Should GPs be paid per consultation?
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
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