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At the heart of general practice since 1960

Should GPs be paid per consultation?

Dr Clare Gerada Paul Stuart

YES

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

 

Dr Beth McCarron-Nash online

NO

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

Readers' comments (14)

  • I think GPs should be paid for offering appointments outside of core hours, and this payment should come from the patient. If you rather have convenience then pay for it (pts can then decide if it makes financial sense to pay for an evening/weekend appointment or take time of work) This increases pts choice, promotes responsibility as the pt is paying and also incentives GPs to open later.

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  • Copayments as well as capitation have existed in NZ for decades. Patients do get 12-15 minutes here, but we do not have"conveyor belt medicine" - most of my friends who are GPs work hard to get to the bottom of the consult - and we are dealing with complex aging /immigrant/ indigeonous/addiction or mental health problems that are similarly difficult to get tertiary services for. The UK mates we know working here say there is no way you would deal with that many problems in a single consult, and that you need to limit peoples "free" attitude to the GP. I have noted UK immigrants taking us to task for "cost" - but then turning up with speed at the slightest sniffle. Your service is overwhelmed - you will have nurse specialists, physician assistants, physios and gp trainees being first port of call, and copayments will happen in order to limit demand. Its inevitable.

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  • I have mooted this for a long time. If we do not do this, consultation rates will rise inexorably , from 4 to 6 in the last 10 years, for example, and soon become 10 per patient year. This is impossible to do and the MAIN reason for GP burnout. The DOH and the managers love list size because they can offload as much work as they wish for the same money. If we provide appointments instead then increasing workloads would increase renumeration making it a fairer system . Regarding gaming, I think we have to accept the honesty of most GPs. In any case, if we do not change , we may lose General Practice altogether as GPs are leaving and even famous practices such as Prof. Fields cannot recruit. An unfair system with increasing workloads with no accompanying renumeration will collapse ultimately as people leave and do not join.

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  • Dr Mcarron-Nash, You are right to say that paying GPs by the number of consultations is not original because it is use is extensive in the rest of the world where better outcomes are achieved, conveyer belt or not. The fixed price model is burying GPs in an avalanche of unfunded work. Only once the growing consultation rate is acknowledged, will it be subject to the universal laws of supply and demand and I would expect deprived areas to do well where acute consultations for self limiting disease are common. GPs are already under tremendous pressure to race through appointments, at least funding consultations would bring in new funds rather than limping on with the broken all you can eat model. You are right to say general practice is under strain from tinkering, what we need is is real reform which the GPC is failing to deliver.

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  • Cost per consultation is a good idea and but first of all the NHS must run pilots to evaluate its usefulness. The waiting list is likely to disappear, GPs may be tempted to recruit more staff to meet the new challenge.
    Alternative views are as follows:
    A. Patients must pay for the following:
    1. home visits
    2. if they DNA
    3. fix charge of 50 pence per script item for all, if patient cannot afford, the NHS must reimburse but everyone must pay
    4. If patients do not listen to the medical advice, they should not have a free treatment. For example patients suffering from Asthma should not smoke to prevent COPD, if they continue to smoke, they must pay for their treatment, not the taxpayers. Like this there are many other examples
    Such measures will prevent a lot of wastage in the NHS
    B. NHS is subsidised rather than completely free and everyone has to pay at least some % of the cost of treatment. This will save the NHS from most funding problems, patients who cannot pay must be given some help from the Government

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  • Is the GPC saying that year on year as consultations get more and more per patient, that we will be paid the same per patient, so mathematically less per consultation each succeeding year? So if we earn about £ 3 take home per consult today, it is going to be £ 2.00 in 3 years time? Dear God, these are our negotiators. No wonder, GPs are disappearing.

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  • Great idea - Private companies can work their slave GPs - sorry 'salaried GPs' even harder.

    Performance manage them - your not seeing enough patients per hour, as we require at least 10 to make a decent profit, so we can sit at home while you work, or give even more money back to our shareholders.

    Partnership - basic practice allowance - so all posts are potentially best filled by GPs who have ownership of their lists and care for patients they know and know them.

    Life long relationships can prosper. Not just whichever face sits in the chair today, while faceless private companies make profits.

    This would force out private companies as they would not receive the income as they are not working in the practices they run.

    Continuity of care needed to cope with increasing demands of ageing population, and with minimal new money in the pot (wasted millions on pointless tendering of contracts could be recycled to pay for co-payments).

    Co-payments should be there to stop over use by those who are worried well, and reduce demand and expectation.

    If we call patients in for health promotion or prevention work/chronic disease it doesn't count from annual limit. Otherwise if > 4 consults a year, top up payment, and top up payment for anti-social hours appointments billable to DOH

    This will force politicians to bite the bullet and address the drumming up of expectation and demand. They then have to use DOH to publicise minimal use and provide health promotion nationally via media and TV etc.

    If we strip money from hospitals by charging A&E attendances like in Ireland - demand will also reduce there - paid for by the patient - unless an Accident or staff deem genuine emergency. (That is what A&E stands for!)

    Free at point of service to still be the core of primary care.

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  • best option is to reduce the number of patients per GP and set a regional limit, eg 800 per GP in high demand areas, 1200 in low demand (eg high student population). Per consultation just leads to rampant abuse - repeat prescription - please see GP etc etc.

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  • In Canada we charge per patient and if more than 15 min for every additional 10mins. works pretty well combined with no beurocracy targets government interference or restrictions.

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  • No because we'll just say come back 82 times instead of sorting the dumb problem out! No one ever pays you to be efficient and continuous. Bring back smaller GPs

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