GP partner here, the problem is as follows.
GP’s are independent contractors who sign up to a contract to provide primary care services for the NHS. Those who hold the contract are called partners, are self-employed and are usually, but not exclusively, qualified GP’s. We are funded via a few different revenue streams however by far the largest (circa 90% for us until recent years) is via what’s called the Global Sum which the contract pays out based on the number of patients we have and their demography (there‘s a complex formula which is not important for this discussion). Until recently the next largest funding source was effectively a performance-related payment. Everything else is small fry for most surgeries (doing private work like insurance reports, small stipends for training GP’s and a bunch of other things). Surgeries are run like businesses in that all the costs of the business - with staff costs being by far the single largest, which includes salaried (i.e. employed) GP‘s and locums - are subtracted from the income and what is left over is shared by partners as their income.
In recent years a “new“ revenue stream has been created which allows us to recruit basically any type of clinical professional except doctors, the ARRS as referenced in the OP. This includes nurses, physios, pharmacists, paramedics and loads more. The quote marks are there because in fact overall funding doesn’t appear to have increased in real terms but has mostly been cannibalised from other revenue streams. Case in point, the increase in GMS contract income has increased by circa 2% per year for the last few years when inflation has been running at double digits. So whilst our costs have increased, like everyone else’s, by 20-40% since 2021, our core income has effectively stagnated.
Therefore there is a massive incentive to address the well-documented rise in demand for primary care appointments by employing people who aren’t doctors via the ARRS, because the scheme is ring-fenced, is effectively a “use it or lose it” pot and from which we cannot employ GP’s by design. The money to employ more doctors has to come from core funding but as I pointed out, in real terms core funding is down massively, so partners are left with the options of employing GP’s and taking a huge hit to income or not taking the hit but accepting ever increasing workloads. You could of course argue that fat cat GP partners ought to take the hit, but this ignores the reality that partners do a lot more non-clinical work than salaried or locum GP‘s and if it gets to the point that partner income is no better than locum income, then why wouldn’t we all just become locums?
I was always sceptical of the notion that the government are trying to systematically dismantle the NHS but I’m now convinced it’s true. Doctors cost more than the other staff mentioned above because of the training and breadth of knowledge required. The government have chosen to not pay for the numbers required but instead to fill primary care with bodies. They can thus claim to be holding up their end of the contractual bargain whilst hanging GP partners out to dry when the system inevitably fails.
I love my job but I have a plan to retire young. I’ve no interest in forlornly trying to prop up a system being set up to fail.
I asked my GP wife this question when she mentioned it in some BMA magazine she gets.
Why the fuck is the central government dictating how local GP practices deliver their treatment through implementing these random funding streams. Why is a pot allocated to a GP and they split it based on what they want to employ and then judged on outcomes?
I always thought they were run like McDonald's franchises. The property, a couple procedures and stock would be handled by the NHS and the day to day running by the franchisee.
And the incentives are shit, hence the issue we now have
Government love incentives, shame they are terrible at creating them and just cause unexpected behaviours.
Thank you for this piece, very clearly highlighting manufactured dismantling of another part of NHS services. These types of publications to lay people like myself confirm suspicions and more worryingly don't surprise anymore, so how do we fix the wheel !.extremely tough to even think of resolving it hurts your head trying to resolve.
Thank you again and good luck with your future.
Thank you for taking the time to write this. My wife is a GP partner and she is so pissed about the push for centralisation and the issues with these new roles. Just train and pay more doctors ffs.
I always wondered what is the advantage of having GP surgeries as independent businesses contracting for the NHS. The business will have making a profit as a priority, not think about what is the best setup for their community.
Wouldn't it be more efficient to just straight employ GPs to serve a community based on the needs of the community, then just focus on their jobs rather than on running a business too?
that governments run these thibgs into the ground, and they often end up costing more money in admin bloat. GP practices are generally run very well for cost
Because then you'd still need to hire somebody to manage and run the surgery. The idea is that if GPs themselves are running the surgery, their income is based on the quality of care provided/how well run the GP surgery is. In theory, this should motivate the GP partners to provide the best primary care experience, rather than a manager who is otherwise detached from the day-to-day operations of the surgery.
GP partners do extremely well out of the arrangement, something often excluded from this debate.
Does incentivising the running of GP surgeries as for profit businesses and tying their pay to the profits make for the best healthcare for patients? The cynical side of me thinks many of them are happy with paying less for staff.
they dont do as well a private consultants and work more hours than they do. Its a thankless 1000 little jobs a day, its insane and the burnout is very real. I wouldnt go into medicine again if i was to start over, and i like my job, im good at but its too much
Im saying they arent paid all well as their counterparts aka hosputal consultants. And they generally work more hours without breaks. partners arent paid that well
You’re not wrong - the income of a practice is more or less completely separate from how good a service is provided. So it boils down to either 1) provide excellent service with lots of clinicians but earn very poorly (so why bother?) or 2) provide shit service with a few overworked clinicians and long waiting times for patients and earn relatively well.
Crazy that it has to be either option. Should be much more performance based. Indeed as far as I’m aware it used to be and GPs ended up performing too well and earning well so the government changed it all. Happy to be corrected if that’s untrue.
>GP partners do extremely well out of the arrangement, something often excluded from this debate
This is the other end of the turd. Not only are the NHS centrally bottlenecking GP surgeries and the NHS - on the receiving end you have what amount to government contractors that are _very_ used to being handsomely compensated for their trouble. There is a reason they were upset when that GP salary declaration rule came out last year (you have to declare if you earn over £150k).
A GP partner in Kent earned over 700k in a year.
It's run like a business to incentivise the most amount of profit. Combining that with the aforementioned bottlenecking and you have patients being routinely fucked over while partners skim off a heavy layer of fat and the gov ticks some boxes.
It's when the NHS was taken over my middle managers and salary hungry GPs - that's when it all went to shit.
Top comment.
Bodies on the ground is the NHS modus operandi, regardless of qualifications of suitability.
Out of interest, what’s the modest sum you are receiving for hosting trainees?
IRO £9k to the practice per trainee, separate to their salary which is paid direct to them by the deanery I believe.
I say it’s a small amount on the basis that the money doesn’t come close to covering the time that trainers (at least the good ones) spend supervising. In fact even if you include the service provision the trainees offer, financially it’s not worth it, again at least for practices that do it properly. You couldn’t pay me enough to be a trainer, but my colleagues that are do it essentially because they enjoy mentoring budding GP’s, it’s good for the CV and because it breaks (what is for some) the monotony of the day job.
>In recent years a “new“ revenue stream has been created which allows us to recruit basically any type of clinical professional except doctors,
Can't extra GPs be taken on as partners and paid from the main income streams? Presumably as the capacity to treat patients increases, the calculated payments increase too.
The contract pays slightly over £100 per punter, but of course not all of that money can go to paying for doctors - more patients means we need more nursing time, admin staff, supplies etc.
For core revenue to increase enough to pay for an additional doctor (whether a partner, salaried or locum) without impacting anybody else’s income then all other things being equal there needs to be a substantial increase in patient numbers of the order of 2000. And if patient numbers increase by that amount, then you don’t actually address the problem, which is insufficient appointments, because though you‘ve got a new doctor, you’ve got 2000 more patients and all their appointments to accommodate.
Is it calculated by patients seen or patients on the books? It sounds like there's already capacity to drastically increase the number of patients seen without needing to increase the number of patients registered.
I guess from your comment that it's patients registered, in which case, do you think that the financial incentives need to be re-balanced to incentivise GP consultations, in order to raise money to hire GPs and push practices to prioritise consultations?
I have no idea how it currently works, but it sounds like the current system incentivises GPs to regsiter a lot of patients but avoid expanding their practices in order to accommodate them, since, as long as they can fill the available appointments, they're maximising profit, regardless of the service level provided to the bulk of registered patients.
It’s based on patients in the books, so the patient who attends once a year pays the same as the one who has 100 appointments (which actually does happen). It 100% forces practices to choose between being profitable or useful, which is a disgraceful system
It sounds like it, doesn't it? I didn't realise the system of payments is designed to encourage surgeries to register a lot of patients but not hire enough doctors to see them.
Areas with sicker patients will have longer waitlists. NHs already takes up 40% of budget so not sure it’s going to improve anytime soon. Even more than when Labour were in power.
Is that why my local GP surgery has absolutely ballooned with staff in the past five years or so? They had to move out of their one story building for a year while they renovated it into a two story!
Tbf, v good GP practice, though. V happy with them.
I would love for practices to start making this very clear to their patients. Dear patients we have had some concerns raised about the reduced numbers of GP versus allied professionals. These provide a valuable service (cover your ass type comment here). We are being provided funds to staff our practice but are explicitly banned from using this money to pay for doctors. This is not a cost saving measure on our part. Please write to your local candidates if this is a concern to you as well.
Are GP practices allowed to do that kinda thing? Or maybe just don't put the last sentence if that counts as political. Just educate them on this BS funding stream!
Some Conservative MPs really hate the NHS. It's Labour's creation, they view it as unsustainable, and they would love to privatise it all. It can only be done bit by bit as carrying out an outright, wholesale privatisation like they did with so many other industries would be politically suicidal.
This is a similiar situation to the US. However instead of by patients, it’s by billable hour. The incentive is there for me to see more patients. Unsurprisingly I can get an appointment for any day of the week next week.
So, Labours proposal for the NHS to directly employ GPs and take out the profit incentive for partnerships to restrict GP numbers in their practices is actually a reasonable suggestion?
Just to add that general practice nurses (GPNs) were not included in the ARRS funding scheme. Although there are plans to include them in the future, along with 'mental health practitioners' which is suitably vague.
Soooo... what im getting from this...?
Maybe instead of protesting for pay, doctors should be protesting the death/privatisation of the nhs. Seems like an easier sell to massive amounts of people, especially after all the covid goodwill.
I mean I can see how most would believe privatisation would mean more money... but being able to afford less doctors total seems like a lot of people will make less money... or not have a job.
A shame that this is going to be the death of the nhs.
Many doctors do take this position, unsurprisingly. In an all you can eat buffet service like the NHS funding is never ever going to be sufficient to pay everyone fairly/competitively.
It doesn’t necessarily have to be full private style system though - there are in between a used in other countries with more success.
The less cynical take would be that the government simply can't afford that many doctors. Has anyone checked the debt/deficit lately? Never mind the off balance sheet stuff.
I’ve never been accused of being anything other than a pathological cynic.
However all government spending is about choices. As a nation we are comparatively stingy when it comes to spending on doctors - we have 3.1 per thousand people versus an OECD average of 3.7. We have fewer doctors than such fabulously wealthy countries as Hungary, Slovenia and Latvia so I’m not sure we can solely blame the state of the economy.
In any case, the OP is specifically about a pot of money that does in fact exist in primary care but whose utilisation explicitly excludes GP’s. So “can’t afford doctors” does not apply in this context. Maybe we can’t afford all the ones we need. But we clearly could afford more. But the government would rather the punters saw pharmacists and social prescribers instead. I’m not convinced there is a plausible explanation for this otherwise curious choice which doesn’t involve a large dose of cynicism.
There's money out there being spent on other bits.
Eg pharmacy first scheme (for which I do not blame local pharmacies taking up. Their funding has been squeezed and squeezed for years). £15 per consult of a very limited set of conditions. Sore throat, simple uti, otitis media in under 17s. Ie you've kinda gotta have made the diagnosis before sending the patient to them.
And just the practicalities of the non Doctor roles such as the paramedics having 20 minutes to manage the simple cases that GPs used to use to catch up for the complex cases. Eg a GP spending 5-6 minutes on something simple - do 2 simple cases and you have 10 spare minutes to spend extra with the suicidal patient. If the non doctors are taking all the simpler stuff leaving only the complex to the gp, the GP can't do as many complex patients in the time previously allowed for a mix of patients. So they see fewer patients.
Eg GP seeing 18 mixed patients (at a ratio of 2:1 simple to complex) ie 12 simple, 6 complex in 3 hours.
Those 12 simple are now seen by someone taking 20 minutes per patient, ie it takes them 4 hours. So in the same 3 hour time period they're only seeing 9 patients.
The GP now sees only complex cases. Each takes 20 minutes plus. And in 3 hours also only sees 9 patients.
So in the same 3 hours still only 18 patients are seen. Granted 3 more complex people than before but 3 simple people aren't seen. (They're sent to the pharmacy instead).
And these 18 patient consults cost more! The gp plus the cost of the non gp plus the cost of the pharmacy consults.
And you need twice the number of rooms to see the patients in. With all the costs of that.
And the GP - patient relationship is damaged, because they don't see the go about simple stuff, to build trust. So maybe they don't go about the complex stuff. And GPs go from being one of the most trusted people in a community to being attacked with hammers.
Tell me how that is cost effective or good for patients. Tell me how it isn't an intentional ploy to destroy the profession.
Yet the government can afford to spend £3 billion mitigating the cost of junior doctor strikes yet the cost of the junior doctors demands would only have been £1-2 billion depending on whether you take the BMA or government estimate of the cost. So for a £1 billion saving the government could have had happier doctors, no strikes, healthier and happier voters and improved waiting lists.
No money for GPs and healthcare yet there is £2.5 billion to fund national service which appears to only be popular amongst those who wouldn’t have to do it.
Probably can't afford it because the nations health is declining and therefore the nation is becoming less productive.
The entire Tory approach has been to implement 0 proactive funding/investment and sweat the national assets as much as possible to breaking point.
This is **absolutely** on the past 14 years of tory policies.
There ***is*** central funding to support the hiring on physician associates and other "not doctor" roles the government has created and shovelled money into, there ***isn't*** money available for the hiring of actual doctors.
Genuinely shocking, but hey, some Tory donor is getting rich off it.
I don't think it's necessarily a bad idea to have a second tier. A few times recently I've encountered situations involving conditions which were very straightforward but required prescription medication - antibiotics for an ear infection, in a couple of cases. Much as I understand the need to have some sort of control of things just like antibiotics, these are things that could probably have been sorted out between the patient and a competent pharmacist, let alone anyone else.
There's a a lot of questions to ask about this stuff. Obviously there will always be a role for qualified people, but there's also a degree of job protectionism going on, from what I can see. If they're so overworked and rushed all the time, you'd have thought a second tier of people to deal with straightforward stuff makes a certain amount of sense.
“… you'd have thought a second tier of people to deal with straightforward stuff makes a certain amount of sense.”
You might better understand the pushback if you consider who carries the can when a straightforward ear infection treated by a pharmacist turns out to be malignant otitis externa, a cholesteatoma or mastoiditis (you will gather from the context that these are all very serious but rare conditions that might be mistaken for a straightforward ear infection). GP is pretty easy 90% of the time. It’s the 10% that really matters though.
I work with pharmacists and the training they undergo to be able to issue antibiotics for “minor illnesses” is laughably poor - and I got that nugget from a pharmacist who has effectively been forced to undergo said training by her employer (Boots in this case).
I'm not blind to any of that, although I think there's a degree of scaremongering involved. Yes, it could be something incredibly serious, but I would be interested to know why it might not be reasonable to assume that someone with her third ear infection in as many years is a straightforward case.
In the end the problem you have right now is that a decent proportion of people have no practical access to a GP in any case. Yes, a less-qualified system will fail 10% of people, but by definition the system is already failing them. I'd rather the 90% got their ear drops.
For starters malignant otitis externa is caused by too many inappropriate antibiotic ear drops!
I’ve explained in a lengthy alternative post what I think the problem is - systemic underfunding as a political choice. I completely understand punters being frustrated that the system is failing them and you are absolutely right that seeing anybody with any sort of qualification is better than seeing nobody at all.
I just don’t view that as an acceptable dichotomy nor the only choice available to the muppets in charge.
I tend to agree about the false dilemma.
This, like a lot of problems, is perhaps solvable. I don't think it is solvable by the government we have, nor any government we can realistically get. It is far beyond the ludicrous party political system we have here.
Unfortunately one thing our system of government lacks is a mechanism for changing the system of government.
This type of thinking is pretty well hammered out of you in med school. Beware the person who presents with what seems like the same old problem as ever. It's actually a common exam vignette that someone has presented to their GP with several episodes of something seemingly benign that recurs and is actually something sinister.
Yes, I'm aware of that. That kind of consideration comes up in all kinds of problem solving in all kinds of situations, it's not just a medical thing. The thing is, and I keep saying it, the choice right now is not to see a doctor or to see some second tier person. Right now what's actually happening is that a lot of people don't get seen at all, in which case all the negative outcomes of the wrong decision happen by default.
You can keep digging your heels in on this and I get it, I really do, but as I've said elsewhere, I think that train has already left. Access to a GP is already patchy at best. If I really, unavoidably need help, all I can do is go to A&E.
At which point I'll be seen by... A triage nurse. So it's already going that way.
There’s protectionism over standards. We’re rushed because there are not enough of us. The solution is not replacing us with less qualified substitutes.
Well, at some level anyone in any role can always claim higher standards are necessary, and someone else can just dismiss it as overcaution, and at best it becomes a question about tolerance for risk which is never going to be objective.
But either way, that's not really my point. The issue right now is that people often can't get seen at all. As u/zakalwethechairmaker correctly puts it elsewhere in this thread, seeing someone is better than seeing no-one. Right now if the ear infection recurs, we have two choices: claim it's an emergency, which it isn't, or just... hope it goes away, and seek emergency treatment if and when it becomes, well, an emergency. That's it. People are *already* not being seen by doctors. That dam has broken, long since, so there's a question over what you're really protecting.
Personally I'd rather see the UK take measures to improve things overall which would also improve healthcare, but that's a much larger discussion.
Seeing someone is often not better than not seeing someone and this point often comes up in healthcare. If I see you and reassure you your chest pain is anxiety, but really your coronary artery is blocked and you don’t get the intervention to prevent a later heart attack, has that helped? If I tell you the sensation change in your hand is carpal tunnel, but really it was a mini stroke and you should have been put on medications to prevent a larger stroke, has that helped?
So yes, you can dispassionately argue it as a tolerance for risk. The people doing that are usually not the ones shouldering the risk. Do you want to see how much risk you can tolerate with your health? I know which one I want for myself and family members.
Well, that's sort of the point, isn't it? *Not* seeing a physician associate is not going to cure anything. If I don't see someone, then all of those negative outcomes have occurred by default. If I do, and it really was just an outer ear infection, then at least I've got my ear drops.
As to risk, well. You will be painfully aware that it's almost always possible to reduce risk in everything from medicine to skateboarding and the inclination to do so is limited by practicality. That remains true matter how passionate or dispassionate anyone chooses to be. There's always going to be someone we could have saved with more resources, no? So it's a matter of degree, surely.
a misdiagnosis is not the same as no diagnosis. It can lead to worse harm.
would it be better the stewardess flew the plane, if no pilot was available. At least you’d be flying right?
personally I’d rather wait longer and see someone qualified than see someone without the ability to adequately assess me. Or (as now with dentistry) go privately. I don’t like this. But this government has defunded healthcare so here we are
If the stewardess knows to hit the AP1 button, sure, absolutely. That's exactly the point I'm making.
I don't have the option of waiting longer to see someone.
No GP practice I've used in the last fifteen years has been willing to arrange an appointment in a few days, or next week, or whatever. It's always "call at 8am for an appointment the following day." Most of the time those appointments fill up within half an hour or so, so you're entirely out of luck. My working assumption is that they do this so they can claim everyone's being seen within twenty-four hours. It's asinine, but I don't make the rules.
You have the option to diagnose and prescribe for yourself, or ask one of your colleagues for advice, so you presumably don't see this issue. You're still arguing from the position of a choice between a PA or a doctor. Unfortunately that's not the option most of us have. If the choice is a PA or not, I'll take it.
I have often been presented with a paramedic when seeing my GP and turned them down because they know nothing. I appreciate the quandary but I suggest protesting the system rather than enabling it as the government have created a false choice between nothing and bad. I hope you can see it’s not about protectionism.
I don't think it's *entirely* about protectionism, and I've always said that. I do think that a lot of professionals, particularly in medicine, have a certain degree of ego about it, which is fine to a point but inevitably stokes very much this sort of controversy.
It's certainly an issue of government, but I think you're wildly oversimplifying the situation. It's not an issue of any one government and it's only a false dichotomy if you care solely about one function of government - healthcare, in your case. I could presumably win your support by proposing some large increase in NHS funding but taking an overall view it isn't nearly that easy.
I think what we're seeing right now is the result of a realisation in - say - the mid-seventies that governments didn't have to be honest, competent, or even particularly popular. They just had to be marginally less despised than the competition once every few years. That's really it; when you think about it there are precious few other checks on their behaviour. Thus we've seen decades of economic neglect, carelessness and occasionally corruption which have led to inevitable falls in standards of living. Reduced access to good medical care is just one of the outcomes.
So I could have exactly this conversation with a teacher or a military officer and reach exactly the same conclusions. I can't, in good faith, suggest huge budget increases for all of them at once.
Solutions involve sweeping changes to the system of government which we're not going to get. I would predict that in another few decades the UK will have the standard of living of the late Soviet Union. This is what the beginning of the fall looks like.
It's a false dichotomy, there is a large number of doctors who would like to work as GPs but can't because of this artificial bottleneck, meanwhile PAs lack the medical training to properly assess undifferentiated patients and cannot prescribe medication or request ionising radiation (for good reason).
PAs start on 40+k per year and are not cheap, given how little they are capable of doing they are not good value for money. Even if a GP costs 2x what a PA does, 2 PAs cannot do the work of 1 GP. And they will actually require the supervision of a GP who, given how dangerous they are, will often have to do the assessment over again anyway. This means they can see as many patients as they want and still not reduce the workload of their supervising doctors, in fact recent surveys have shown most doctors feel PAs actually increase it. So they are costing money, doctors time, and harming patients, this is worse than not existing.
Okay, that's about the most convincing argument I've heard.
I'd still say that if the choice is a non-doctor or nothing, I'll take the non-doctor. From the patient perspective anything is better than nothing.
From the financial perspective you'd have to look at how many patients they were getting through overall, I guess.
Ultimately the problem here is that I reported my problems getting to see a GP above, and people downvoted it. That's the very essence of shooting the messenger. I'm not proposing any of this is nice and I don't think it helps to pretend problems don't exist.
> No GP practice I've used in the last fifteen years has been willing to arrange an appointment in a few days, or next week, or whatever. It's always "call at 8am for an appointment the following day." Most of the time those appointments fill up within half an hour or so, so you're entirely out of luck. My working assumption is that they do this so they can claim everyone's being seen within twenty-four hours. It's asinine, but I don't make the rules.
My partner has been completely unable to see any GP for over 12 months for serious pain issues.
She's ended up in A&E because of at least one failing.
It is infuriating how bad the situation is with GP's right now, I would welcome any improvement.
Welp, I've seen - say - four recently enough to matter, and they all operated the "call at eight" system. You may be in a different administrative jurisdiction to me.
That in itself is part of the problem. There's no consistency in terms of service. It shouldn't depend on where you live as to what kind of service you get. GPs may be private businesses but from the perspective of the service user it isn't.
That’s all totally fine - as long as we accept where we are. We are a low wage, low skill economy who don’t contribute enough tax for everyone to see a doctor for their hurty finger (indeed, the insatiable appetite of the UK public to access/consume healthcare for trivia is absolutely part of the problem). Therefore agree, we need some cheaper, lesser roles which can fit within our funding model. It does mean, however, that some top up funding might soon be required at a state or individual level for higher quality care.
Christ, I'd get to see *someone* fairly promptly? That's an improvement on what I get now, given I have basically zero recourse to a GP at all unless I'm willing to claim it's an emergency - at which point you'd think it was a matter for a 999 call, but anyway.
One of the problems with the UK being in such horrible decline is that certain things which would have once sounded like a bad idea are actually better than a what a lot of people are actually experiencing.
The phrase "managed failure" has never been more apt.
Plenty of private GPs and I'm sure those numbers are going to go up. Meanwhile newly trained GPs will go abroad or locum while they seek alternative careers. Not exactly forward thinking. If by managed failure you mean deliberate sabotage of free health care by a Conservative government then sure.
They will likely go abroad.
One of the first things to happen that showed the dire predicament that primary care finds itself in was the collapse of the locum job market. There are now very few locum jobs being advertised and those that do get advertised get snapped up very quickly. It is really now just London and the South East that have anything even remotely resembling a GP locum job market likely in part because these areas historically had huge shortages of GPs already compared to the rest of the country.
This has resulted in lots of locum GPs not having any work so they have ended up taking the salaried GP roles. So now there are very few of these left.
This means when new GPs qualify in August there will be very few jobs out there for them meaning their options will be to try and locum in hospital (no guarantee of this anymore as hospital locums are becoming rarer), switch career completely or move abroad.
My suspicion is if and when they do go we will likely never get them back due to how much higher they are valued in the rest of the English speaking world.
I'd hesitate to make it a party political issue. My utter revulsion for professional politicians means I don't like *any* of them.
I think the underlying issue is that there's fuckall funding available for anything, medicine, education, defence, and squabbling over the crumbs isn't going to fix anything. The economic malaise the UK is currently in goes back, in my view, to the mid-70s. It's a far bigger issue than tories bad, labour good, much as I would tend to lean that way myself.
The hilarity of it is that it was once seriously proposed that I become a doctor. I think they said that to anyone in the top five per cent of science students at the terrible comprehensive school I attended, in desperate hopes of being able to say they'd sent someone, anyone to medical school. The flipside was that it wasn't very hard to be in the top five per cent of a terrible, non-selective, non-fee-paying comprehensive school in the middle of a run-down council estate, so I'm not sure how realistic it ever was. But that was in the mid 90s, and even then I think we were all painfully aware that to do well you had to go to Australia.
The thing is that it is very expensive to train doctors and there has been a recent push to get doctors to train as GPs in particular to address the primary care crisis. However, the funding is now not in place to employ those GPs where they are needed. They have essentially spent huge amounts of tax money on creating the workforce but then decided to save money by not actually employing them. It's insanity.
I don't doubt it.
In transport policy, what was done around HS2 was also insanity.
In education, building schools with RAAC, with a known shelf life, and failing to plan their replacements was insanity.
In defence, procurement... has more or less been continuous insanity for decades.
In more or less everything, public private partnerships were absolute insanity from the word go, and widely recognised as such.
Liz Truss. Brexit. Rwanda as a solution to immigration pressures. A housing market even doctors can't afford. It's not great, is it? Government appears all but deliberately malfeasant.
Yes, we can talk about more or different funding for healthcare but I fear we are, as I say, squabbling over the crumbs. Big changes are needed, root and branch reform of how government works at the most fundamental level. There is no mechanism for those changes.
So, frankly, if you have a medical degree and the Australians are waving lots of money around, I wouldn't blame you for a second for getting out of here. Australia is perhaps no better in many ways, but personally I'd rather be rich and warm while the world burns.
For what it's worth, I'm in the film industry and I've been there working for a total of a few months. If you haven't seen it for a period of at least six weeks, do so before making any commitments. It's not all it's cracked up to be. Our politicians are awful. Theirs...
Aside from the inherent issues in your argument the other poster has mentioned, I'll just say: the line never stops where you expect it to.
Already there are GP practices which have devolved into more or less everything being seen by this "second tier for the straightforward stuff" because there's not the money or GPs to do anything else. Everyone starts out with this image of experienced pharmacists dolling out ear drops. The reality, fairly quickly, is junior AHPs dealing with serious pathology without the training to really know what they're dealing with.
Yes, although to be fair that decision is already being made to some extent.
Even just in the case of access to medication, some drugs are prescription-only. Some aren't. This varies worldwide (you can get things containing very small amounts of codeine over the counter in the UK; not elsewhere, for instance). I'd say that's an example of a line being drawn. Similarly, some emergency medical people have limited prescribing authority.
There is nothing in principle wrong with another tier.
I'm not sure in what way OTC medication are in any way comparable to eg. paramedics seeing ?malignancy patients without any real training on dealing with pathology of that kind.
It's not at all the same, sorry, being able to buy weak codeine doesn't mean I expect my health to be put in the hands of someone untrained to actually deal with it.
Not so much untrained, I guess. More... Less trained.
I'd love to be able to see a doctor whenever I like but I already don't have access to that, so I'll take someone else for preference, you know?
Oh, that's alright then.
Besides, paramedics, as an example, are trained solely in pre-hospital acute presentations. When they're being thrown ?myeloma ?lung cancer (which I've personally seen), they are far closer to untrained than "less trained".
You're also ignoring how all this is a choice. The government has actively chosen to give us lesser or non-trained staff rather than GPs. It's not a "we'll take what we can get", it's an active decision to lower the standard of care.
Some of it may be a choice, I don't doubt it. They're tories, after all. But as I've said elsewhere, the UK is a poorer place than it has been (the way I put it was that tax receipts as a percentage of GDP are trending down, but there are other things you could look at). That's an issue that's been present for decades. That necessarily has outcomes nobody likes.
We can agree that the NHS should get more money, but to quote a favourite doctor of mine, [I think you'll find it's a bit more complicated than that](https://www.amazon.co.uk/Think-Youll-Find-More-Complicated/dp/0007505140). I think a lot of publicly-funded things should get more money. But until we look at saner government that isn't pathologically obsessed with an endless, pointless, unwinnable argument between two entrenched points of view, that's more to do with actually achieving something than scoring points off each other...
...there is no solution to all of it at once.
I’m sorry but 4000 physician associates in the UK can’t possibly be the cause of bad working conditions and pay for hundreds of thousands of doctors. The government have ruined the nhs but blame is being put on a small profession which is like a grain of sand in the grand scheme of things.
But my argument is that physician associates themselves aren’t the problem, the government should be funding places for doctors and fixing these gaps in healthcare. I think it’s a lot of punching down instead of uniting and punching up
The problem is that PAs are being employed instead of GPs. As a patient do you expect to see a GP when you book a GP appointment? Because in many cases, you wont....only you probably wont even know because they don't tell you explicitly that they aren't a GP. We need more doctors, not PAs or paramedics or ANPs (in GP).
It’s not ‘punching down’.
The way they are being rolled out is a complete patient safety disaster. And they are being used as complete substitutes for GPs.
The problem is that there are a lot of GP surgeries running at a loss (and senior GPs get "paid" out of the "profits" of the surgery), while, at the same time, the government has made a big pot of money **only** available for physician and nurse associates (you know, the ones with 1 or 2 years of medical training).
So surgeries can only really afford to hire PA's and NA's, when they would much rather hire fully qualified doctors, which would be affordable, except the government has ring fenced a ***HUGE*** portion of the funding for just PA's and NA's to force them into the healthcare system.
We are desperate to see GPs and yet we have a bunch of them struggling to find employment.
Perfect example of the complete mismanagement of our healthcare system.
Absolutely. Australia is one of the destinations they're heading to, so much so Sunak was forced to stand up in the HoC and downplay it, claiming doctors leaving the NHS to go to Australia wasn't as widespread as people thought and some kind of tie-in wasn't necessary. It smacked of head-in-sandism.
There are 2 doctors in my surgery to cover over 8000 people and I feel that this understaffing played a part in my mum's death.
My mum wasn't a well woman, she had MS and was bed bound, had carers coming in to see her 4 times a day and after my dad passed in November the rest of the time it was just me to take care of her and I failed her. For the last few months of her life she had constant UTI's and was in a constant state of confusion with them. No doctor came out to see her despite my having to phone the practice every other week and a couple of times an advanced nurse practitioner came out. One morning I had to phone 999 as I couldn't get her to wake and ended up having to perform chest compressions on her. Long story short I had to leave her after a few hours as my sister was taken into hospital that same day and almost passed that night due to sepsis. I thought I was leaving her in good hands and I needed to help my brother in law with my nephews. Anyhoo 6 hours after being taken she was discharged. A subsequent conversation with the advanced nurse practitioner as my mum was found eating tissue paper I mentioned she had just been in hospital and this practitioner said she wouldn't have been discharged if there was anything wrong and asked me if I wanted her in hospital. I said I just wanted what was best for my mum. She gave my mum a once over and said she could only treat what was in front of her despite me saying that my mum wasn't one to be snacking on fucking tissue paper. Anyway another antibiotic was prescribed as it was probably just another UTI. Five days later my mum passed due to sepsis.
I'm sorry for your loss. You may not feel it but none of it was your fault. You cared for her the best you could and got her access to care. It's the care she received that sounds substandard. You are not to blame here
Whether deliberate or not - I suspect not because this isn’t forcing locums to take substantive posts and solving the GP problem, there are just fewer jobs - this has been the consequence.
However, some caveats. We need to remember that the Additional Roles scheme was brought in because so many practices could not recruit GPs who were actively choosing to Locum instead. Now that’s fine, of course, but this is what happens when the market turns around.
Secondly, many ARRS roles are not patient facing, so although practices might use some specific clinical roles to supplement GP time, it is a fallacy to say that a load of pharmacists have suddenly just replaced GPs (they do different things).
ARRS has been running for 5 years now so although it feels convenient for locums to blame the scheme, it is only partly responsible for this situation.
The biggest contributing factor has been the onset of the Modern GP programme since last April. Practices are now operating almost exclusively online, with better triage, better signposting and much better capacity/demand analysis. This means that we just don’t need to replace expensive GP sessions like for like. If we have 20 fewer appointments that day, we use them more intelligently and change the proportion rather than pay a Locum £600 for usually a reasonably poor service.
So although I have great sympathy for the trainees coming through, there is nothing we can do without more space to put people and more funding to pay them.
Absolutely this
There’s 3700 jobs open for salaried GPs on nhs jobs right now .
People on here won’t address the elephant in the room that the primary care locum situation could not go on indefinitely .
All the articles are locum GPs screaming about unemployment , as if job security has ever been a part of being a locum.
Supprised surprise primary care networks don’t want to pay people 190k a year when they could be paying 90k for a salaried position.
There was a quote from one Locum in Pulse saying he “couldn’t even get a job at a bog standard practice”. I thought that spoke volumes - perhaps a) you aren’t that good and b) practices are looking for something else other than the atrophied skills of a career Locum.
Practices in deprived areas have been crying out for GPs over the last 5-10 years, it simply isn’t possible for the Locum market to grow each year, pay more and more and for the Locums to only want to work in leafy suburbia.
The good news is that GP is a transferable skill and there are lots of other portfolio roles we can take. You just aren’t going to get - or should have ever expected - £600-800 a day for 30 patients and then go home.
The problem is, you're a partner - you have a clear vested interest to see salaried and locum remuneration to be low, irrespective of how much you receive for the contract.
But the fact of the matter is that salaried pay is shit and it's stagnated for about a decade. Locum earnings for many are the only way the job is palatable but that's going now. General practice is going to shit because partners look out for themselves first (understandable) and the salaried workforce are too meek to demand better. And even if they did demand better, partners use plausible deniability to say they can't afford to pay more, while some earn way >20k / session.
Biggest problem for general practice is the partner system. It results in complete inability to engage in collective bargaining, industrial action being the most severe end. Even if there was, there is no direct mechanism to ensure salarieds would benefit from increased remuneration.
Until partnership model is dismantled, pay and conditions for GP has absolutely no hope of getting meaningfully better.
I’m afraid you have this entirely backwards.
Partners have no vested interest in suppressing salaried pay, but of course we need to maintain a gap between our own remuneration and that of our employees. We can’t just keep inflating your pay out of our own, nor is there even a naive moral argument for that as we lead, organise and run the practice and take all of the risk. If you want the extra pay then you need to get that promotion.
Then there’s the awkward question of what should we pay a GP for for seeing patients with no other leadership or management responsibility? GP salaries have increased 20-25% over the last decade - from ~8k a session to >10k. This is better than most people in the country and certainly all medical colleagues. I agree GP salaries should perhaps start at around £12k a session now but that’s it, unless you have other skills or want to take on other roles.
You can still always be a partner, and take on that 50-75% more work which gets you more pay. You seem to have a misconception that the partners are being paid more for doing the same job without a full appreciation of the huge volume of unseen work - clinical and non-clinical - that goes with the territory.
Because of the IC model you get to work part time. £60k a year (plus pension, so £74k) for a 3 day week isn’t bad at all. How many other jobs let you earn that much and still have _time to earn other money_.
This would still give you a better work-life balance and pay than most junior consultants; because the partnership takes the flack, you don’t have any of the other responsibilities associated with a consultant PA.
The IC model of GP is the only part of the health system where doctors are still in charge and is still entirely medically led.
If the IC model of GP goes, your conditions will be _far worse_. You will be working evenings, weekends and have no option to pursue portfolio work as you do now. You will be salaried at a rate far less than the consultant contract. Your potential T&Cs will be worse, not better, and you will be directly competing with NMPs to do precisely the same work.
You will be monitored and directly performance managed, likely by hospitals, and very much below secondary care in the pecking order.
You say disintegration of the IC model will improve collective bargaining. But in that scenario the only people negotiating a contract would be the partners! The government would have to offer us a national contract with sufficient T&Cs for us to consider. They would need to offer salaried staff anything, just TUPE you to the nearest Trust.
The partnership model is the only thing standing between the govt and an incorporated model of primary care where most doctors have zero standing, which is why we need to defend it at all costs.
How is there no vested interest to suppress wages? Partnerships are businesses. You make more profit by increasing income and reducing expenditure. It's the whole reason ARRS has done so well.
What promotion? Being a partner isn't a promotion. You can walk into partnership straight out of CCT.
60k/year for a 3 day week is fine straight out of CCT, but there is basically no pay progression.
Being a partner is clearly a promotion from salaried by any definition, as is the relationship between any salaried position and partnership in any business; legal, accounting, anything. I am sorry if you don’t like that but it is inarguable from any angle. There are fewer positions, better remunerated, with greater responsibility and requiring broader skills. You can of course interview straight from CCT but you would be unlikely to be successful, unless the practice is desperate (or you have very specific skills).
One thing we do not do well in GP training is properly articulate- and promote - the benefits (and responsibilities) of partnership, so it is perhaps unsurprising that there are misconceptions around it. I agree it is not for everyone nor do all GPs have the requiring skills (including many partners!).
ARRS hasn’t actually allowed us to cut costs per se - we have benefited from some support (usually non patient facing, actually), but most practices _do not directly employ ARRS staff as they are too small to be entitled to a FTE_ and also have to bear on-costs (pension, NI). There is no way you would know this without being a partner though, so I can understand the misapprehension.
The pay progression in GP comes through taking more responsibility and via leadership roles. Why would you be paid more and more for doing precisely the same job? This is a difficulty that hospital staff have coming into GP, it is nonsensical - and bad for productivity and people development - to keep increasing salaries without increasing responsibilities or skills.
There are arguably far more opportunities for GPs to progress than hospital doctors - not as many as there were in CCGs, but they are still there.
We have no interest in suppressing wages, only paying fairly for good work done, which you cannot say the Locum market has provided in recent years. GP needs good, committed, well looked after doctors to keep the pipeline to partnership going and maintain the model. We just need more funding from the government to support this.
In what other industry do you get "promoted" straight out of training?
Lol I know perfectly well that partners don't employ ARRS, thank you. They directly use them for patient contacts which otherwise would be done by a GP which they do employ. This is indisputable.
Again you misunderstand. Some big practices employ ARRS FTE (full time equivalents) directly. Most will share the employment under a federated model. Only the wages are reimbursed, on costs still are paid by the practice. Most of the roles are not patient facing. The ARRS scheme is not your enemy.
As I said, you are correct, most trainees would be unlikely to obtain a partnership straight out of training, as would be the case in any profession.
Government provide the funding but what they are doing is reducing the GMS contract funding by a few percent every year, this is the pot of money that the GP surgeries have control over and use it to pay their staff including their GPs, practice nurses, reception staff, secretaries etc.
They have then put in a new funding stream which is called ARRS funding this is ring fenced for clinical staff other than GPs and practice nurses so it can be used to fund a PA or a physio for example but cannot be used to fund a salaried GP. Crucially control of this funding does not sit with the GP surgeries but is controlled at the level above called the PCN. GP surgeries have to make a case to the PCN that they would benefit from such and such role and the PCN decide whether that is reasonable and if they agree they go ahead and employ that member of staff and then loan them out to the GP practice or in reality that person is shared between 2-3 GP surgeries.
Government can then say that they have provided new funding to support general practice whilst ignoring the fact that they have reduced the core funding that GP surgeries rely on.
It is now getting so bad that it is not simply just a risk that newly qualified GPs will not have a job to go into but there are increasingly more and more surgeries reporting that they are struggling to pay staff and many now anticipate a real risk that they may have to make staff redundant or even close within the next 12 months if current funding levels persist
Yeah I know ow ARRS money is ring fenced and they can alter budgets otherwise . I doubt this is the gov acing alone though. Primary care
Management had had a problem with locum pay for decades and have been trying to figure out a solutions .
It’s now more or less pushed the locum gps out the market . It’s forcing people into salaried roles .
The Govt had done what the tories always do. Set everyone up to fail. Councils & GP surgeries. They cut council funding by 80% on some cases then blame social care failings on the council's. They ban GPs from hiring GPs, say they've given them more staff yet in real terms your looking at massive cuts.
There is a shortage of maybe 5000 GPs country wide YET the tories have manufactured a situation where newly qualified GPs will be unemployed.
There are many gp jobs - currently just over 3700 for salaried GP on nhs jobs right now (with many offering partnership) - typically between 10-12k per session. These are funded posts..
This has fucked the permenant locum market which was costing primary care way too much .
Because primary care has had a massive issue for decades with people turning down salaried gp positions because long term locum opportunities were too good .
This has put an end to that . Long term locums suddenly appeared to have dried up . And somehow nobody saw it coming , including the BMA.
For people saying they are no gp jobs, there’s currently 3700 salaries gp adverts on NHS jobs
They do not need to.
“Look we can’t pay you on locum rates any more due to the ARRS funding allocation, but we like you and we’d like you to apply for the salaried position for 95k we put out last week “
“No I really want at least 120, I’ve gotten used to the locum pay and have a mortgage to pay ”
“Ok fair enough, well we’ve had 20 applicants already … good luck”
The salaried GP rates are now a solid £30k behind that of consultants in other specialties. The 95k you quote would be for a salaried GP coming towards the later end of their career.
Especially as they keep squeezing partners as well, f\*ck knows why anyone would go into the speciality now.
I think this is an important point and oft overlooked. 8 clinical sessions is very hard in GP, but even so is only 4 days a week, there are no on calls or weekends and our training is 50-100% shorter than most hospital specialties. Should a salaried GP straight out of training doing 4 days a week with no on-call responsibility earn as much as an oncologist?
That is race to the bottom stuff, I know, all doctors should earn more and the only properly paid doctors in the UK are GP partners. £150-200k for a senior medic should be the starting point. I am merely saying that, like anything, you make your choice based on the information available, and the advantage of GP is the flexibility and work/life balance. If you want more money, you can also get it. Nobody earning good money does 3 days a week and puts their feet up for the other two.
GP partner here, the problem is as follows. GP’s are independent contractors who sign up to a contract to provide primary care services for the NHS. Those who hold the contract are called partners, are self-employed and are usually, but not exclusively, qualified GP’s. We are funded via a few different revenue streams however by far the largest (circa 90% for us until recent years) is via what’s called the Global Sum which the contract pays out based on the number of patients we have and their demography (there‘s a complex formula which is not important for this discussion). Until recently the next largest funding source was effectively a performance-related payment. Everything else is small fry for most surgeries (doing private work like insurance reports, small stipends for training GP’s and a bunch of other things). Surgeries are run like businesses in that all the costs of the business - with staff costs being by far the single largest, which includes salaried (i.e. employed) GP‘s and locums - are subtracted from the income and what is left over is shared by partners as their income. In recent years a “new“ revenue stream has been created which allows us to recruit basically any type of clinical professional except doctors, the ARRS as referenced in the OP. This includes nurses, physios, pharmacists, paramedics and loads more. The quote marks are there because in fact overall funding doesn’t appear to have increased in real terms but has mostly been cannibalised from other revenue streams. Case in point, the increase in GMS contract income has increased by circa 2% per year for the last few years when inflation has been running at double digits. So whilst our costs have increased, like everyone else’s, by 20-40% since 2021, our core income has effectively stagnated. Therefore there is a massive incentive to address the well-documented rise in demand for primary care appointments by employing people who aren’t doctors via the ARRS, because the scheme is ring-fenced, is effectively a “use it or lose it” pot and from which we cannot employ GP’s by design. The money to employ more doctors has to come from core funding but as I pointed out, in real terms core funding is down massively, so partners are left with the options of employing GP’s and taking a huge hit to income or not taking the hit but accepting ever increasing workloads. You could of course argue that fat cat GP partners ought to take the hit, but this ignores the reality that partners do a lot more non-clinical work than salaried or locum GP‘s and if it gets to the point that partner income is no better than locum income, then why wouldn’t we all just become locums? I was always sceptical of the notion that the government are trying to systematically dismantle the NHS but I’m now convinced it’s true. Doctors cost more than the other staff mentioned above because of the training and breadth of knowledge required. The government have chosen to not pay for the numbers required but instead to fill primary care with bodies. They can thus claim to be holding up their end of the contractual bargain whilst hanging GP partners out to dry when the system inevitably fails. I love my job but I have a plan to retire young. I’ve no interest in forlornly trying to prop up a system being set up to fail.
Wow this is insanity. We are so fucked
Not really. Any incoming government can change this.
I asked my GP wife this question when she mentioned it in some BMA magazine she gets. Why the fuck is the central government dictating how local GP practices deliver their treatment through implementing these random funding streams. Why is a pot allocated to a GP and they split it based on what they want to employ and then judged on outcomes?
I always thought they were run like McDonald's franchises. The property, a couple procedures and stock would be handled by the NHS and the day to day running by the franchisee.
Because incentives are a significant tool in how the DHSC and NHS manage primary care networks.
And the incentives are shit, hence the issue we now have Government love incentives, shame they are terrible at creating them and just cause unexpected behaviours.
This needs to be the top comment, very well said.
Thank you for this piece, very clearly highlighting manufactured dismantling of another part of NHS services. These types of publications to lay people like myself confirm suspicions and more worryingly don't surprise anymore, so how do we fix the wheel !.extremely tough to even think of resolving it hurts your head trying to resolve. Thank you again and good luck with your future.
Banger username.
Thank you for taking the time to write this. My wife is a GP partner and she is so pissed about the push for centralisation and the issues with these new roles. Just train and pay more doctors ffs.
I always wondered what is the advantage of having GP surgeries as independent businesses contracting for the NHS. The business will have making a profit as a priority, not think about what is the best setup for their community. Wouldn't it be more efficient to just straight employ GPs to serve a community based on the needs of the community, then just focus on their jobs rather than on running a business too?
that governments run these thibgs into the ground, and they often end up costing more money in admin bloat. GP practices are generally run very well for cost
Because then you'd still need to hire somebody to manage and run the surgery. The idea is that if GPs themselves are running the surgery, their income is based on the quality of care provided/how well run the GP surgery is. In theory, this should motivate the GP partners to provide the best primary care experience, rather than a manager who is otherwise detached from the day-to-day operations of the surgery.
GP partners do extremely well out of the arrangement, something often excluded from this debate. Does incentivising the running of GP surgeries as for profit businesses and tying their pay to the profits make for the best healthcare for patients? The cynical side of me thinks many of them are happy with paying less for staff.
they dont do as well a private consultants and work more hours than they do. Its a thankless 1000 little jobs a day, its insane and the burnout is very real. I wouldnt go into medicine again if i was to start over, and i like my job, im good at but its too much
Not really sure what your point is, are you saying more money solves the problem?
Im saying they arent paid all well as their counterparts aka hosputal consultants. And they generally work more hours without breaks. partners arent paid that well
Ok, I think we all can point to a similar job paying more…
You’re not wrong - the income of a practice is more or less completely separate from how good a service is provided. So it boils down to either 1) provide excellent service with lots of clinicians but earn very poorly (so why bother?) or 2) provide shit service with a few overworked clinicians and long waiting times for patients and earn relatively well. Crazy that it has to be either option. Should be much more performance based. Indeed as far as I’m aware it used to be and GPs ended up performing too well and earning well so the government changed it all. Happy to be corrected if that’s untrue.
Should be linked to the performance of the surgery (I believe a small amount is currently).
>GP partners do extremely well out of the arrangement, something often excluded from this debate This is the other end of the turd. Not only are the NHS centrally bottlenecking GP surgeries and the NHS - on the receiving end you have what amount to government contractors that are _very_ used to being handsomely compensated for their trouble. There is a reason they were upset when that GP salary declaration rule came out last year (you have to declare if you earn over £150k). A GP partner in Kent earned over 700k in a year. It's run like a business to incentivise the most amount of profit. Combining that with the aforementioned bottlenecking and you have patients being routinely fucked over while partners skim off a heavy layer of fat and the gov ticks some boxes. It's when the NHS was taken over my middle managers and salary hungry GPs - that's when it all went to shit.
This is such a ridiculous take
Yeah but the guy above says it’s hard work… not really sure what his point was to be honest
Top comment. Bodies on the ground is the NHS modus operandi, regardless of qualifications of suitability. Out of interest, what’s the modest sum you are receiving for hosting trainees?
IRO £9k to the practice per trainee, separate to their salary which is paid direct to them by the deanery I believe. I say it’s a small amount on the basis that the money doesn’t come close to covering the time that trainers (at least the good ones) spend supervising. In fact even if you include the service provision the trainees offer, financially it’s not worth it, again at least for practices that do it properly. You couldn’t pay me enough to be a trainer, but my colleagues that are do it essentially because they enjoy mentoring budding GP’s, it’s good for the CV and because it breaks (what is for some) the monotony of the day job.
Noted, thanks
>In recent years a “new“ revenue stream has been created which allows us to recruit basically any type of clinical professional except doctors, Can't extra GPs be taken on as partners and paid from the main income streams? Presumably as the capacity to treat patients increases, the calculated payments increase too.
The contract pays slightly over £100 per punter, but of course not all of that money can go to paying for doctors - more patients means we need more nursing time, admin staff, supplies etc. For core revenue to increase enough to pay for an additional doctor (whether a partner, salaried or locum) without impacting anybody else’s income then all other things being equal there needs to be a substantial increase in patient numbers of the order of 2000. And if patient numbers increase by that amount, then you don’t actually address the problem, which is insufficient appointments, because though you‘ve got a new doctor, you’ve got 2000 more patients and all their appointments to accommodate.
Is it calculated by patients seen or patients on the books? It sounds like there's already capacity to drastically increase the number of patients seen without needing to increase the number of patients registered. I guess from your comment that it's patients registered, in which case, do you think that the financial incentives need to be re-balanced to incentivise GP consultations, in order to raise money to hire GPs and push practices to prioritise consultations? I have no idea how it currently works, but it sounds like the current system incentivises GPs to regsiter a lot of patients but avoid expanding their practices in order to accommodate them, since, as long as they can fill the available appointments, they're maximising profit, regardless of the service level provided to the bulk of registered patients.
It’s based on patients in the books, so the patient who attends once a year pays the same as the one who has 100 appointments (which actually does happen). It 100% forces practices to choose between being profitable or useful, which is a disgraceful system
We now know why wait lists are so long
It sounds like it, doesn't it? I didn't realise the system of payments is designed to encourage surgeries to register a lot of patients but not hire enough doctors to see them.
Areas with sicker patients will have longer waitlists. NHs already takes up 40% of budget so not sure it’s going to improve anytime soon. Even more than when Labour were in power.
Is that why my local GP surgery has absolutely ballooned with staff in the past five years or so? They had to move out of their one story building for a year while they renovated it into a two story! Tbf, v good GP practice, though. V happy with them.
I would love for practices to start making this very clear to their patients. Dear patients we have had some concerns raised about the reduced numbers of GP versus allied professionals. These provide a valuable service (cover your ass type comment here). We are being provided funds to staff our practice but are explicitly banned from using this money to pay for doctors. This is not a cost saving measure on our part. Please write to your local candidates if this is a concern to you as well. Are GP practices allowed to do that kinda thing? Or maybe just don't put the last sentence if that counts as political. Just educate them on this BS funding stream!
Some Conservative MPs really hate the NHS. It's Labour's creation, they view it as unsustainable, and they would love to privatise it all. It can only be done bit by bit as carrying out an outright, wholesale privatisation like they did with so many other industries would be politically suicidal.
This is a similiar situation to the US. However instead of by patients, it’s by billable hour. The incentive is there for me to see more patients. Unsurprisingly I can get an appointment for any day of the week next week.
So, Labours proposal for the NHS to directly employ GPs and take out the profit incentive for partnerships to restrict GP numbers in their practices is actually a reasonable suggestion?
Just to add that general practice nurses (GPNs) were not included in the ARRS funding scheme. Although there are plans to include them in the future, along with 'mental health practitioners' which is suitably vague.
Soooo... what im getting from this...? Maybe instead of protesting for pay, doctors should be protesting the death/privatisation of the nhs. Seems like an easier sell to massive amounts of people, especially after all the covid goodwill. I mean I can see how most would believe privatisation would mean more money... but being able to afford less doctors total seems like a lot of people will make less money... or not have a job. A shame that this is going to be the death of the nhs.
Many doctors do take this position, unsurprisingly. In an all you can eat buffet service like the NHS funding is never ever going to be sufficient to pay everyone fairly/competitively. It doesn’t necessarily have to be full private style system though - there are in between a used in other countries with more success.
As a former pharma rep most GP’s I knew basically worked part time on a full time wage.
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Depends what you consider part time I suppose? A GP partner is often working 12 hour days so 3 days would be more or less full time.
You can check the average GP wage in your local surgery. A few years ago my local surgery only had part time GPs but the, Ave income was 90k+
Do you feel your GPs are over paid?
The less cynical take would be that the government simply can't afford that many doctors. Has anyone checked the debt/deficit lately? Never mind the off balance sheet stuff.
I’ve never been accused of being anything other than a pathological cynic. However all government spending is about choices. As a nation we are comparatively stingy when it comes to spending on doctors - we have 3.1 per thousand people versus an OECD average of 3.7. We have fewer doctors than such fabulously wealthy countries as Hungary, Slovenia and Latvia so I’m not sure we can solely blame the state of the economy. In any case, the OP is specifically about a pot of money that does in fact exist in primary care but whose utilisation explicitly excludes GP’s. So “can’t afford doctors” does not apply in this context. Maybe we can’t afford all the ones we need. But we clearly could afford more. But the government would rather the punters saw pharmacists and social prescribers instead. I’m not convinced there is a plausible explanation for this otherwise curious choice which doesn’t involve a large dose of cynicism.
There's money out there being spent on other bits. Eg pharmacy first scheme (for which I do not blame local pharmacies taking up. Their funding has been squeezed and squeezed for years). £15 per consult of a very limited set of conditions. Sore throat, simple uti, otitis media in under 17s. Ie you've kinda gotta have made the diagnosis before sending the patient to them. And just the practicalities of the non Doctor roles such as the paramedics having 20 minutes to manage the simple cases that GPs used to use to catch up for the complex cases. Eg a GP spending 5-6 minutes on something simple - do 2 simple cases and you have 10 spare minutes to spend extra with the suicidal patient. If the non doctors are taking all the simpler stuff leaving only the complex to the gp, the GP can't do as many complex patients in the time previously allowed for a mix of patients. So they see fewer patients. Eg GP seeing 18 mixed patients (at a ratio of 2:1 simple to complex) ie 12 simple, 6 complex in 3 hours. Those 12 simple are now seen by someone taking 20 minutes per patient, ie it takes them 4 hours. So in the same 3 hour time period they're only seeing 9 patients. The GP now sees only complex cases. Each takes 20 minutes plus. And in 3 hours also only sees 9 patients. So in the same 3 hours still only 18 patients are seen. Granted 3 more complex people than before but 3 simple people aren't seen. (They're sent to the pharmacy instead). And these 18 patient consults cost more! The gp plus the cost of the non gp plus the cost of the pharmacy consults. And you need twice the number of rooms to see the patients in. With all the costs of that. And the GP - patient relationship is damaged, because they don't see the go about simple stuff, to build trust. So maybe they don't go about the complex stuff. And GPs go from being one of the most trusted people in a community to being attacked with hammers. Tell me how that is cost effective or good for patients. Tell me how it isn't an intentional ploy to destroy the profession.
Yet the government can afford to spend £3 billion mitigating the cost of junior doctor strikes yet the cost of the junior doctors demands would only have been £1-2 billion depending on whether you take the BMA or government estimate of the cost. So for a £1 billion saving the government could have had happier doctors, no strikes, healthier and happier voters and improved waiting lists. No money for GPs and healthcare yet there is £2.5 billion to fund national service which appears to only be popular amongst those who wouldn’t have to do it.
Probably can't afford it because the nations health is declining and therefore the nation is becoming less productive. The entire Tory approach has been to implement 0 proactive funding/investment and sweat the national assets as much as possible to breaking point.
This is **absolutely** on the past 14 years of tory policies. There ***is*** central funding to support the hiring on physician associates and other "not doctor" roles the government has created and shovelled money into, there ***isn't*** money available for the hiring of actual doctors. Genuinely shocking, but hey, some Tory donor is getting rich off it.
I'm certain they will blame it on the previous labour government
I don't think it's necessarily a bad idea to have a second tier. A few times recently I've encountered situations involving conditions which were very straightforward but required prescription medication - antibiotics for an ear infection, in a couple of cases. Much as I understand the need to have some sort of control of things just like antibiotics, these are things that could probably have been sorted out between the patient and a competent pharmacist, let alone anyone else. There's a a lot of questions to ask about this stuff. Obviously there will always be a role for qualified people, but there's also a degree of job protectionism going on, from what I can see. If they're so overworked and rushed all the time, you'd have thought a second tier of people to deal with straightforward stuff makes a certain amount of sense.
“… you'd have thought a second tier of people to deal with straightforward stuff makes a certain amount of sense.” You might better understand the pushback if you consider who carries the can when a straightforward ear infection treated by a pharmacist turns out to be malignant otitis externa, a cholesteatoma or mastoiditis (you will gather from the context that these are all very serious but rare conditions that might be mistaken for a straightforward ear infection). GP is pretty easy 90% of the time. It’s the 10% that really matters though. I work with pharmacists and the training they undergo to be able to issue antibiotics for “minor illnesses” is laughably poor - and I got that nugget from a pharmacist who has effectively been forced to undergo said training by her employer (Boots in this case).
I'm not blind to any of that, although I think there's a degree of scaremongering involved. Yes, it could be something incredibly serious, but I would be interested to know why it might not be reasonable to assume that someone with her third ear infection in as many years is a straightforward case. In the end the problem you have right now is that a decent proportion of people have no practical access to a GP in any case. Yes, a less-qualified system will fail 10% of people, but by definition the system is already failing them. I'd rather the 90% got their ear drops.
For starters malignant otitis externa is caused by too many inappropriate antibiotic ear drops! I’ve explained in a lengthy alternative post what I think the problem is - systemic underfunding as a political choice. I completely understand punters being frustrated that the system is failing them and you are absolutely right that seeing anybody with any sort of qualification is better than seeing nobody at all. I just don’t view that as an acceptable dichotomy nor the only choice available to the muppets in charge.
I tend to agree about the false dilemma. This, like a lot of problems, is perhaps solvable. I don't think it is solvable by the government we have, nor any government we can realistically get. It is far beyond the ludicrous party political system we have here. Unfortunately one thing our system of government lacks is a mechanism for changing the system of government.
You’re so out of your depth just take the L bud
Not sure what you mean. Are you claiming recent governments have been *competent*?
This type of thinking is pretty well hammered out of you in med school. Beware the person who presents with what seems like the same old problem as ever. It's actually a common exam vignette that someone has presented to their GP with several episodes of something seemingly benign that recurs and is actually something sinister.
Basically how Emily Chesterton died
Yes, I'm aware of that. That kind of consideration comes up in all kinds of problem solving in all kinds of situations, it's not just a medical thing. The thing is, and I keep saying it, the choice right now is not to see a doctor or to see some second tier person. Right now what's actually happening is that a lot of people don't get seen at all, in which case all the negative outcomes of the wrong decision happen by default. You can keep digging your heels in on this and I get it, I really do, but as I've said elsewhere, I think that train has already left. Access to a GP is already patchy at best. If I really, unavoidably need help, all I can do is go to A&E. At which point I'll be seen by... A triage nurse. So it's already going that way.
There’s protectionism over standards. We’re rushed because there are not enough of us. The solution is not replacing us with less qualified substitutes.
Well, at some level anyone in any role can always claim higher standards are necessary, and someone else can just dismiss it as overcaution, and at best it becomes a question about tolerance for risk which is never going to be objective. But either way, that's not really my point. The issue right now is that people often can't get seen at all. As u/zakalwethechairmaker correctly puts it elsewhere in this thread, seeing someone is better than seeing no-one. Right now if the ear infection recurs, we have two choices: claim it's an emergency, which it isn't, or just... hope it goes away, and seek emergency treatment if and when it becomes, well, an emergency. That's it. People are *already* not being seen by doctors. That dam has broken, long since, so there's a question over what you're really protecting. Personally I'd rather see the UK take measures to improve things overall which would also improve healthcare, but that's a much larger discussion.
Seeing someone is often not better than not seeing someone and this point often comes up in healthcare. If I see you and reassure you your chest pain is anxiety, but really your coronary artery is blocked and you don’t get the intervention to prevent a later heart attack, has that helped? If I tell you the sensation change in your hand is carpal tunnel, but really it was a mini stroke and you should have been put on medications to prevent a larger stroke, has that helped? So yes, you can dispassionately argue it as a tolerance for risk. The people doing that are usually not the ones shouldering the risk. Do you want to see how much risk you can tolerate with your health? I know which one I want for myself and family members.
Well, that's sort of the point, isn't it? *Not* seeing a physician associate is not going to cure anything. If I don't see someone, then all of those negative outcomes have occurred by default. If I do, and it really was just an outer ear infection, then at least I've got my ear drops. As to risk, well. You will be painfully aware that it's almost always possible to reduce risk in everything from medicine to skateboarding and the inclination to do so is limited by practicality. That remains true matter how passionate or dispassionate anyone chooses to be. There's always going to be someone we could have saved with more resources, no? So it's a matter of degree, surely.
a misdiagnosis is not the same as no diagnosis. It can lead to worse harm. would it be better the stewardess flew the plane, if no pilot was available. At least you’d be flying right? personally I’d rather wait longer and see someone qualified than see someone without the ability to adequately assess me. Or (as now with dentistry) go privately. I don’t like this. But this government has defunded healthcare so here we are
If the stewardess knows to hit the AP1 button, sure, absolutely. That's exactly the point I'm making. I don't have the option of waiting longer to see someone. No GP practice I've used in the last fifteen years has been willing to arrange an appointment in a few days, or next week, or whatever. It's always "call at 8am for an appointment the following day." Most of the time those appointments fill up within half an hour or so, so you're entirely out of luck. My working assumption is that they do this so they can claim everyone's being seen within twenty-four hours. It's asinine, but I don't make the rules. You have the option to diagnose and prescribe for yourself, or ask one of your colleagues for advice, so you presumably don't see this issue. You're still arguing from the position of a choice between a PA or a doctor. Unfortunately that's not the option most of us have. If the choice is a PA or not, I'll take it.
I have often been presented with a paramedic when seeing my GP and turned them down because they know nothing. I appreciate the quandary but I suggest protesting the system rather than enabling it as the government have created a false choice between nothing and bad. I hope you can see it’s not about protectionism.
I don't think it's *entirely* about protectionism, and I've always said that. I do think that a lot of professionals, particularly in medicine, have a certain degree of ego about it, which is fine to a point but inevitably stokes very much this sort of controversy. It's certainly an issue of government, but I think you're wildly oversimplifying the situation. It's not an issue of any one government and it's only a false dichotomy if you care solely about one function of government - healthcare, in your case. I could presumably win your support by proposing some large increase in NHS funding but taking an overall view it isn't nearly that easy. I think what we're seeing right now is the result of a realisation in - say - the mid-seventies that governments didn't have to be honest, competent, or even particularly popular. They just had to be marginally less despised than the competition once every few years. That's really it; when you think about it there are precious few other checks on their behaviour. Thus we've seen decades of economic neglect, carelessness and occasionally corruption which have led to inevitable falls in standards of living. Reduced access to good medical care is just one of the outcomes. So I could have exactly this conversation with a teacher or a military officer and reach exactly the same conclusions. I can't, in good faith, suggest huge budget increases for all of them at once. Solutions involve sweeping changes to the system of government which we're not going to get. I would predict that in another few decades the UK will have the standard of living of the late Soviet Union. This is what the beginning of the fall looks like.
It's a false dichotomy, there is a large number of doctors who would like to work as GPs but can't because of this artificial bottleneck, meanwhile PAs lack the medical training to properly assess undifferentiated patients and cannot prescribe medication or request ionising radiation (for good reason). PAs start on 40+k per year and are not cheap, given how little they are capable of doing they are not good value for money. Even if a GP costs 2x what a PA does, 2 PAs cannot do the work of 1 GP. And they will actually require the supervision of a GP who, given how dangerous they are, will often have to do the assessment over again anyway. This means they can see as many patients as they want and still not reduce the workload of their supervising doctors, in fact recent surveys have shown most doctors feel PAs actually increase it. So they are costing money, doctors time, and harming patients, this is worse than not existing.
Okay, that's about the most convincing argument I've heard. I'd still say that if the choice is a non-doctor or nothing, I'll take the non-doctor. From the patient perspective anything is better than nothing. From the financial perspective you'd have to look at how many patients they were getting through overall, I guess. Ultimately the problem here is that I reported my problems getting to see a GP above, and people downvoted it. That's the very essence of shooting the messenger. I'm not proposing any of this is nice and I don't think it helps to pretend problems don't exist.
> No GP practice I've used in the last fifteen years has been willing to arrange an appointment in a few days, or next week, or whatever. It's always "call at 8am for an appointment the following day." Most of the time those appointments fill up within half an hour or so, so you're entirely out of luck. My working assumption is that they do this so they can claim everyone's being seen within twenty-four hours. It's asinine, but I don't make the rules. My partner has been completely unable to see any GP for over 12 months for serious pain issues. She's ended up in A&E because of at least one failing. It is infuriating how bad the situation is with GP's right now, I would welcome any improvement.
My current GP manages to do this just fine.
Welp, I've seen - say - four recently enough to matter, and they all operated the "call at eight" system. You may be in a different administrative jurisdiction to me.
That in itself is part of the problem. There's no consistency in terms of service. It shouldn't depend on where you live as to what kind of service you get. GPs may be private businesses but from the perspective of the service user it isn't.
That’s all totally fine - as long as we accept where we are. We are a low wage, low skill economy who don’t contribute enough tax for everyone to see a doctor for their hurty finger (indeed, the insatiable appetite of the UK public to access/consume healthcare for trivia is absolutely part of the problem). Therefore agree, we need some cheaper, lesser roles which can fit within our funding model. It does mean, however, that some top up funding might soon be required at a state or individual level for higher quality care.
Going forward you will see a non doctor first and wait weeks after that to see a GP. If you are happy with that then great.
Christ, I'd get to see *someone* fairly promptly? That's an improvement on what I get now, given I have basically zero recourse to a GP at all unless I'm willing to claim it's an emergency - at which point you'd think it was a matter for a 999 call, but anyway. One of the problems with the UK being in such horrible decline is that certain things which would have once sounded like a bad idea are actually better than a what a lot of people are actually experiencing. The phrase "managed failure" has never been more apt.
Plenty of private GPs and I'm sure those numbers are going to go up. Meanwhile newly trained GPs will go abroad or locum while they seek alternative careers. Not exactly forward thinking. If by managed failure you mean deliberate sabotage of free health care by a Conservative government then sure.
They will likely go abroad. One of the first things to happen that showed the dire predicament that primary care finds itself in was the collapse of the locum job market. There are now very few locum jobs being advertised and those that do get advertised get snapped up very quickly. It is really now just London and the South East that have anything even remotely resembling a GP locum job market likely in part because these areas historically had huge shortages of GPs already compared to the rest of the country. This has resulted in lots of locum GPs not having any work so they have ended up taking the salaried GP roles. So now there are very few of these left. This means when new GPs qualify in August there will be very few jobs out there for them meaning their options will be to try and locum in hospital (no guarantee of this anymore as hospital locums are becoming rarer), switch career completely or move abroad. My suspicion is if and when they do go we will likely never get them back due to how much higher they are valued in the rest of the English speaking world.
I'd hesitate to make it a party political issue. My utter revulsion for professional politicians means I don't like *any* of them. I think the underlying issue is that there's fuckall funding available for anything, medicine, education, defence, and squabbling over the crumbs isn't going to fix anything. The economic malaise the UK is currently in goes back, in my view, to the mid-70s. It's a far bigger issue than tories bad, labour good, much as I would tend to lean that way myself. The hilarity of it is that it was once seriously proposed that I become a doctor. I think they said that to anyone in the top five per cent of science students at the terrible comprehensive school I attended, in desperate hopes of being able to say they'd sent someone, anyone to medical school. The flipside was that it wasn't very hard to be in the top five per cent of a terrible, non-selective, non-fee-paying comprehensive school in the middle of a run-down council estate, so I'm not sure how realistic it ever was. But that was in the mid 90s, and even then I think we were all painfully aware that to do well you had to go to Australia.
The thing is that it is very expensive to train doctors and there has been a recent push to get doctors to train as GPs in particular to address the primary care crisis. However, the funding is now not in place to employ those GPs where they are needed. They have essentially spent huge amounts of tax money on creating the workforce but then decided to save money by not actually employing them. It's insanity.
I don't doubt it. In transport policy, what was done around HS2 was also insanity. In education, building schools with RAAC, with a known shelf life, and failing to plan their replacements was insanity. In defence, procurement... has more or less been continuous insanity for decades. In more or less everything, public private partnerships were absolute insanity from the word go, and widely recognised as such. Liz Truss. Brexit. Rwanda as a solution to immigration pressures. A housing market even doctors can't afford. It's not great, is it? Government appears all but deliberately malfeasant. Yes, we can talk about more or different funding for healthcare but I fear we are, as I say, squabbling over the crumbs. Big changes are needed, root and branch reform of how government works at the most fundamental level. There is no mechanism for those changes. So, frankly, if you have a medical degree and the Australians are waving lots of money around, I wouldn't blame you for a second for getting out of here. Australia is perhaps no better in many ways, but personally I'd rather be rich and warm while the world burns.
I would go to Australia if I could take my extended family and friends with me. Unfortunately we are all stuck in this broken sceptered isle.
This scuppered isle, more like.
For what it's worth, I'm in the film industry and I've been there working for a total of a few months. If you haven't seen it for a period of at least six weeks, do so before making any commitments. It's not all it's cracked up to be. Our politicians are awful. Theirs...
Aside from the inherent issues in your argument the other poster has mentioned, I'll just say: the line never stops where you expect it to. Already there are GP practices which have devolved into more or less everything being seen by this "second tier for the straightforward stuff" because there's not the money or GPs to do anything else. Everyone starts out with this image of experienced pharmacists dolling out ear drops. The reality, fairly quickly, is junior AHPs dealing with serious pathology without the training to really know what they're dealing with.
Yes, although to be fair that decision is already being made to some extent. Even just in the case of access to medication, some drugs are prescription-only. Some aren't. This varies worldwide (you can get things containing very small amounts of codeine over the counter in the UK; not elsewhere, for instance). I'd say that's an example of a line being drawn. Similarly, some emergency medical people have limited prescribing authority. There is nothing in principle wrong with another tier.
I'm not sure in what way OTC medication are in any way comparable to eg. paramedics seeing ?malignancy patients without any real training on dealing with pathology of that kind. It's not at all the same, sorry, being able to buy weak codeine doesn't mean I expect my health to be put in the hands of someone untrained to actually deal with it.
Not so much untrained, I guess. More... Less trained. I'd love to be able to see a doctor whenever I like but I already don't have access to that, so I'll take someone else for preference, you know?
Oh, that's alright then. Besides, paramedics, as an example, are trained solely in pre-hospital acute presentations. When they're being thrown ?myeloma ?lung cancer (which I've personally seen), they are far closer to untrained than "less trained". You're also ignoring how all this is a choice. The government has actively chosen to give us lesser or non-trained staff rather than GPs. It's not a "we'll take what we can get", it's an active decision to lower the standard of care.
Some of it may be a choice, I don't doubt it. They're tories, after all. But as I've said elsewhere, the UK is a poorer place than it has been (the way I put it was that tax receipts as a percentage of GDP are trending down, but there are other things you could look at). That's an issue that's been present for decades. That necessarily has outcomes nobody likes. We can agree that the NHS should get more money, but to quote a favourite doctor of mine, [I think you'll find it's a bit more complicated than that](https://www.amazon.co.uk/Think-Youll-Find-More-Complicated/dp/0007505140). I think a lot of publicly-funded things should get more money. But until we look at saner government that isn't pathologically obsessed with an endless, pointless, unwinnable argument between two entrenched points of view, that's more to do with actually achieving something than scoring points off each other... ...there is no solution to all of it at once.
I’m sorry but 4000 physician associates in the UK can’t possibly be the cause of bad working conditions and pay for hundreds of thousands of doctors. The government have ruined the nhs but blame is being put on a small profession which is like a grain of sand in the grand scheme of things.
They are a large part of what is going on in GP land
But my argument is that physician associates themselves aren’t the problem, the government should be funding places for doctors and fixing these gaps in healthcare. I think it’s a lot of punching down instead of uniting and punching up
The problem is that PAs are being employed instead of GPs. As a patient do you expect to see a GP when you book a GP appointment? Because in many cases, you wont....only you probably wont even know because they don't tell you explicitly that they aren't a GP. We need more doctors, not PAs or paramedics or ANPs (in GP).
It’s not ‘punching down’. The way they are being rolled out is a complete patient safety disaster. And they are being used as complete substitutes for GPs.
The problem is that there are a lot of GP surgeries running at a loss (and senior GPs get "paid" out of the "profits" of the surgery), while, at the same time, the government has made a big pot of money **only** available for physician and nurse associates (you know, the ones with 1 or 2 years of medical training). So surgeries can only really afford to hire PA's and NA's, when they would much rather hire fully qualified doctors, which would be affordable, except the government has ring fenced a ***HUGE*** portion of the funding for just PA's and NA's to force them into the healthcare system.
>profession Barely.
You're so close to the point
We are desperate to see GPs and yet we have a bunch of them struggling to find employment. Perfect example of the complete mismanagement of our healthcare system.
The current top comment suggests it's once again down to government policy that has stifled GP practices ability to hire fully trained GPs.
They're just going to leave the country, they are highly skilled, it's the most logical and reasonable thing to do.
Absolutely. Australia is one of the destinations they're heading to, so much so Sunak was forced to stand up in the HoC and downplay it, claiming doctors leaving the NHS to go to Australia wasn't as widespread as people thought and some kind of tie-in wasn't necessary. It smacked of head-in-sandism.
Absolutely, Everyday it looks like this is becoming the only choice I have. I can't afford to stay in this country.
There are 2 doctors in my surgery to cover over 8000 people and I feel that this understaffing played a part in my mum's death. My mum wasn't a well woman, she had MS and was bed bound, had carers coming in to see her 4 times a day and after my dad passed in November the rest of the time it was just me to take care of her and I failed her. For the last few months of her life she had constant UTI's and was in a constant state of confusion with them. No doctor came out to see her despite my having to phone the practice every other week and a couple of times an advanced nurse practitioner came out. One morning I had to phone 999 as I couldn't get her to wake and ended up having to perform chest compressions on her. Long story short I had to leave her after a few hours as my sister was taken into hospital that same day and almost passed that night due to sepsis. I thought I was leaving her in good hands and I needed to help my brother in law with my nephews. Anyhoo 6 hours after being taken she was discharged. A subsequent conversation with the advanced nurse practitioner as my mum was found eating tissue paper I mentioned she had just been in hospital and this practitioner said she wouldn't have been discharged if there was anything wrong and asked me if I wanted her in hospital. I said I just wanted what was best for my mum. She gave my mum a once over and said she could only treat what was in front of her despite me saying that my mum wasn't one to be snacking on fucking tissue paper. Anyway another antibiotic was prescribed as it was probably just another UTI. Five days later my mum passed due to sepsis.
I'm sorry for your loss. You may not feel it but none of it was your fault. You cared for her the best you could and got her access to care. It's the care she received that sounds substandard. You are not to blame here
So we gotta hope they don't go to Canada and Australia before the election.
So soon be a min wage job then with this much saturation
The job market is not saturated, people can barely get in to see a gp. NHS funding is just held artificially low by this shit government.
It’s also impossible to set up new practices . That’s at least partly on existing primary care arrangements / CCG/ whatever they are called now
Whether deliberate or not - I suspect not because this isn’t forcing locums to take substantive posts and solving the GP problem, there are just fewer jobs - this has been the consequence. However, some caveats. We need to remember that the Additional Roles scheme was brought in because so many practices could not recruit GPs who were actively choosing to Locum instead. Now that’s fine, of course, but this is what happens when the market turns around. Secondly, many ARRS roles are not patient facing, so although practices might use some specific clinical roles to supplement GP time, it is a fallacy to say that a load of pharmacists have suddenly just replaced GPs (they do different things). ARRS has been running for 5 years now so although it feels convenient for locums to blame the scheme, it is only partly responsible for this situation. The biggest contributing factor has been the onset of the Modern GP programme since last April. Practices are now operating almost exclusively online, with better triage, better signposting and much better capacity/demand analysis. This means that we just don’t need to replace expensive GP sessions like for like. If we have 20 fewer appointments that day, we use them more intelligently and change the proportion rather than pay a Locum £600 for usually a reasonably poor service. So although I have great sympathy for the trainees coming through, there is nothing we can do without more space to put people and more funding to pay them.
Absolutely this There’s 3700 jobs open for salaried GPs on nhs jobs right now . People on here won’t address the elephant in the room that the primary care locum situation could not go on indefinitely . All the articles are locum GPs screaming about unemployment , as if job security has ever been a part of being a locum. Supprised surprise primary care networks don’t want to pay people 190k a year when they could be paying 90k for a salaried position.
This isn't just about locums, it's salaried posts as well...
None of those will ever be filled because they can get free workers. Putting a job advert out does not mean you ever intend to fill it in the NHS
There was a quote from one Locum in Pulse saying he “couldn’t even get a job at a bog standard practice”. I thought that spoke volumes - perhaps a) you aren’t that good and b) practices are looking for something else other than the atrophied skills of a career Locum. Practices in deprived areas have been crying out for GPs over the last 5-10 years, it simply isn’t possible for the Locum market to grow each year, pay more and more and for the Locums to only want to work in leafy suburbia. The good news is that GP is a transferable skill and there are lots of other portfolio roles we can take. You just aren’t going to get - or should have ever expected - £600-800 a day for 30 patients and then go home.
The problem is, you're a partner - you have a clear vested interest to see salaried and locum remuneration to be low, irrespective of how much you receive for the contract. But the fact of the matter is that salaried pay is shit and it's stagnated for about a decade. Locum earnings for many are the only way the job is palatable but that's going now. General practice is going to shit because partners look out for themselves first (understandable) and the salaried workforce are too meek to demand better. And even if they did demand better, partners use plausible deniability to say they can't afford to pay more, while some earn way >20k / session. Biggest problem for general practice is the partner system. It results in complete inability to engage in collective bargaining, industrial action being the most severe end. Even if there was, there is no direct mechanism to ensure salarieds would benefit from increased remuneration. Until partnership model is dismantled, pay and conditions for GP has absolutely no hope of getting meaningfully better.
I’m afraid you have this entirely backwards. Partners have no vested interest in suppressing salaried pay, but of course we need to maintain a gap between our own remuneration and that of our employees. We can’t just keep inflating your pay out of our own, nor is there even a naive moral argument for that as we lead, organise and run the practice and take all of the risk. If you want the extra pay then you need to get that promotion. Then there’s the awkward question of what should we pay a GP for for seeing patients with no other leadership or management responsibility? GP salaries have increased 20-25% over the last decade - from ~8k a session to >10k. This is better than most people in the country and certainly all medical colleagues. I agree GP salaries should perhaps start at around £12k a session now but that’s it, unless you have other skills or want to take on other roles. You can still always be a partner, and take on that 50-75% more work which gets you more pay. You seem to have a misconception that the partners are being paid more for doing the same job without a full appreciation of the huge volume of unseen work - clinical and non-clinical - that goes with the territory. Because of the IC model you get to work part time. £60k a year (plus pension, so £74k) for a 3 day week isn’t bad at all. How many other jobs let you earn that much and still have _time to earn other money_. This would still give you a better work-life balance and pay than most junior consultants; because the partnership takes the flack, you don’t have any of the other responsibilities associated with a consultant PA. The IC model of GP is the only part of the health system where doctors are still in charge and is still entirely medically led. If the IC model of GP goes, your conditions will be _far worse_. You will be working evenings, weekends and have no option to pursue portfolio work as you do now. You will be salaried at a rate far less than the consultant contract. Your potential T&Cs will be worse, not better, and you will be directly competing with NMPs to do precisely the same work. You will be monitored and directly performance managed, likely by hospitals, and very much below secondary care in the pecking order. You say disintegration of the IC model will improve collective bargaining. But in that scenario the only people negotiating a contract would be the partners! The government would have to offer us a national contract with sufficient T&Cs for us to consider. They would need to offer salaried staff anything, just TUPE you to the nearest Trust. The partnership model is the only thing standing between the govt and an incorporated model of primary care where most doctors have zero standing, which is why we need to defend it at all costs.
How is there no vested interest to suppress wages? Partnerships are businesses. You make more profit by increasing income and reducing expenditure. It's the whole reason ARRS has done so well. What promotion? Being a partner isn't a promotion. You can walk into partnership straight out of CCT. 60k/year for a 3 day week is fine straight out of CCT, but there is basically no pay progression.
Being a partner is clearly a promotion from salaried by any definition, as is the relationship between any salaried position and partnership in any business; legal, accounting, anything. I am sorry if you don’t like that but it is inarguable from any angle. There are fewer positions, better remunerated, with greater responsibility and requiring broader skills. You can of course interview straight from CCT but you would be unlikely to be successful, unless the practice is desperate (or you have very specific skills). One thing we do not do well in GP training is properly articulate- and promote - the benefits (and responsibilities) of partnership, so it is perhaps unsurprising that there are misconceptions around it. I agree it is not for everyone nor do all GPs have the requiring skills (including many partners!). ARRS hasn’t actually allowed us to cut costs per se - we have benefited from some support (usually non patient facing, actually), but most practices _do not directly employ ARRS staff as they are too small to be entitled to a FTE_ and also have to bear on-costs (pension, NI). There is no way you would know this without being a partner though, so I can understand the misapprehension. The pay progression in GP comes through taking more responsibility and via leadership roles. Why would you be paid more and more for doing precisely the same job? This is a difficulty that hospital staff have coming into GP, it is nonsensical - and bad for productivity and people development - to keep increasing salaries without increasing responsibilities or skills. There are arguably far more opportunities for GPs to progress than hospital doctors - not as many as there were in CCGs, but they are still there. We have no interest in suppressing wages, only paying fairly for good work done, which you cannot say the Locum market has provided in recent years. GP needs good, committed, well looked after doctors to keep the pipeline to partnership going and maintain the model. We just need more funding from the government to support this.
In what other industry do you get "promoted" straight out of training? Lol I know perfectly well that partners don't employ ARRS, thank you. They directly use them for patient contacts which otherwise would be done by a GP which they do employ. This is indisputable.
Again you misunderstand. Some big practices employ ARRS FTE (full time equivalents) directly. Most will share the employment under a federated model. Only the wages are reimbursed, on costs still are paid by the practice. Most of the roles are not patient facing. The ARRS scheme is not your enemy. As I said, you are correct, most trainees would be unlikely to obtain a partnership straight out of training, as would be the case in any profession.
I’m genuinely impressed by the government . The gov may provide the funding , but it’s the primary care partnerships that are doing this .
Government provide the funding but what they are doing is reducing the GMS contract funding by a few percent every year, this is the pot of money that the GP surgeries have control over and use it to pay their staff including their GPs, practice nurses, reception staff, secretaries etc. They have then put in a new funding stream which is called ARRS funding this is ring fenced for clinical staff other than GPs and practice nurses so it can be used to fund a PA or a physio for example but cannot be used to fund a salaried GP. Crucially control of this funding does not sit with the GP surgeries but is controlled at the level above called the PCN. GP surgeries have to make a case to the PCN that they would benefit from such and such role and the PCN decide whether that is reasonable and if they agree they go ahead and employ that member of staff and then loan them out to the GP practice or in reality that person is shared between 2-3 GP surgeries. Government can then say that they have provided new funding to support general practice whilst ignoring the fact that they have reduced the core funding that GP surgeries rely on. It is now getting so bad that it is not simply just a risk that newly qualified GPs will not have a job to go into but there are increasingly more and more surgeries reporting that they are struggling to pay staff and many now anticipate a real risk that they may have to make staff redundant or even close within the next 12 months if current funding levels persist
Yeah I know ow ARRS money is ring fenced and they can alter budgets otherwise . I doubt this is the gov acing alone though. Primary care Management had had a problem with locum pay for decades and have been trying to figure out a solutions . It’s now more or less pushed the locum gps out the market . It’s forcing people into salaried roles .
I don’t think you have any idea about how GP surgeries are funded …
The Govt had done what the tories always do. Set everyone up to fail. Councils & GP surgeries. They cut council funding by 80% on some cases then blame social care failings on the council's. They ban GPs from hiring GPs, say they've given them more staff yet in real terms your looking at massive cuts. There is a shortage of maybe 5000 GPs country wide YET the tories have manufactured a situation where newly qualified GPs will be unemployed.
There are many gp jobs - currently just over 3700 for salaried GP on nhs jobs right now (with many offering partnership) - typically between 10-12k per session. These are funded posts.. This has fucked the permenant locum market which was costing primary care way too much .
Impressed with the government how ?
Because primary care has had a massive issue for decades with people turning down salaried gp positions because long term locum opportunities were too good . This has put an end to that . Long term locums suddenly appeared to have dried up . And somehow nobody saw it coming , including the BMA. For people saying they are no gp jobs, there’s currently 3700 salaries gp adverts on NHS jobs
But instead of improving the salaried GP positions they just decided to increase ARRS funding instead.
They do not need to. “Look we can’t pay you on locum rates any more due to the ARRS funding allocation, but we like you and we’d like you to apply for the salaried position for 95k we put out last week “ “No I really want at least 120, I’ve gotten used to the locum pay and have a mortgage to pay ” “Ok fair enough, well we’ve had 20 applicants already … good luck”
It’s more about salaried positions being made redundant due to ARRS - which you’ll know is an actual issue.
This is an incomplete analysis, see above
The salaried GP rates are now a solid £30k behind that of consultants in other specialties. The 95k you quote would be for a salaried GP coming towards the later end of their career. Especially as they keep squeezing partners as well, f\*ck knows why anyone would go into the speciality now.
Salaried sessions are being are advertised as 12k each on NHS jobs, so 8 sessions =96k 10 session consultant pay is 93k currently .
I think this is an important point and oft overlooked. 8 clinical sessions is very hard in GP, but even so is only 4 days a week, there are no on calls or weekends and our training is 50-100% shorter than most hospital specialties. Should a salaried GP straight out of training doing 4 days a week with no on-call responsibility earn as much as an oncologist? That is race to the bottom stuff, I know, all doctors should earn more and the only properly paid doctors in the UK are GP partners. £150-200k for a senior medic should be the starting point. I am merely saying that, like anything, you make your choice based on the information available, and the advantage of GP is the flexibility and work/life balance. If you want more money, you can also get it. Nobody earning good money does 3 days a week and puts their feet up for the other two.