Dosh

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.