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At the heart of general practice since 1960

Switching to a 'fee for service' model wouldn't do UK GPs any favours

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Payment by capitation is not a fair way to reward GPs for the work that they do. In effect we are paid a flat rate - with a performance-related top up - for the number of patients registered with us, which takes little or no account for the amount of work we do.

But things may change.

The recent LMC national conference voted in favour of GPs being paid for the work they did, a fee for service.

On the face of things this would seem to be a fairer way to be paid, though there are hurdles and potential difficulties. For the concept to move from being an LMC motion, to GPC policy, then successfully negotiated with the Department of Health may take a minor miracle. Why would our employers, who are trying to make efficiencies over the next five years, suddenly want to pay us for what we do, which would undoubtedly mean an increase in funding for primary care?

The GPC would need rather a large amount of leverage, and the only one that I can think of that would work, except it probably wouldn’t, is the threat of industrial action. I imagine that this threat would only be used if fee for service was seen as the only thing that could save general practice.

Assuming that perhaps some time after 2020 the GPC lobbies hard for fee for service, I would still have my doubts that it could lead to a reduction in workload and an increase in pay.

Unless funding increased dramatically there would have to be a spending cap. GPs wouldn’t be able to simply work harder and harder to meet the demands of their patients if it all had to be paid for. At some point, perhaps in February or March each year, we would find that we were working for nothing once the money for that year had run out. You can imagine the conversations we’d be forced to have with patients: ‘I’m sorry Miss Jones, you can’t get your Depo Provera injection as we won’t get paid for it. Yes, sorry we didn’t have a large enough budget. You’ll have to write to your MP. The condoms are free though.’

Friends from Europe, where a fee for service operates but often is paid for by health insurance companies rather than the state, tell me that GPs spend a lot of their time chasing their own payments. The issues process of counting, checking and accounting for will be time-consuming and costly.

While a fee for service may seem fairer on the face of things, if it ever comes to pass the devil will really be in the detail.

If it does actually make general practice profitable and/or equitable then perhaps it will become more attractive for junior doctors - as well as private health companies.

Dr Samir Dawlatly is a former secretary of the RCGP’s adolescent health group and a GP in Birmingham.

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Readers' comments (17)

  • Its being able to refuse work that you don't want to do, something which we can't do at the moment. Other staff can do the payment chasing, but its giving the GPs the freedom to decide how hard they want to work and to earn in proportion. Plus the fact that this could be a step in the copayment direction, which would drive down demand, which I'm always in support of.

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  • You are assuming this all takes place in a service funded centrally by taxation, a quaint system supposedly admired yet never copied around the world.

    If Miss Jones could pay a proportion of the cost to get a convenient appointment for this she would be able to have this done for 12 months of the year.

    As it is she is a beggar to MPs and government.

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  • Works for Australia

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  • Works everwhere else in the world. Comparable western countries deliver better healthcare for their most disadvantaged with co-payments and insurance. See France, Germany, Australia, Canada and New Zealand...

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  • A far better system

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  • Samir, get with the times. I was in your position once. Young naive British GP. Was a partner too as well as an LMC rep and university tutor. I left for a fee for service nation and things have never been better. I no longer work in a Stalinist system and work as I see fit. A professional once again. You seem to be one of the know all Brits I used to encounter who would talk down about any form of "privatization" coming into the system. Some of my die hard medic mates used to lambast GPs for wishing to charge patients in eligible for NHS services which they wanted their own gp provide and yet saw nothing wrong with tescos being able to provide the services privately!!!
    Wake up. Your opinions mean nothing anyway in a Stalinist system run by a government monopoly that decides on the allocation of resources and delivery of products. You know what works in the rest of the world so keep kidding yourself that it won't work over there if it makes you feel better about yourself. Meanwhile these rest of the world continues to move forward whilst you flog yourselves to death and guys like you can keep pontificating about how to fix a system you really have no control over!!

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  • I tried Australia, as an OOH locum, 26 years ago. Chasing the Medicare fees, and Private fee bad debts did my head in. Returned to the UK for its capitation model, and still believe its the best model. If issues concerning QOF, CQC, AQP tenders etc. (frequently discussed here) could be resolved, opinions might change.

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  • Yep keep a system that pays nought for all the extra work GP's do. Another top column.........GP UK RIP. Ex-GP Partner, much happier in Oz. Aged 37

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  • This doctors columns are usually utterly bland but this claptrap really takes the biscuit!. Insipid, unoriginal thoughts mostly echoing the ideas of those that would rather capitulate than be on the front foot attacking the enemy! What future is there if our young doctors recycle old stereotypes in columns such as these and show no revolutionary vigour???

    For goodness sakes this is just the type of nonsense along with the "it's never been a better time to be a GP" trash that is causing the young to pack their bags and emigrate. No wonder the government can walk all over you when they effectively have no opposition.

    It is clear to me that what's happening in the NHS is not working. Outcomes are poor despite high spending. Patients are unhappy and professional morale is at an all time low. Unless one is living in an ideological utopia it's hard to imagine any system in which there aren't any losers. To outright dismiss a fee for service model which operates in many countries successfully is ignorant.

    Another post by the author spoke about part time workers including himself. Being "part of the problem". Now were beginning to see regular posters in the comments sections echoing this and calling for enforced full time work!! One of the benefits of living in a free country is that you can choose your working conditions and lifestyle. If it's your choice and you are able to work part time then you should be able to. It's the job of workforce planning to adjust to the realities of modern life and train and recruit appropriately.

    Come on pulse. It's up to you to find the next generation of peverleys who can add fire to the debate of where the health service is going, and not these spineless yes men who are helping to bring forth Armageddon!!

    The "it won't work over here" card doesn't offer any solutions at a time when ship is sinking fast

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  • hurrah for the above comment. Pulse take note. This magazine is fast becoming a joke.

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