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The waiting game

My big idea - GPs should charge patients for services

Dr Peter Swinyard

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Simon Stevens’ Five Year Forward View and the later GP Forward View were remarkable and insightful documents which set the tone for how the NHS could change and run well into the future. There was, however, an extremely large elephant in the room. Money. Cold, hard cash.

The Five Year Forward View demanded not only increased funding from central government, which has by and large been forthcoming, if slowly – but also some £23bn of ‘efficiency savings’. It is at the edge of credibility to think that this level of savings can ever be achieved in a service which has been looking at cost efficiencies for nearly two decades. There are no further operating efficiencies possible in general practice. Whatever system we use to replace the 2004 contract has to break the traditional ‘free at the point of use’ system. This will bring hate mail and Facebook vitriol down upon me but I can think of no other way of controlling demand. The idea of paying to see the doctor/nurse at the practice has been voted down at successive LMC Conferences but by decreasing margins.

But I suggest we think about plastic bags. Since a charge of 5p per bag was introduced, the use of plastic bags at supermarkets has reduced by 85%. I advocate a £5 charge to see any healthcare practitioner in the surgery and for electronic and phone consultations to remain free. The charge should be refundable for those on low incomes – France manages it, we can manage it. This measure alone will reduce front end demand.

There are no further operating efficiencies possible in general practice

Then we need to think about how we are paid. I have had a salutary year acting as practice manager as well as a clinician and I am astonished at the appalling and arcane claim systems, designed by no-one in particular and almost unusable. CQRS, the claims system for enhanced and other services and the reporting system for some activity, has had no single person in charge. Ever. And it shows. We need more of a block contract than an item of service. Admittedly the latter incentivises us to chase immunisations and so on but the time spent doing so may be better used with patients.

We all need to have the phones manned 8am to 6.30pm and the doors open most of that time. The cost of doing so is not much different if you are a rural practice of 1,500 patients and one GP or an urban practice with 15,000 patients and 10 GPs. So there needs to be a Basic Practice Allowance again (like the Red Book) to take this into account. Then we need a properly funded block contract (don’t say global sum!) to cover all the other things we do including many of the enhanced services – there should be opt outs with abatement of pay rather than item by item opt ins. We are not going to get rich on £25 an hour from patient fees (my solicitor charges £350). There will be accusations of gaming and calling back for unnecessary reviews, but this will tip the balance to more efficient phone and Skype and other electronic models.

The nature of our practices is perforce changing with the shortage of GPs and the remaining GPs are becoming more consultant in nature, with patients being seen initially by people of lesser training and the more complex coming to the GP for management. New payment models must recognise this and reward good practice – Excellence Awards, anyone?

We need to keep general practice at a human scale. I do not think that the path down which we are being forced of having ever larger practices is in the interest of patients or their medical attendants. Economic necessity does not always make for good patient care. The innovative and resourceful driving force that is general practice needs the nurturing and funding to allow it to blossom again before we all give up and allow ourselves to be taken over by conglomerates. Or is it too late already?

Dr Peter Swinyard is a GP in Swindon and is chair of the Family Doctor Association

This is part of our ‘Great GP Debate’ season. If you would like to write a blog on how you see the future of general practice, then please email the Editor at

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Readers' comments (12)

  • Azeem Majeed

    Because the growth in NHS funding in the foreseeable future will be very restricted, we will see more calls for GPS to be allowed to charge patients for medical services (in the same way that opticians, dentists and NHS Trusts already can). Alternatively, we may see more patients opting to have a ‘backup’ private GP to their NHS GP. There are now numerous companies offering private GP appointments via PC or smartphone, such as Babylon and Push Doctor.

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  • as funding declines then we should simply respond by reducing provision of services. that will translate into less GP's in the practice. We should not respond to this personally. Unfortunately we serve a population that has chosen the conservative party to lead us and demanded Brexit, when it came to a national democratic vote. no point at looking at what ifs.

    The Private GP's do not work, patients do not have money for this and most of these ventures fail abysmally. Babylon pay peanuts and push doctor don't have the numbers coming through the door.

    Personally my response has been to reduce practice sessions and funding and then look to work in other services that need GP's. has lead to equalising of the situation.

    - anonymous salaried!

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  • Knowledge is Porridge

    Rather than charge £5 per appointment, why not charge £2 per prescription item with no exemptions? It's a start...And it would keep gp's out of the firing line. No need for any new structures of claiming back money, proof of exemption, handling money. Just a plain and simple need to finance the NHS, that also encourages people to use it sparingly and avoid the tablet for every ill mentality.

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  • Knowledge is Porridge

    Just one more thought: no medication available OTC should be available on prescription at lower cost. Eg OTC generic beconase at £4, therefore minimum cost for prescription also £4 (per spray, £8 for two!).
    It's like the John Lewis promise in reverse. Never knowingly cheaper when prescribed by your GP.

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  • GP payment should be per consultation - like in Australia.
    Government and not patients should make this payment.
    This way the number of appointments provided to patients will increase.
    All GPs will then have to work a reasonable number of hours to make a decent income.
    So both patients and GPs will be benefitted.
    If practice boundaries are removed, it will be even better.
    There will then be real competition between GP surgeries.

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  • Council of Despair

    payment by activity ?

    it's fairer - the harder you work the more you get paid.

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  • There should be no exemptions- some days, approximately 75% of the patients I see are exempt from paying for prescriptions.

    Instead of charging for consultations(for obvious reasons), why not consider an NHS levy. 10% tax on choices that might lead to increased use of the NHS in the future with no exemptions. Fags/vapes/tobacco, booze, fast food, takeaways, sugary drinks/snacks, high fat products, eating out etc, etc. If you indulge occasionally, you won't be forking out a lot. If I'm at MaccieD's/KFC/Gregg's everyday, it'll cost me. As with the carrier bag charge, it might result in people making the right choices and the health of the country improves dramatically. If not, it'll be a massive financial boost for the NHS and services can then be properly funded.

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  • It is already too late to save general practice because of the lack of trainers .
    It might have been saved with increased funding - any of the above schemes would have helped .
    Politicians are unaware of what we do and therefore do not value our profession.
    They are also scared of the Daily Mail . There is no last gasp for primary care -just Cheyne - Stokes.
    We will be missed .

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  • Council of Despair

    it's interesting that in the rest of the globe charging for consultations is used - is there any actual evidence that it leads to worse outcomes or is it the case that we don't want to upset anyone so don't like to talk about it.

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  • David Banner

    Interesting and well considered article, but no political party is ever going to advocate charging patients to see a GP. If A&E remains free it will be swamped as never before. And if phone calls are free we will rapidly become poorly paid call centre operatives.
    But charging everyone a nominal amount for prescriptions is long overdue, and would attract far less controversy.

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