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A faulty production line

Thinking the unthinkable

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Rarely has a Pulse survey attracted such widespread coverage – and rarely has it prompted such intense debate.

In a story we published yesterday, we reported that in a poll of some 440 GPs, 51% said they would support charging a small fee for GP appointments. Some 36% said they would not support charging, with the rest ‘don’t knows’.

It was a striking finding – not least because in a similar poll we conducted last September, only 34% of GPs said they would support charging – and it’s been covered widely in the national press today, on the front page of the Daily Express and ‘I’, and in the Guardian, Independent and the Times among others.

Much of the reaction has been very hostile, as you would expect. Any suggestion that patients could be charged for access to the NHS is a hugely controversial one; any suggestion that it could be GPs who do the charging doubly so. Many have been disbelieving that so many GPs could support such an idea, and there have been the usual misguided attacks on ‘greedy GPs’ as a result.

Yet read the comments from those who responded to our survey – or indeed the comments that have been left since we published the story – and it is clear that many grassroots GPs do believe that it may now be time to introduce a charge. Not to make money or unfairly penalise patients, simply to help manage demand and help general practice cope with an unsustainable workload.

Peverley – our award-winning columnist, and the weary voice of a profession if ever there was one – put the case eloquently but robustly in a piece he wrote this time last year: ‘Free at the point of abuse

This profession deeply depresses me at times, and it always comes back to the fact that our services are free at the point of use (or abuse, if you will).

Some 90% of my time, or rather 100% on the day of supposed industrial action, is taken up by about 5% of our patients, and there is no evidence to suggest that they are the 5% that need it most…

The patients we are actually here for cannot get easily accessible appointments because of the tedious minority who spend far too much of our time indulging their hobby of free, self-indulgent self-aggrandisement.

I honestly believe that the time for free access to medical care is over; ruined by the selfish few.

So does that mean GPs as a profession really want to charge patients? No. Many are vehemently opposed, believing that any kind of charge would irrevocably damage the doctor-patient relationship and would be the first step on a slippery slope towards privatisation.

I would also argue that no matter how they responded to the survey, the vast majority of GPs fervently believe in the principle of an NHS which is free at the point of delivery, and if they now support charges do so only with the greatest reluctance. There are all kinds of problems – practical, moral, ethical – with charging patients. Ministers have already firmly said they have no plans to do any such thing, but I’d hazard a bet that if Jeremy Hunt were to turn around tomorrow and try to introduce a charge, the profession as one would rise up in opposition.

No, what this survey result shows is that general practice is now creaking under intense, unprecedented pressure, with a backdrop of rising patient demand matched by a huge increase in GPs’ workload over the past year, thanks largely to commissioning and the imposed GP contract. While some of today’s headlines are inevitably negative, it can only be a good thing that this pressure, workload and the stress GPs face are being discussed more widely in the national media.

Charging may not be the answer, but the views of GPs expressed in this poll should serve as a wake-up call to both politicians and the public. Politicians must realise that GPs are now stretched to breaking point. And the public must realise that while it’s all very well bashing GPs for thinking the unthinkable, how a cash-strapped NHS copes with rising demand is a debate we’re all going to have to take part in over the next few years.


On methodology

Finally, a quick word about the survey’s methology. The survey – and indeed Pulse itself – has come in for some pretty harsh criticism online from those who oppose charging, who believe it is flawed and therefore not representative of the views of the wider GP population. (Dr AnneMarie Cunningham has very thoroughly summarised some of the concerns here).

We ran the survey through SurveyMonkey, asking a series of questions covering multiple GP topics to avoid selection bias. It was advertised to all of our readers through our website and email newsletters, and we offered the incentive of a Kindle Fire which will be awarded to one randomly chosen respondent.

We received several hundred responses from readers across the UK. As part of the questionnaire respondents were asked to provide their job title. We then screened out a small number non-GPs to analyse the results for this question.

Such a survey is obviously not a scientific study, and was not weighted in any way. However it was conducted in exactly the same way as we always conduct surveys and from past experience the results we get from readers closely match the wider views of the profession. This survey, for instance, accurately predicted the poor turnout in last year’s pensions industrial action, while our findings in January on what GPs were doing to prepare for the contract imposition were echoed by medical accountants. The current survey also covered a wide range of topics and its findings on NHS 111 seem to reflect polls elsewhere, while an unpublished finding that between 53% and 72% of GPs have signed up to the new DESs seems similar to what official figures from local area teams show).

So, it was a small, unweighted sample, and in no way scientific research. But we’re confident the findings reflect the views of our readers – even if those who support charging are perhaps those least likely to be politically active and make their voice heard.

(You can also read a much better informed analysis of the survey methodology, our reporting of it and potential weaknesses from the Picker Institue’s director of research and policy Chris Graham.)

Steve Nowottny is the editor of Pulse. You can follow him on Twitter @stevenowottny.


Readers' comments (14)

  • Thankyou everyone for your comments, useful to get the feedback.

    @Peter McEvedy, @Shaba Nabi - it was certainly not our intention to do any harm to the profession, and in general I don't think the coverage last week did - the tone of the Daily Express front page in particular was disappointing but the wider debate is one many GPs would welcome I think, and it was encouraging to see so many of the papers that picked up on it - including even the Express - acknowledge that the pressure on GPs is becoming unmanageable.

    Those who are opposed to charging may well believe any coverage at all is unhelpful - however Pulse sees its mission as reporting on the broad spectrum of GP opinion and representing all of our readers.

    @Anonymous 26 July, 8.05pm - You are right, we don't have any evidence on that point - however that is my impression from speaking to readers and also from the free text comments we received in the survey. Asking not only whether GPs support charging but why they support charging would be an interesting question for a future survey.

    Steve Nowottny
    Editor, Pulse

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  • Ian King is right - forget everything - just pay us per item or per appointment, not one figure for everything.
    Since we are a bunch of lazy golfers, paying us per appointment should be cheap and easy.
    The DOH and the papers can be satisfied they get exactly what they pay for. £20 per appointment is fine - forget pensions etc - that would be our problem.

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  • Those who support charging for consultations are politically naive and cannot see the wood for the trees.

    There are 6 outcomes of charging. All are negative:

    1. People who need help will be inhibited from seeking it and present later with their important illnesses or will go to A+E, thereby exacerbating the hospital crisis and reducing the workload of GP, spelling the beginning of the end of general practice as a job/discipline (because if the NHS can manage without general practice it will stop providing it).
    2. People with chronic illnesses will avoid the doctor, so that the quality of longterm care for IHD, diabetes, mental health problems and asthma will deteriorate... just when we have achieved measurable improvements in morbidity. The poor will get sicker and the rich will continue to thrive. Is that what we want?
    3. The worried well will happily pay the fee and expect spectacular and instant service for their money. They will have longer and more frequent appointments. They will want some beef for their buck. They will also be less ready to accept advice without prescription. "I have paid for this consultation!"
    4. The government will reduce payments into general practice, arguing that GPs cannot expect to be paid twice for their work. At the same time they will put a limit on the charge that can be levied and exempt the very people who create the greatest workload. GPs will be no better off financially, and probably worse off.
    5. Virgin, G4S, Tesco and Serco will offer a flashier form of GP with high prices, doctors that never say no, paying its GPs low sessional rates for working unsocial hours. Patients will be attracted with low (loss leader) insurance rates at first. These will gradually rise, as will the profits. But they won's accrue to the GPs on zero hour contracts.
    6. Proper general practice, with continuing care, sensitivity to patient need, support for the disadvantaged, health promotion, and clinical care unsullied by profit motive will be dead (like NHS dentistry and optometry), replaced by a cynical, grasping, greedy, tax-avoiding big business that sends all its profits overseas. We will have killed it.

    As regards the fee that we should have to charge to maintain the infrastructure of general practice, including premises, nursing, equipment etc., with the added superstructure of a fee-collecting and complex accounting system and longer opening hours, my guess that nothing short of £50 a consultation could maintain the system.

    I think we should be careful what we wish for!

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  • 1) The simple solution to protect hospitals is to charge more than GP for A+E minors at the same time diverting resources and patients to primary care where they will get more appropriate service.
    2) The NHS could still target chronic disease by providing free targeted clinics for diabets/dissability etc Charging potentially could open up more resources for chronic disease management by discouraging worried well attendances.
    3) The worried well should be put off attending for a chat if the charges are set correctly. This is the point of charging. Patients already expect a lot in consultations - I doubt this will change much!
    4) No-one said that all the charges would go straight to the practice. Extra cash should be spent where it is needed the most.
    5) Tesco could already offer private clinics if they wanted but running general practice is unlikely to have good enough profit margins for them. They would still have to pay GPs the going rate just like the locum market.
    6) Charging is not the same as rampant profiteering. It is likely that charges would be highly regulated by the government. The NHS might actually improve by admitting that free at the point of delivery is no longer sustainable if quality is to be maintained.
    7) I doubt charging would need that much extra accounting, our accounts are already complex and this would simply be another item on the balance sheet.

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