A thread about General Practice.

Here’s a news story with a not uncommon sensationalist headline: https://twitter.com/skynews/status/1344628671865303042

The predictable response is for many to rightly ask, “Why should GPs be paid for doing their job?” and variations of “I could do it for £10”

The headline invites these reactions...the point is to generate sensationalism rather than accurately portray the truth behind the story

@skynews @bbcnews @guardian @Telegraph @thetimes @TheSun @DailyMirror @Daily_Express all do this, all the time.

They fall in the trap laid for them, designed to divide and conquer both the general public and non primary care NHS staff.

#gplife #generalpractice

We need to unpick how General Practice works far better than we do, and the @rcgp @NWERCGP @TheBMA @BMA_GP could help do this better an currently.

Let’s start with an obvious statement, which many think is true.

“GPs are part of the NHS”

Easy right?

#gp #teampgp

Not so easy.

GPs are subcontractors to @NHSEngland (in England, it’s different-ish in Wales, Scotland and NI)

NHSE gives individual practices a set amount of funding to provide primary care services.

https://www.england.nhs.uk/contact-us/privacy-notice/how-we-use-your-information/our-services/primary-care-commissioning/

The amount provide is fixed and based on the number of patients and a complex formula that tries to allocate more money to more deprived areas, acknowledging that these patients are likely to be more complicated
#teamgp #gplife

This leads to our first common misconception, often a trap that MPs including many a health minister @DHSCgovuk misunderstand.

They tell the public to expect certain things from a GP, but these don’t reflect the contract they have agreed to with those practices.

#teampgp

The funding works out at something like £80-150 per patient per year. In return, practices have to offer unlimited doctor and nurse appointments, along with other services as specified in the contract.

@babylonhealth charge £149/year for online GP only https://www.babylonhealth.com/pricing 

But don’t GPs earn loads of money?

Well they do. There’s two parts to this though.

Firstly, why shouldn’t they? The job is hard, and as a society we using pay to reflect that. Compared to other similar countries, uK doctors earn less, so the wage doesn’t seem out of line.

Something that is really important here though is that the reported GP pay sometimes confuses take home pay and business turnover.

As individual partners in a business, the share might look huge, before you factor in building, utility, staff and other costs.

#gppartner #teamgp

I’m not saying that GPs are poor, and far from it. But it’s not as much as you might think, and often less than consultants in a hospital setting. That’s an important comparison, as hospital doctors are often thought to be “better”.

This MUST NOT become a thread pitting GPs and consultants against each other. But they are different and shouldn’t be compared without understanding.

GPs are largely self employed, consultants employed. The latter aren’t responsible for their business, but GPs are.

Every receptionist, practice nurse, health care assistant and so on are employed by the GP, not the NHS. That funding we mentioned before? It has to cover all these costs.

Unlike any other business though, the GP can’t negotiate prices or regulate demand.

GPs have to do all that asked of them, within the contract, but with no ability to claim more money for more work, or any way to regula the demand. Pharmacists have a similar deal with the government. @UK_COP and @rcgp are very aware of the immense burdens this is creating.

Why? As individual businesses, GPs won’t be supported if they make a loss. They will go under, and the owners (known as GP partners) will go bankrupt.

Hospital consultants aren’t quite so involved with how a hospital financing works.

So next time you see a quoted figure about a GP earning over £100k, dig a bit deeper to see what that actually means.

Some do earn more, and they do so by doing lots of additional income generating work, not from providing the simple general practice they are contracted to do.

What counts as additional work? Any not in the GMS (General Medical Services) contract.

https://www.england.nhs.uk/gp/investment/gp-contract/

There is less in here than you might think as a member of the public. Take a look, it might surprise you.

@TheKingsFund explains well: https://www.kingsfund.org.uk/publications/gp-funding-and-contracts-explained

The vaccine that @skynews claim GPs will get £10 per jab for is an example of additional work. GPs can choose to do the extra work, and the contract specifically states that they mustn’t neglect their other duties to do so. It’s additional work is prefaced like this.

So £10 sounds a steal right? It does if you imagine a crisp tenner going in a GPs pocket. It’s not that simple. To earn that £10 requires a nurse/pharmacist/doctor to give the vaccine. They need to be trained in anaphylaxis management. They need to be able to consent the patient.

To start to think about at tenner, consider the work required to consent just one patient with dementia. It requires a family discussion and an assessment of best interests. It then requires two staff to make up and then give the jab as kindly as possible.

This process might take 30 minutes. We then need to add the admin - recording the jabs and consent measures, let’s say 5 minutes each. In a care home of 50 dementia patients, that equates to 25x2 people-hours of clinical work and 3 hours of admin = 53 hours

For £500 remember.

Of course, some care homes will have less dementia patients and it will be an quicker process. Overall, that £10 probably covers the cost of the staff needed to deliver the service, but perhaps not boring things like extra admin staff time, or any unforeseen circumstances.

This particular extra work is known as an “Extended Service” and these come in several flavours, like Direct ES and Local ES.

Individual practices have to do sums like above to figure out if they have the staff and time to do them.

But also, if they want to. If the services takes time, the it’s reasonable to expect profit from that if it’s something you don’t want to do.

In the case of vaccination, it’s good for GPs to do, so most offer their time at cost value, and don’t make a profit.

It’s another example of the weird place General Practice finds itself... a business but one that has to operate as if it weren’t. Businesses earn profit to get through rough times, and in good times they can reap rewards. GPs rarely get the latter, which is why headlines hurt

A big part of this is recognising that “GP” means several things. It’s both individual GPs, who are doctors vs “General Practice” a medical speciality, and general practices (individual businesses that the NHS subcontracts).

#teamgp #gplife #gp #primarycare #nhs

So when @skynews says that GPs will earn £10/jab, what they mean is the individual businesses, not the GPs themselves. And as we’ve now realised, that £10 essentially covers the cost of extra nurse and doctor time to do all the stuff around the giving of the vaccine.

A similar headline might read “Cleaning company paid £15million to provide fifteen million pounds’ worth of cleaning time”.

Granted, it’s not snazzy.

But it’s true, and doesn’t seek to distract and divide people.

I know what I prefer.

#TeamGP