There are many uncertainties about the future of healthcare in the United Kingdom. This is largely because health is inherently political and, unfortunately, appears to be used by politicians to garner votes in forthcoming elections or gain points in opinion polls, without a great deal of thought being given to the consequences and feasibility of promises and plans. One of the major areas of concern is the funding of primary care.
It is estimated that 8.4% of the annual £110 billion NHS budget is spent on primary care, with a good general practice making up most of that. Although the numbers seem vast, in percentage terms that amount of investment is probably not enough, but that is an argument that is being fought on many fronts already.
As a GP partner, I have an inherent interest in how we actually get paid and how that might be contributing to the state of general practice in the UK. Since 2004, the majority of GP practices are paid a fixed rate on the number of patients registered with their practice, with top up payments for deprived areas (being phased out), extra services, and “performance” related pay. Whether a practice has high or low consulting rates they would receive the same amount of income. The same amount is received for a patient who has 20 or 30 home visits a year as for someone who never visits the GP.
There is, effectively, a ceiling on income, no matter what the demand is from patients.
Although there are no concrete, up to date figures, it is estimated that demand—as measured by the number of consultations with GPs—is increasing. Furthermore, the amount of administrative “performance” related paperwork that is needed means that GP partners and their colleagues are doing more work for the same amount, or less in real terms, of income. Those with a fixed salary are paid for what they do, but the partners are not, as they get a profit share.
If this service model (or business model) was transposed onto the law sector, for example, it would be like saying that a law firm would be expected to serve 2000 members of the public, per lawyer, and get a fixed rate of payment from a “law tax.” As a result, people could use the law firm as much as they wanted with no charge, limited only by the availability of their lawyer. Each lawyer would be able to supplement his/her income with bonuses for winning cases, but wouldn’t be able to turn away hopeless clients with no chance of winning. It’s not a perfect analogy, but it illustrates a point.
If demand from patients continues to rise—either through their inability to handle self-limiting minor illnesses, social problems, and difficult life situations, or through pharmaceutical companies increasingly medicalising risk factors—then the current model of general practice will break. But what is the alternative?
Between 1990 and 2004 practices were paid, in part, for the work they did, with a tariff for items of service. Could GPs return to a system of being paid for the work they actually do?
One of the advantages of this system could be greater fairness: those that work harder and see more patients would get paid more. It would put GP partners more in line with hospital consultants who get paid by session. I struggle to think of any other effectively self-employed profession that is paid a flat rate, no matter how much work they do.
However, a simple paid for your work scheme is likely to be very difficult to implement. It is impossible to predict how much a practice may have to do in one month, let alone one year. If a budget is set for a practice, what happens when they reach near the limit or exceed it? Would this mean that they would continue to provide a service at a reduced payment, or with no payment at all, as is the case with NHS dental services?
Or could general practice operate without a budget at all—and simply be paid for everything that it does, for every single interaction that happens to take place? The danger of that could be that practices could subconsciously or even consciously generate work, over investigate, and over-medicalise their patients in order to generate more payments—as many people feel is the case in the United States. It is highly unlikely that budgets would be unlimited for obvious reasons.
A Gordian knot, a rock and a hard place, an impossible problem are some of the phrases that spring to mind. The solution may be curbing patient demand, but this is politically unpalatable and likely to be as difficult as returning a genie into its bottle. The current system seems set to implode, or emigrate en masse to Australia, but the alternatives seem equally fraught with problems. I imagine that any potential solution will need a careful mix of old and new thrown together with a bit of invention and resolve.
Samir Dawlatly is a GP partner at Jiggins Lane Surgery in Birmingham. He combines clinical practice with being a part time house husband and an interest in social media, as well as publishing poems, essays, and blogs. He can be found on Twitter as @sdawlatly.
I have read and understood BMJ policy on declaration of interests and declare the following interests: I am a member of the RCGP online working group on overdiagnosis.