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At the heart of general practice since 1960

Should GPs stop ‘gaming’ the system?

Two GPs debate

dr david unwin square

YES. We must rediscover our purpose as GPs 

I remember a ‘golden time’ in the 1980s when our practice hardly ever talked about money. Later in the Thatcher era we became part of a ‘marketplace’ with new payments for extra work and then QOF incentives. We responded with gusto.

Over the years, though, I have felt increasingly uncomfortable with our lack of discernment in this rush to maximise income. Particularly when I sense a general acceptance that it’s ‘all a game’ as we need to keep income up ‘at all costs’.

One day in 2010 I overheard someone describe GPs as ‘a bit like prostitutes – pay them and they will do anything’. As my indignation cooled I realised I had sleepwalked into a lack of critical evaluation and accepted we should jump through each hoop – and be paid. The multitude of Government-led, top-down initiatives has compounded this slide into commodification. Over the years each new wave left me feeling exhausted and guilty for not being able to keep up.

This undermining of our judgment and control has further led to GPs doing the minimum to get the points, and also, dare I say it, even less scrupulous behaviour. Schemes such as NHS Health Checks, the Avoiding Unplanned Admissions DES, various CCG referral or prescribing incentive schemes and some aspects of the QOF have led to outcry about misuse of resources and ethical concerns, yet many of us signed up.

My own lodestone is remembering why I became a doctor – not to become rich, but to make a difference to my patients’ lives

A personal watershed came in 2014 with the dementia identification scheme – the enhanced service paying £55 for each new dementia case added to the register.1 As Dr Martin Brunet said at the time: ‘The payment is not on the basis of caring for our patients, but on the diagnostic label we apply – this creates a major conflict of interest that is unethical. Should we declare this to the patient when we make a diagnosis?’2

I am not suggesting we should never act on the suggestions made by pop-up boxes that intrude on our consultations, but we have a duty to weigh up their pros and cons. Perhaps we should be honest with ourselves about the potential to corrupt that cash has, and the need to prioritise the patient’s agenda during a brief 10-minute appointment.

My own lodestone is remembering why I became a doctor – not to become rich, but to make a difference to my patients’ lives. 

Dr David Unwin is a GP partner in Southport, Merseyside, and RCGP clinical expert in diabetes


dr peter swinyard square

NO. GPs have to survive the perversities of the NHS

Since the loss of the nice, simple Red Book in 2004, making the best of our GP contracts has become a dark art indeed.

The Red Book had become unfit for purpose with the pool system of payment. We were meant to be entering a brave new world in which all GP activity would be properly funded – a global sum to keep the doors open and provide the basics and enhanced services for the rest.

Instead it has meant that the only way to keep a practice’s head above water, especially for those with a disadvantageous Carr-Hill formula, is to go after every scrap of funding.

Many of the tasks we undertake do not appeal to our professionalism at all. They are often dreamed up in sandwich-filled rooms in NHS England Central – or, even worse, by the secretary of state when he feels ‘something must be done’. Some enhanced services make me cringe. And yet we must do them, because incomes are under such pressure that we have to grab everything.

If this is how our political masters deem we are to be paid, we have to accept

A classic example is the Avoiding Unplanned Admissions DES, which forced us to run through a list of questions with our supposedly 2% most frail patients.3 Now, frailty is hardly spread evenly across practices. One 80-year-old lady I rang was happy to answer – but she had just got back from her line dancing class and was on her way to Zumba. It seemed unfair to ask where she planned to die. If I ask her to name her next of kin, will that help her avoid being admitted to hospital? No, but there is a lot of hard-won cash attached.

There is no shame in this. These schemes are planned by those who consider themselves better and wiser than front-line GPs. They have statistics to show these tasks need doing, even if a medical student could work out they are a waste of time.

So, should we chase the pennies? I regret the answer is yes. Funding in general practice has shrunk to the point that new doctors don’t see the point of becoming partners and giving the lifetime commitment to an area, which improves continuity and quality of care. Practices are closing because they can’t make a living. If this is how our political masters deem we are to be paid, we have to accept. That does not mean we cannot protest or try to make the system more effective in the future.

Dr Peter Swinyard is chair of the Family Doctors Association



1 Pulse: GPs to be paid £55 for every dementia diagnosis under new identification scheme. October 2014.

2 Pulse: Giving GPs ‘cash for diagnoses’ is unethical. October, 2014

3 Pulse: Unplanned admissions DES specification. April, 2014




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Readers' comments (5)

  • In this crazy world with increased Political control of nearly everything those at the top are forcing the minions to dance to their tunes. Of course the Politicians are also being controlled by the puppeteers, the elite, think banks, multinationals, military industrial complex. Money is the easiest way to control the masses and it is by this way extreme forms of Government, such as fascism or its equivalent communism start. Everybody has a personal threshold of how much they will allow money to inflence their actions. This threshold also depends on how much individuals subjectively want or feel they the money.

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  • What Dr Unwin fails to take into account is that most of the money we are forced to chase has been recycled from another closed income stream. If we refuse these enhanced services then our income doesn’t stand still, it shrinks, rapidly. Partners will bail and practices will fail. There may be little dignity in being a beggar dancing for change, but the alternative is to starve to death.

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  • Dr Unwin mentioned a "golden time" and in doing so removed his argument from current general practice and placed it into an era that has not existed for a long time. He essentially ended his argument at that point.

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  • Dr Unwin has completely misunderstood the situation. Mrs Thatcher's "Marketplace" that he mentions has nothing to do with payments to GPs, that was in secondary care. Payments to GPs have always been compartmentalised, paid in dribs and drabs, piecemeal, bit by bit, claim after claim. this was as true with the payments schedule under the red book as it was under the 1990 contract with CDM clinics and now since 2004 under nGMS. All that has changed is the amount of money associated with each component of the payments catalog. GPs have always been paid from a schedule, all that has changed is the definition of items in the schedule. Oh and more recently, the amount of the money per item and the amount of work needed for each item and the number of items needed to make a living wage. All have gone south which is why in the 1980s he didn't need to think about money, there was enough and it was easier to access.
    As others have said this is a non debate.
    Paul C

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