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We need to talk about the GP partners who game the system

We need to talk about the GP partners who game the system

Editor Jaimie Kaffash argues that the 1% of partners who are cutting corners are making life harder for the 99% who aren’t 

I can just imagine the conversations between GPC England and health ministers.

‘GP practices desperately need funding. We can’t afford to hire GPs.’

‘No more funding. More than 2,000 partners earn more than £225k.’

‘But they are the exceptions. The majority are taking home relatively modest pay. And can’t afford to provide the care they want to give.’

‘No more funding. More than 2,000 partners earn more than £225k.’

‘Waiting times are increasing. The vast majority of GP partners are burning out, trying to do their best – some have even had to stop paying themselves. This is a profession on the brink, and there is a simple solution that will benefit them and patients – more funding.’

‘No more funding. More than 2,000 partners earn more than £225k.’

Although this is imagined, I know there is a vague element of truth in this. Ministers are in the wrong, and are looking for an excuse not to stump up funding.

However, although this might make me unpopular among some of our readers, I do also feel as though it is time to talk about the GP partners who are making life tougher for all the others.

As our lead this morning reveals, there are growing concerns from GP leaders that additional roles reimbursement scheme (ARRS) funds are being used inappropriately. Some GP partners are being accused of ‘substituting’ GPs with lesser-qualified staff, such as physician associates, and pocketing the difference.

Now, it is important to say that they are a small minority. The vast majority of GP partners want to provide the best care they can for their patients. They put money into hiring the most qualified people they can afford and they only hire lesser-qualified staff when they absolutely have to.

But there are some who are looking to cut corners. This shouldn’t be a surprise. In all professions, there are people who are more motivated by money. And I certainly don’t want to curtail GPs’ entrepreneurial spirit or their ability to maximise profits.

However, the way the ARRS is designed does allow GP partners to misuse funding. There is nothing to stop them from hiring PAs to replace GPs for free. The only thing stopping them would be an inadequate CQC rating. But I have argued numerous times that the use of these lesser-qualified staff doesn’t have an immediate, obvious effect – the failure to spot urgent red flags is, thankfully, rare.

Instead, the replacement of GPs with other staff results in more defensive medicine, in patients being passed around the health service, and an overall worsening in standards of care. These structural issues aren’t ones that tend to bother the CQC, who are more bothered about refrigeration temperatures.

So what is the solution? We need to add GPs to the ARRS – that is a no-brainer at this stage. But this won’t prevent the manipulation of the ARRS. With a set budget, from a purely financial point of view, it would still be beneficial to use all this funding on hiring the cheapest staff.

Increasingly, I am coming round to a more radical idea – for staff to be funded centrally by the NHS, as they have been previously. Again, this isn’t to curtail GPs’ entrepreneurial spirit. But I don’t feel like staffing is an area where GP practices should be having to make efficiencies. The Government is responsible for funding the education and training of GPs, so it is in everyone’s best interests that they ensure all these trained GPs are being used.

Of course, there would need to be careful planning so practices retain independence, and that individual GPs aren’t treated as commodities. It may even be these are incompatible demands (and, if so, I would err on the side of retaining practices’ and individual GPs’ autonomy).

But from the Government’s side, this would negate any fears around headlines about taxpayers’ money being used to make the richest GPs even richer. From GPs’ point of view, this removes the Government’s flimsy excuse and should therefore lead to increased overall funding. Moreover, it will stop the ludicrous situation where we are seeing unemployed GPs.

So I hope this is something that GPC England are at least considering in negotiations with NHS England and the Government. By clipping the wings of those GP partners who do game the system, it might benefit the 99% of them who don’t. 

Jaimie Kaffash is editor of Pulse. Follow him on X (formerly Twitter) @jkaffash or email him at editor@pulsetoday.co.uk


          

READERS' COMMENTS [16]

Please note, only GPs are permitted to add comments to articles

So the bird flew away 27 June, 2024 1:36 pm

The thing with these rich 1% (maybe up to 10% in some cities) is that usually they’re very close to local NHSE managers who turn a blind eye because these 1% are also the tools managers use to introduce new (idiotic, divisive) schemes. They might be PCN CDs or similar types.
The other purpose this 1% serve is, as you say, politicians will use the fact of them earning >£200k to deny proper funding to the majority decent GPs, tarring them with the same brush. The best way to expose the 1% is if locally their GP colleagues shamed and outed them, for the higher purpose of properly funded patient care.
Re central funding of staff sounds like a very good idea to me as well, but as an unintended consequence, it could be just lead to a step away from salarying all GPs..

So the bird flew away 27 June, 2024 1:44 pm

*it could be just a step away..*

John Graham Munro 27 June, 2024 1:57 pm

These are the same G.Ps who would expect a Locum for free

Yes Man 28 June, 2024 9:18 am

Oh there are a lot more than just a few.

David Jarvis 28 June, 2024 11:52 am

I am not a £200k GP. If the people running the system designed it properly to reward good patient care then those £200k plus Drs would likely still earn the same. They often run large and efficient practices and are good at claiming appropriate reward as set by the powers that be. So I get they are used against us but the responsibility for the system just needs to design it better. Not blame those who work in it. It however a bit rich when as GP’s we are dumped on regularly by other parts of the NHS with work that is not remunerated. These other organisations are passing on work that they are paid for and not doing. They are gaming the system. If money moved for all such episodes then GP funding would rise significantly or work dumping would stop.

Some Bloke 28 June, 2024 11:52 am

think the only solution to this is more inspections, CQC are far too soft, what’s needed is unannounced raids, preferably with forced entry and with fire alarms activating. All surgery staff to line up outside. Get your documents ready.
Nurse?- step aside, we’ll deal with you later. Need to make sure you’re not some ANP.
GP?- free to go. eh…wait a minute, that one could be a Partner, so stay here.
PA?- into the van you go my friend. Re- education center awaits you.
Is that fair enough?

Christopher Jones 28 June, 2024 9:40 pm

I disagree. The government has chosen a system which values tickboxes above actual healthcare. You are maligning the doctors who have identified where the goalposts actually are, and are now standing in the right place.

The government could choose to prioritise and reward quality of care if they preferred. This would be an easy fix to the “problem.”

daniel mcgowan 28 June, 2024 9:47 pm

To earn those figures they gave probably taken over other surgeries, usually ones that were failing and closed. I don’t know why GPs who do this and turn the failing business around are vilified. Its a net benefit to nhs and they are rightly compensated for running a larger more successful business. If it was a private company doing such a job the Tories would be praising them.

Matt Greenwood 29 June, 2024 7:42 am

@editor where is the 2000 figure taken from?

C B 29 June, 2024 5:35 pm

I am saddened by this article which does not reflect the true financial cost of a “rich GP”, the risks and extra burden of work. A partner earning 225,000 may not be much richer than a salaried GP earning 100,000. Let’s do the maths shall we for a hypothetical GP partner earning £225,000. This figure is the gross amount which may include the notional rent for the practice building they work in. The 45,000 rent does not cover the cost of the mortgage for the building so they have a shortfall of 5000 for the mortgage they also have to pay taxes on the notional rent. After the mortgage payment is removed the 225,000 has gone down as follows 225,000- mortgage 50,000 a year= 175,000. This 175,000 also amount includes their employers contribution to the NHS pension about 12% which the salaried GP would not have to pay. Therefore the true figure this “rich GP partner earns is 155,000. Because they earn over 100,000 they lose their 12,750 personal allowance and pay 45% tax on some of their pay and they will pay about 47,875 of taxes which leaves them about 107,000 per year before paying in pension. An equivalent full time salaried GP is 100,000 a year. They don’t lose their personal tax and don’t pay the 45% tax bracket so they pay only 25,000 tax and earn 85,000 a year before pension.

Now 20,000 more a year for that “rich Gp” doesn’t sound so generous does it? when they carry the extra burden and responsibility of a partner, are liable for redundancy pay and may end up in negative equity if the practice building falls into disrepair. So much for being rich….

Dylan Kay 29 June, 2024 8:58 pm

I do wonder whether a legal minumum of patients per GP so that if a surgery has x number of patients, the surgery must have y number of WTE GP’s and ensure funding follows this policy.
There is something sour in taste with the practices gaming the system. There are always bad apples who will take advantage of a system even if the morality is at best dubious.

Centreground Centreground 1 July, 2024 10:28 am

I would agree that 1% seems a reasonable figure for the numbers of GPs involved although the catastrophic destructive influence of some of these GPs across the country has been largely overlooked and their negative impact affects 100% of their colleagues as they occupy positions of power which in my opinion has been misused for decades.
They strategically select positions on LMC boards, as PCN CD leads, ICB and NHSE board positions where they are able to gather information primarily for their own personal , practice or their private group gain.
The point made about taking over failing practices overlooks the point that these GPs specifically target these types of struggling practice via information gathering via PCNs , LMCs, ICB board positions often with the misleading stated intention of assisting but sometimes with a view to a later making their own bid to take over this practice although not openly stated.
The endeavour by some GPs to gain positions for power or profiteering/monetary gain at expense to others is further demonstrated by PCNs where constantly we are told about schemes such as those relating to health inequalities (as the favoured justification) which could have been delivered at a fraction of the cost by GP practices themselves, but ego and self-congratulatory tendencies does not allow these power motivated GP groups to refer to the obvious.
When considered and examined it will be clear that many groups who have been taking over failing practices have individuals with connections on the above influential boards and it these very small groups of GPs who have without being noticed feathered their own nest by creating large lucrative private GP groups via gathering of APMS or other contracts and also in fact PCN groups motivated by personal huge financial gains and to the detriment of all patients and GP colleagues at all levels.
The effect of the negative and destructive influence of this small but disturbing group of GPs in having either assisted the government in fragmenting Primary Care should not be overlooked and the continuing negative impact of these individuals and their private groups / limited companies continues unabated .
There is as mentioned previously, nothing wrong with making a business successful , efficient, patient centred and additionally high earning as we frequently see and should indeed strive for but where it is at cost to the wider health community & colleagues, the Inverse Power GP rule applies and as these negative small groups of Power GPs become excessively richer, Primary Care continues to become poorer as a whole and this needs firm action to protect the wider NHS as well as Primary Care.

Finola ONeill 2 July, 2024 1:44 pm

Centralising anything including staffing for primary care is a bad idea. Everything managed centrally is inefficient and costly and over managed cf trusts, ICSs, NHSE itself.
Want better GP services and more GPs managing care. A single qof indicator providing significant budget that is tied to GP time spent with patient (face to face or phone; patient’s choice). Add in a qof for patient satisfaction and job done.
Surgeries have to provide more appts with GPs to get their funding and it will therefore happen.

Matthew Shaw 3 July, 2024 12:05 pm

i am not sure they are all gaming. I suspect some work 70+ intense hours a week carrying a lot of responsibility.
We all know GPs are saving the NHS millions – replace the partnership model and there will be no ownership and primary care costs will double or triple with no improvement. Just look around the world or at the community trusts costs for district nursing etc..
But it is a problem – justify £225k to a hostile NHSE, political elite and media? I dont think so. It will be interesting to see what Labour do. They may push a non partner model with centralised control [nightmare] which will drive the emergence of private primary care.

David Simpson 3 July, 2024 4:57 pm

Some Gp’s earn £225k. how much do the top earning MP’s earn on top of their “full time” salary?. I would counter by giving out the average Gp salary. I think we all know practices who game the system just as in all walks of life. However is £225k too much for a GP? You could employ 3 Mp’s for that

Merlin Wyltt 7 July, 2024 9:55 pm

Excellent-we are now destroying each other.