Pulse editor-in-chief Jaimie Kaffash on his radical solution to the workforce crisis
I have a confession – I am a bit of a coward. For years, I have had a plan for the future of general practice, but was worried it was a bit too radical for readers.
But now, it seems, it is GPC England policy. And that policy is for GP staff costs to be paid directly by the NHS. Not in the form of the additional roles reimbursement scheme, but by the way of the Government paying for staff that practices actually need to provide appropriate care.
There are a number of benefits for this. First, by having staff costs paid direct, you remove one of the biggest barriers to increased funding for general practice. Governments are reluctant to increase general practice funding in large part because of their fears around headlines about money going into greedy GPs’ pockets. By ringfencing this funding, you remove any excuse for not increasing funding. And subsequently any blame for workforce issues – and, connected to that, patient access – goes directly towards government, as it should.
Second, while the trope around money going to the pockets of GP partners is well overblown, the current funding arrangement does reward GP partners who employ cheaper staff. Let me be clear – 99% of GP partners don’t do this. But – like any profession in history – there are some who are greedy. Changing the incentives would just remove the chance to be better rewarded for providing slightly worse care.
This is not without complications. Even if we agree to move to this system in principle, the details will be all important. How will practices receive the money? Would there be an element of weighting based on patient population, and if so, would we adopt the Carr-Hill formula (hopefully not) or a new allocation calculation?
Meanwhile, this would only work if practices can apply for new staff as and when needed, but the criteria for eligibility and the hoops they jump through must be sensible (and, as it stands, I am not optimistic this would be the case for anything the Government brings in).
I also use the term ‘practices’ throughout deliberately. I am not as against primary care networks as many, but practices must still be the core unit within general practice. As such the core staff must sit there.
I realise that, for many GP partners, this suggestion might be seen as a watering down of the partnership model, and I don’t really disagree. But, for me, the benefits outweigh the costs
I’ve long argued that general practice isn’t a normal business; no other business has only a single contract with a customer that they don’t negotiate directly with. A conventional business would either be able to walk away from a contract they don’t like, change customers or renegotiate terms. At the moment, GPs have the worst of all worlds – bound to a substandard contract, and blamed for anything that goes wrong.
I do not think that having staffing costs moved away from core funding would affect autonomy. There are ways practices can innovate, but I fundamentally believe any staffing costs saved through innovation should be reinvested into the workforce. This wouldn’t stop the most innovative practices from increasing profits, but they just would not be able to do this through cutting their workforce.
Furthermore, it goes without saying that this wouldn’t suffice on its own. General practice needs more funding in general, and even in terms of workforce, any change would be pointless without a huge investment in premises as there simply isn’t the space to house the necessary staff at the moment.
I’ve said many a time that radical solutions are needed for general practice, and I think this is a radical solution that will work. I am just glad that GPC England are braver than me.
Jaimie Kaffash is editor-in-chief of Pulse
Market pay rates is a signal that emerges at the point of negotiation for each individual employer and staff member. How do you match a job with equal hours where one might be more intense, or with a patient group a clinician is more comfortable managing, or what about a job with more in hours work vs one with unsocial hours work but more flexibility? What if one Gp prefers intense but highly paid work and another less intense but less highly paid / hour? What about flexibility of annual leave? How do you square those who want work out of hours to be free during the day vs those who don’t? What is the value of a supportive workplace vs one that is a more collection of solo clinicians approach? How to resolve issues around cost of living in different areas – and how then to work out the price of a Gp in an expensive area where there still might be GPs willing to work as they are second wage earners vs remote areas where a Gp is the top wage earner?
How do you calculate the value of remaining profits to partners where some do a lot of work and others do less or employ more salaried staff? How do you account for the risk / reward of remaining partners with wildly varying demographics, staffing challenges and building contracts?
The socialist calculation problem was lost in the famines, poverty and tyranny of 20th Century Communist experiments. Central payment would be a step towards even more central planning in the NHS – let’s please avoid that.
Historically most famines, poverty and tyrannies occurred in times when there was no or little state planning, and everything was left to merchants and free markets, ie, from ancient Greeks, via the Dark Ages, mediaeval England, through Victorian poverty of the masses and up to the 1950s – ie prior to a post-Keynesian rise in government planning.
Nobody defends communism absolutely these days. But, you cannot ignore all the evidence since the 1990s that the Chicago school free market monetarists went too far the other way and neoliberal policies also have not served us well. Recall the dotcom bust and 2007-08 global crash and credit crunch (for which we are still paying), and also neoliberal policy experiments destroying successful economies in other parts of the world (and now Trump is experimenting with mercantilist anti-freemarket protectionist tariffs policies).
Economists are, of course, fools and economics is not a science (like physics, for example), so its utility to politicians is to massage opinion. Economists cannot predict with any certainty. Hence, to paraphrase the late Queen “why didn’t you knobs see the crash coming?”. It’s because they were busy with their noses deep down and reading tea leaves for rent- and profit-seeking and they failed to see the Truck smashing down on everything.
Like everyone else, we’re all “capitalists” now, but what some of us are against is the sort of capital approach that’s called zombie, or cannibal, or casino capitalism, and which financialises both real, derived and now virtual worlds, just to enrich the 1%.
As I don’t believe there should be an internal market in the public sector/NHS, then it follows that the blunt tools that economists like to prestidigitate with are also invalid, eg price and value theory. So, for me, I’m a big fan of the private sector, but it should stay outside of what we as a country want to include in our public good. Therein lies the Road to Freedom (Stiglitz).
For the NHS, we need the internal market kicked out, less regulation (as in the private sector) especially as doctors are professional, and funding which is in line with the values for which we elect government.
Salarying all GPs removes the profit motive over which some GP principals spend too much of their physical and mental time (instead of seeing patients), and arguably its time has come.
Government to pay for 1 full time GP per 1000 patients as per BMA advice. (37.5 hours per week; likely 6 clinical-2 admin sessions-recent pulse article in 2024-sessions so long 9 session full time is out of date).
Pay equivalent to consultant FT; number of GPs for practice calculated by patient population.
Amount paid to practice on condition that that many GP sessions, clinical and admin, provided.
Either salaried or partner can provide the sessions.
Different salaries depending on location or intensity of work is making something simple more complicated than it needs to be.
They don’t do this for consultant or nursing jobs around the country-apart form London weighting.
Just get the numbers of GPs right-1 FT per 1000 patients, salary equivalent to consultants, and get the money to the practices.
Who else do they think will be managing this complex, aging population.
The less time we have with patients the more copious pointless secondary care referrals happen. While patients just keep asking to see a GP, and if possible the same one, to get some useful, practical help.
It’s a complete nonsense at the moment. Chasing our tails, hospital chasing their tails, millions of referrals that may not be needed if continuity of care and enough time with patient, GPs with enough training and experience, managing them.
I also feel that the only way of equalising to some extent the disparities within General Practice are most likely via a possibly less efficient salaried service set at a suitable rate with significant clinical admin time. I don’t, however, believe as with some of the other comments that face-to-face consultations for which we are specifically trained at great length and paid variably at very high rates of £85 to £100 per hour is something that can be complained about, as this is the job everyone themselves chose at an earlier stage and hopefully did not end up as a GP by accident. As my next milestone after well over 3 decades of seeing patients at mainly 10mins appointments working full time in different clinical roles including partner , locums etc. over time until relatively recently, is to reduce my own commitment and do other things within general practice rather than retire (although under consideration). Hence for myself personally I think it unreasonable I will have to adhere to directions given by others, many who have always chosen to be part time (as is their prerogative), undertake other allied roles who have seen nowhere near the patient numbers I have seen in line with others in my position. The more difficult GP aspects overlooked in my view are dealing with the management of staff whether admin, other clinical staff or doctors who do the minimum and require oversight in whatever respect in addition to dealing with complaints from staff or patients, on call urgent calls for suicidal or other patients , safeguarding incidents alerted by HVs etc, routine safeguarding with its risks , dealing with urgent results on the day as well as routine results ,safeguarding meetings with allied staff , urgent home visits, ensuring financial viability , medical aspects of CQC , staff not urning up, mandatory external case reviews involving other staff, medicines targets and ICB target achievements etc. etc.. All the responsibility of these aspects bypasses those who just do F2 F consultations but nonetheless they rely on these facets being in place, despite no accountability for these crucial aspects of a General Practice’s existence and they may even have minimal awareness of the existence of such requirements. The variability in different practices, their locations, premises , recruitment issue disparities, practice populations variations , historic funding variations etc are other complicating factors which will be unknown to those who do not need to cope either with low relative funding or the fortunate group with high funding per patient. It sounds simple to move to all salaried service despite myself agreeing this is likely, although a well thought out remodelled partnership scheme would be more efficient ; however, this salaried service seems inevitable. Nonetheless, we should not fool ourselves that the F2F work GPs or others do will be the saviour as it is the hidden work that is yet unseen which will eventually crush the NHS GP service and finances even more so than they are already. .
⬆️ except that would require nearly 100,000 GPs …….think🤔