How should GPs be paid and regulated?

The final meeting of our panel to Build a Better General Practice discussed the potential payment methods for general practice and the results of our survey on contractual models. The survey is now closed

Partnership model still popular

In our previous survey, there was a complete split on the question of whether the current partnership model is obsolete – an average score of 2.5 out of 5. But there was a lot of support for the statement ‘it is possible to work in autonomous businesses and provide adequate clinical care’, which got a score of 4.02

Analysing based on age, the younger generations were in fact a little more in favour of a partnership-style model than the older ones.

Respondents were definitely not in favour of moving to a similar model as hospitals, run by the NHS and managers, even if headed by a medical director. Yet overwhelmingly, GPs say that running a business shouldn’t take any time away from clinical care.

Contractual model

It was pointed out that the results were a rejection of large organizations with lots of salaried GPs, which is one that NHS England are promoting in some areas.

The survey asked about businesses – deliberately not about the partnership model. However, GPs’ feelings about such a model will of course depend on what it comprises. For example, should running a business also involve unlimited liability against the premises cost, or rent reimbursements.

The younger members of the panel said it was understandable that younger GPs were more interested in running businesses, as they do develop transferable skills that allows them to diverge outside healthcare.

Autonomy

The panel speculated that the real reason GPs are in favour of a business model of general practice is because of the autonomy it configures on them.

There was a consensus that this isn’t working in the current model as GPs do feel undervalued. But looking at secondary care colleagues who are salaried to the NHS trusts, and it is clear they too feel really undervalued.

GPs feel that they are not treated as professionals, but as ‘naughty schoolchildren who have to be controlled, regulated and told what to do’.

Controlling the budget is one way that GPs can feel a sense of control, and give that extra sense of professionalism that is eroded by over-regulation.

The small business approach also supports innovation. GPs are well ahead of hospitals when it comes to use of technology.

The case of the ARRS is indicative of why GPs need more autonomy – the restrictions around the roles has put more pressure on the system. The USP of general practice of being staffed by GPs is that they know a little about everything, which makes them very cost effective. But the roles specified by the ARRS are more risk averse, leading to more referrals to secondary care – which we are already seeing.

The model itself is not the main point – the aim should be finding a system that gives GPs autonomy, and makes them feel valued as professionals.

How should general practice be funded?

Even in a system started from scratch, with unlimited funding, where the funding comes from still matters. Funding from taxation only will still leave it to the whims of any future government who may not wish to continue our policy of money as no object.

The options would include co-payments, or an insurance system.  Co-payments could widen health inequalities, as could an insurance model. However, a hybrid model of insurance plus public funding could help manage demand and could be developed to incentivise GPs to focus on preventative care.

Would it be beneficial for a minimum funding guarantee for general practice, or even a certain percentage of overall NHS funding? General practice funding has decreased from 11% of NHS funding, to 7%-8%, and at a time that there has been a real-terms decrease in NHS funding.

However, funding guarantees might not be the best thing for general practice – it should be a case of seeing how much money is needed for general practice and providing it accordingly.

If we were to have a free at the point of use service, it might be helpful to have a penalty for misuse of the service. 

Payment system

If general practice was to be run as a business, the mechanism to pay practices will affect how the system functions. 

There has been calls for a system of payment by activity.

But the panel felt that the most important thing is to simplify the payment system. This could be capitation, but with payments that are clear and traceable – which is not the case at the moment. The complexity could also be a way of smuggling through funding cuts.

If general practice was to be given more autonomy through increased base funding, would there need to be greater oversight on how it was spent?

There are pros and cons to incentive payments in a capitation system. QOF was a great idea when it first came in, but is no longer fit for purpose. An incentives system that is based on outcomes – which has to be done on a wider population basis – might work.

Medicine does move on, and GPs should be adopting new developments, but does this necessarily need incentivising through the payments system? 

With the current contract, a lot of administration work is being added to the contract.

Regulation

Patients would want to know that general practice is being regulated so they are safe, and that is reasonable. This should be through clear, agreed standards.

Decades ago, there were simply professional standards, and they were pretty short – pretty mush focused on not sleeping with your patient and don’t get put in jail.

Now, the CQC regulates the organisational aspects, while the GMC regulates professional standards and GPs have to ensure they remain on the performers list. This leads to overregulation. Plus, the CQC’s standards do not seem to be evidence based, are too descriptive and take away from good care. They do not look at the patient experience either.

LMCs used to manage practices, but this is problematic. 

The ideal regulator is one that is a genuine friend to the profession, that also does education, training and mentoring. 

Professional development

There is little evidence so far that appraisal and revalidation improve patient safety.  Yet it takes a lot of time away from clinical care. In secondary care, it has also been used as a performance management tool in secondary care.

GPs, in general and in common with all professionals, want to continue their professional development and their learning. But the tick box culture, and having to record this, actually reduces professionalism and is infantilising.