Saturday, 26 January 2008


There has been some discussion over at NHS Blog Doctor about how much patients would be willing to pay to see a GP. For the last year for which I have figures (to 31st March 2007) my net NHS income per consultation was roughly £21. That figure is after paying all expenses but before tax and superannuation are deducted, and is derived by simply dividing my income by the number of consultations I carried out during the year.

However our practice has high running costs, and our gross income (before deduction of expenses) is just over twice our net income. So my gross NHS income per consultation was roughly £44. What is the other £23 per consultation being spent on? As well as the rent of our premises, heating and lighting, telephone and secretarial costs, we also employ phlebotomists and practice nurses who run their own clinics. Expenses rise inexorably every year and it is difficult to keep them under control. Our staff have been getting their inflation-based pay rise every year (while our NHS income has remained static) and several staff have moved up the pay scale. Changing standards in medical practice mean that we now have to have an oxygen supply in our premises (costing us some £500 per annum) and use disposable speculae and instruments which work out much more expensive than the cost of maintaining the autoclaves we used to use.

So would you have to pay £44 to see your GP if we all resigned from the NHS? I don't think so. If that happened then, as Dorothy said in The Wizard of Oz, we wouldn't be in Kansas any more. Everything would be different. For a start, nursing consultations (and having blood taken) would be priced separately from GP consultations, so the cost of a GP consultation would fall but a charge would be made to see the nurse or phlebotomist. More fundamentally, our entire way of practising would change. We would no longer be bound to the Quality and Outcomes Framework, and so would immediately cease collecting enormous amounts of data during our consultations, and would not have to spend a lot of time manipulating the data, writing protocols and all the other time-consuming (and hence expensive) activities required for a high QOF score. We would also no longer be in thrall to the PCT's Prescribing Advisor, constantly monitoring our prescribing and fiddling around changing patients from one drug to another to keep costs down.

Under a system where our income depended on the number of consultations we performed, we would change our behaviour to increase their number but decrease their complexity. Repeat prescriptions would no longer be issued by computer every two months with an annual review by the doctor, but might be issued personally by the doctor at a two-monthly consultation with a brief review each time. Similarly smears, immunisations, contraception and other simple review consultations would no longer be handed over to nurses but done by GPs.

To maintain my current income I would have to charge somewhere between £21 and £44 per consultation, but probably towards the lower end of that range. Market forces would apply, for GPs would be in competition with each other and primary medical care services provided by Tescos, Boots, Virgin and many other private sector providers. Our selling points would be a personal service with continuity provided by experienced doctors, for the private sector would probably be using young doctors doing sessions. The fees we could charge would ultimately be determined by what the market would bear. Evening and weekend sessions could be provided (possibly at an increased charge) if it were profitable to do so. Getting an appointment at a time to suit you would also depend on market forces, including how much work the doctors wanted to do. Only one patient can be seen at once, and doctors would adjust their working hours according to how much income they require. A less popular doctor would have empty slots, a popular doctor would be booked up but patients would evidently think it worth the wait.

Matters would be complicated by the Government, who would have to provide some sort of financial support for patients with low income. They would also have to decide whether to subsidise the cost of prescribed drugs, because in a private system the patient would have to pay the full cost of all drugs prescribed. A few of our patients have annual drug bills well in excess of £100,000 which are far beyond their (or indeed my) ability to pay. The Government would probably attach strings to that support, such as a maximum charge for consultations for those patients and limitations on what could be prescribed for them. A two-tier system might develop in which poor patients got brief consultations and cheap drugs, while patients able to pay would get longer consultations and a full range of drugs. Insurance companies might also step in to offer policies to patients to cover their primary medical care costs.

For what it's worth, my opinion is that GPs are too conservative (with a small C), conformist, and committed to their mortgages and private school fees to take the enormous risks of resigning from the NHS. The Government will compromise slightly and get its way. GPs will keep plodding on, adapting themselves as best they may, while those who can afford to will vote with their feet and resign. My own intention to resign next year is not entirely due to dissatisfaction at the way the Government is treating the NHS, but it certainly played a part.


Fiona Marcella said...

As the receptionist in our local out of hours clinic I could have made quite a nice bit of dosh today - two patients offered to pay. Mind you one was from Hong Kong and the other was American.

There are definitely sections of this government (and allied interests such as some nurse managers I have met) who are revelling in their attempt finally to bring the bloody minded independent GPs to heel after the government's failure to do so in 1948. Mind you quite what a LABOUR government is doing using private companies to do it is beyond me.

Anonymous said...

i for one would much prefer 100 % commercial relationship with GPs

this would then incentivise them and their receptionists to actually want to see me, and treat me with basic dignity and courtesy

if the state chooses to subsidise GP access it should just give the patients the money for an appointment, and let the patient take that money to any GP they like

then there will be a little compeition for better opening hours, cleanliness of the site, speed of answering the phone, etc

this is the only way to improve the shit quality of GP care in the UK at the moment

Fiona Marcella said...

Hmmm - anonymous, your GP could certainly go private like the dental services round here.

Our dentist (along with all the established practices in town) has opted out of the NHS.

HIS face is happier and less lined than before. HE is more attentive and his receptionists ring me up to remind me of appointments rather than shouting at me and threatening to throw me off this list if I forget them, so yes, there have been improvements in a way.

But the premises and personnel haven't changed. He's still sterilising his instruments in the kind of steriliser that our GP surgery was told was inadequate for purpose (NOT either a medic or a microbiologist so NO idea whether this was ridiculous hype or evidence based caution but his is still chugging away whereas ours has been consigned to the scrapheap to be replaced by hospital systems and endless form filling).

The main change has been that we now have to stump up £10 a month for the privilege of being on his list before we've had any treatment at all and we are still debating whether we can pay for our adult daughters who are poorer than we are on account of being, in order of age, 1) a benefits claimant whose current diagnosis might suggest that her psychiatrist doesn't like her and 2) a student nurse.

Oh - and the dentist's opening hours have diminished still further and he provides no evening or weekend cover at all.

cogidubnus said...

Sadly if payment was required up-front for consultation (never mind any fee for staying on the list) then this would result in exactly the situation faced by a large number of people with NHS me...

As a family man I'm well over the income limits for benefits (and therefore free dental treatment) but simply cannot afford the money my dentist requires every time both I and the missus attend for fillings/extractions/ my missus stays signed on and I've let mine lapse...

So I sit at work taking two paracetomol and two ibuprofen every four hours when I get toothache...(gawd I can sometimes get cocodemol and that's marvellous stuff)... if I get an abcess I lance it with with a (sterilised) needle...and if it gets too much and I need an extraction, I can generally handle that too...alternatively if it's a really tough molar I can usually live with it until it gets loose enough to pull...

Alas, I am sure this is not what Nye Bevan had in mind...

So much for NHS Dentistry...What are we to do if the GP service follows suit?

Dr Andrew Brown said...

Thanks everyone for your comments.

Cogidubnus: I think you will find that the current generation of GPs will not abandon their patients. One of the strengths of the NHS over the past 50 years has been that GPs are responsible for a defined group of patients, many of whom they know personally. Although we may groan inwardly when Mrs Grump walks through the door, we feel responsible for her and wouldn't want her to suffer. There is a serious danger that the Government will commoditise medicine, and that in future you will have the same relationship with your doctor as you do with the check-out staff at Tesco.