Payment by capitation is not a fair way to reward GPs for the work that they do. In effect we are paid a flat rate – with a performance-related top up – for the number of patients registered with us, which takes little or no account for the amount of work we do.
But things may change.
On the face of things this would seem to be a fairer way to be paid, though there are hurdles and potential difficulties. For the concept to move from being an LMC motion, to GPC policy, then successfully negotiated with the Department of Health may take a minor miracle. Why would our employers, who are trying to make efficiencies over the next five years, suddenly want to pay us for what we do, which would undoubtedly mean an increase in funding for primary care?
The GPC would need rather a large amount of leverage, and the only one that I can think of that would work, except it probably wouldn’t, is the threat of industrial action. I imagine that this threat would only be used if fee for service was seen as the only thing that could save general practice.
Assuming that perhaps some time after 2020 the GPC lobbies hard for fee for service, I would still have my doubts that it could lead to a reduction in workload and an increase in pay.
Unless funding increased dramatically there would have to be a spending cap. GPs wouldn’t be able to simply work harder and harder to meet the demands of their patients if it all had to be paid for. At some point, perhaps in February or March each year, we would find that we were working for nothing once the money for that year had run out. You can imagine the conversations we’d be forced to have with patients: ‘I’m sorry Miss Jones, you can’t get your Depo Provera injection as we won’t get paid for it. Yes, sorry we didn’t have a large enough budget. You’ll have to write to your MP. The condoms are free though.’
Friends from Europe, where a fee for service operates but often is paid for by health insurance companies rather than the state, tell me that GPs spend a lot of their time chasing their own payments. The issues process of counting, checking and accounting for will be time-consuming and costly.
While a fee for service may seem fairer on the face of things, if it ever comes to pass the devil will really be in the detail.
If it does actually make general practice profitable and/or equitable then perhaps it will become more attractive for junior doctors – as well as private health companies.
Dr Samir Dawlatly is a former secretary of the RCGP’s adolescent health group and a GP in Birmingham.
