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Should GPs be paid per consultation?

Dr Clare Gerada Paul Stuart


At the moment, GP workload is out of control, while care is becoming more and more complex. GPs feel overwhelmed. 

For the first time in 25 years, my surgeries have begun to run late consistently and, as Pulse recently reported, GPs are beginning to report seeing as many as 84 patients in one day. 

The NHS has served us well and was established, either by accident or design, to maximise financial efficiency and minimise gaming and it’s amazing how a system of remuneration established nearly 70 years ago still works so well.

However, hospitals have already moved from a population-based funding model to a per-contact system, despite the increased risk of gaming, fragmented care and higher costs. If GPs want to survive, they must switch too.

In an ideal world, I would not be in favour of such a move, with its potential to recreate problems such as the fee-per-case issue. But these are not ideal times. At the very least, there must be an acknowledgment that we need a payment system based on our real workload, factoring in complexity and deprivation, rather than just on list size. 

Consultation rates now average around six per patient per year and yet funding has not risen from when this figure was three. 

General practice must get a fairer share of the NHS budget (the RCGP suggests 10%) to be sustainable.

Yes, a per-consultation model is open to abuse, but these are desperate times for general practice. The profession needs to consider how to ensure we are funded to deliver the care our patients need and we want to provide. A payment per 1,000 consultations, with adjustments for deprivation and other factors, could work.

If we don’t have a radical solution, the future of our profession – and worse – the quality of care are at risk.

Professor Clare Gerada advises NHS London, is a former RCGP chair and a GP in south London


Dr Beth McCarron-Nash online


Paying GPs by the number of consultations they deliver is not a new idea and, despite years of debate, no one has successfully explained how to overcome its obvious flaws. The current system is tried and tested and, while not perfect, it is at least fair.  

GPs face rising workload, declining resources and decaying premises, but none of these pressures would be relieved by abandoning the per capita system. Of course we must fight for the funding we urgently need, but paying GPs simply on the number of consultations they deliver could turn general practice into conveyor-belt medicine. 

 And we must be realistic. The challenging economic climate makes the likelihood of negotiating a fair consultation rate extremely unlikely, decreasing our incomes further.  

But more importantly, we should never consider any change to the contract that creates even the slightest chance of a perverse incentive for GPs. It almost goes without saying that a per-consultation system would be a disincentive to GPs to work in areas of complexity or deprivation. The need for longer consultations would result in lower incomes in these areas. 

Under a per-consultation model, GPs would face psychological pressure to hurry through appointments. It is inevitable that care would suffer; getting to the bottom of a patient’s problem would quickly become blurred by other considerations, all linked to money. 

GPs’ work is qualitative, not quantitative, and we must never be incentivised to hurry. 

At a time when general practice is under unprecedented strain, what we don’t need is a wholesale tinkering. A lack of support and investment is the problem, not a bad capitation system.  

Dr Beth McCarron-Nash is a GP in Devon and a GPC negotiator

Readers' comments (14)

  • Pointless debate

    govt wont introduce FEE FOR SERVICE there because costs will rise. At the moment capitation keeps the UK GPs working like slaves and they get less and less for doing more and more work!! A PERECT SYSTEM FOR A GOVERNMENT AS THEY ALWAYS KNOW THEY CAN KEEP EXPENDITURE WITHIN A DEFINED BUDGET and flog the PROLES (GP's) HARDER AND HARDER AND HARDER UNTIL THEY BURN OUT, BREAKDOWN OR WORSE....... SOCIALISM!!! NEO STALINISM WHATEVER YOU CALL IT, ITS BLOODY BRILLIANT;

    secondly the BMA/ GPC ARE A BUNCH OF COMMUNIST DO GOODERS; quite happy to let in the private providers to cream off profits whilst keeping their holier than thou aims of free at the point at delivery alive-- look at the number of times motions at the LMC conference such as charging your own patients for services not funded on the NHS such as flu jabs, gets kicked into the LONG GRASS, whilst its ok for boots and superdrug to offer these services;

    im happy I left THE UK. I charge patients for missed appointments because they've wasted my time; patients know whats covered by the govt and what they need to pay for (sick notes, all forms. letters etc)



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  • as anonymous above said, there is absolutely no point debating an argument which GPs will never win. DOH/gov will never move to a model where it costs them more. everything they do is to reduce costs to them.

    it would be like QOF, huge explosion of funding only then for DOH to realise they had no clue the extent of the consultations GPs are doing and the funding will be out of control and they will spend the next 10 years clawing it back.

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  • Reward work, pay per consultation and make general practice a level playing field or it is doomed

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  • Ultimately workloads, if impossible, will soon drive this species to extinction. There is no perfect system but part capitation, part consultation may be the answer. Otherwise no one will stay in a system that pays less and less each year per item.

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