from you Una. Respect.

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  • Bob Hodges

    "So ashamed of Wiltshire for proposing this. It will backfire."

    Jesus Wept!

    Can it get ANY worse than it now? How CAN it 'backfire'?


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