Why do GPs take on unfunded LES work?

In the second piece of our investigation on local enhanced services, Harry Hetherington looks at why GPs take on unfunded LES work  

Our analysis of local enhanced services (LES) provision across England uncovered variation in availability and funding, which GPs have described as a ‘lottery’ and a patchwork without ‘rhyme or reason’. GPs tell Pulse that this variation has led to practices offering LESs at a loss. ‘Many LESs may have slipped over into loss-making territory, or at the very least, things that were clearly viable are now marginal,’ says Dr Paul Evans, a Gateshead GP.  

So why do GPs still provide these services? In this piece, we look at the ‘multitude’ of reasons why this happens – including professional duty, the relationships GPs have with their patients, the complex ways these services are funded and make money, and expectations from both patients and secondary care on what services GPs should be providing. 

Professional duty and GPs’ unique relationship with their patients  

GPs often take on unfunded or underfunded LES because of a strong professional duty of care to their communities and patients. ‘Practices often prioritise patient safety and continuity of care over financial considerations,’ says BMA deputy chair Dr David Wrigley. ‘Refusing to provide services due to a lack of funding can risk delays, poorer health outcomes and complaints, placing GPs in an ethically difficult position.’

‘When it comes to providing services a lot of GPs will ask three questions: Does it improve care for the patients? Does the service we offer make our staff wellbeing better? And is it making money?’ Tower Hamlets GP Dr Selva Selvarajah tells Pulse. ‘And for a lot of us, the first trumps the other two.’ 

On top of GPs’ professional duty to do their best for their patients, experts and GPs say that explaining to a patient that you’re not going to do something because you’re not getting paid for it is a conversation almost impossible to have. ‘For us to turn around to our patients and say “we’re not going to do this anymore because of funding issues” can be quite challenging,’ says Dr Selvarajah. He explains that all practices in Tower Hamlets have phlebotomy services in-house because it is better for patients than having to go to hospital at the blood test done. ‘Even though the contract value has been shrinking, we’ve decided to continue providing that service because it is benefitting for patients for getting the blood test done and processed far quicker,’ he says.  

Manchester GP Dr Steve Taylor, who is also the Doctors’ Association UK (DAUK) GP co-lead, has seen similar occurrences in his practice. ‘Occasionally my partner here in minor surgery will take somebody’s big toenail off if they have got an ingrowing toenail,’ he says. ‘There’s no funding for that, but he’ll do it, because he’s always done it. I suspect the next generation of GPs won’t do that.’  

Hampshire GP Dr Matt Prendergast says there are a ‘multitude of different factors’ determining a practice’s decision whether to provide a LES. The motivation to attract patients to boost list size may encourage practices to provide a service as a ‘loss leader’. ‘You as a business want to be providing lots of different things to attract and keep patients’, he says. 

‘It’s in the best interest of the patient. We often joke that whenever anyone says this phrase, it’s a big red flag that you’re being asked to take on extra workload that’s not yours,’ says Surrey GP partner Dr Dave Triska. ‘Almost invariably, when that sentence appears somewhere, what’s coming after it is something that’s not your actual job.’ He says that in some cases, returning inappropriate workload transfer back to secondary care it is met with a response similar to: Why don’t you want to look after this patient with cancer? It’s much better for them to see you in the community. Would you force them to come all the way up to the hospital for this? His ICB does not prostate cancer monitoring via a LES, but the local trust asks the practice to do prostate cancer monitoring ‘all the time’, he says. And while this approach may have historically worked on GPs, the goodwill has largely ‘ran out’ now.  

The RCGP says that it speaks to the dedication that GPs and their teams have to their patients, that they so often go above and beyond to make sure patients receive the care they need, even when this work is not properly resourced. ‘But this is not sustainable,’ RCGP president Professor Victoria Tzortziou Brown tells Pulse. ‘Particularly given that workload in general practice is increasing, and we’re dealing with intense workforce pressures.’  

The complexity of working out whether a GP practice is providing a LES at a loss 

Working out whether a LES is being provided at a loss can be complicated, and this is another reason why practices may continue providing them, GPs and experts tell Pulse. Some practices continue to provide LESs that would have made sense to provide at one point in time, but that are no longer financially viable, but this is often complex to recognise. ‘Many LESs will wither in value as inflation eats away at them because relatively few are uplifted properly,’ says Dr Evans. 

Some practices are providing LESs at a loss because not every GP is minded or has the time to break down a LES by cost to work out if it is making or losing money. ‘It’s down on the list of priorities of how do I get through my day and home to my kids on time?’ says Dr Triska. ‘It’s always going to be one of those things that slips a little bit because you have to make a conscious effort to do it. It’s not something that’s part of the daily routine.’ He adds that GPs are sometimes completely unaware that these services are costing them money. When it became apparent the local phlebotomy LES offer was loss-making, Dr Triska’s practice stopped doing it until the offer was changed. ‘But I think most people, certainly my local colleagues, weren’t aware it was a big loss maker, because they hadn’t actually sat down and worked out the cost of a person taking the blood minus however many appointments per hour, and similar,’ he says. ‘We are not running a logistics business, although we are, in reality, but we don’t feel we are, so they don’t actually do logistics very much.’ 

Pressure to meet expectations  

Another reason GPs still provide these services is that there is an expectation for them to be providing them. ‘Work being passed down will raise the expectations that certain work can be done,’ says Dr Taylor. ‘It’s a bit like the national campaigns out there to promote prostate checks – which is brilliant and good – but those campaigns will often have millions of pounds behind them, but the end result is going to your GP without any expectation that GP has got any additional capacity to deal with that.’ 

Dr Wrigley says that there can be significant system pressure from secondary care and commissioners, with work historically undertaken in hospitals increasingly transferred into general practice, sometimes informally and without appropriate resourcing, leaving GPs managing additional workload even where no LES or adequate funding exists. This can also mean that many practices are concerned that opting out of LESs, even when they are underfunded, could damage future commissioning relationships or reduce local service provision. Dr Wrigley also points out that GPs refusing to provide services they have previously provided ending risks disrupting patients and established workflows and that this can leave GPs ‘feeling obliged to continue providing care to avoid a postcode lottery for their patients’, even where no dedicated funding stream exists. 

Action being taken 

The RCGP says that on top of better funding for local services, GPs require ‘far more transparency’ from ICBs about the budgets they are given, and how this money is then allocated to general practice. ‘GPs and patients need to understand whether funding is reaching the frontline services patients rely on’, Professor Tzortziou Brown says. 

And there needs to be a better understanding from secondary care of which work GPs should be or shouldn’t be doing. This kind of workload transfer is ‘illustrative of a big misunderstanding, particularly from hospitals, about what primary care and secondary care contracts entail’, according to Dr Triska. 

GPs say action by unions and LMCs has contributed to a better understanding of what GPs can and cannot do. Dr Selvarajah credits previous and current collective action with ‘increasing awareness’ among GPs about ‘what is contractual and what’s not contractual’ and ‘what’s being paid for and what’s not being paid for’. At the recent UK LMC conference, LMC leads shared examples of a how a ‘critical mass’ of GP practices taking actions such as actively declining to take up LESs could compel commissioners to offer better value for money. Rejecting a large ‘bundled’ offer which represented poor value for money ‘caused the ICB to find more attractive ways of encouraging GPs to provide the LES’, as one LMC lead put it. 

This approach may offer the best way forward for GPs to secure proper funding to provide LESs. ‘If GPs aren’t prepared to serve notices on LESs that are loss-making, then there is no impetus for ICBs to commission these things fairly,’ says Dr Evans.

Read all of the other parts of our LES LOTTERY investigation here