Timmy in the Telegraph

On the subject of GPs and contracts and what do we do:

Finally there’s a solution – though it would meet serious resistance – which is to change how, not how much, GPs are paid. Currently the system is based on capitation fees, which awards care providers based on the number of patients registered at their practice. Change reward from how many registered patients they refuse to see face to face, to pay according to how many appointments they do undertake and marvel in wonder as the queues disappear. But then that would be to treat revered professionals as mere jobbing tradesmen like plumbers or lawyers, so we may be waiting quite some time.

43 thoughts on “Timmy in the Telegraph”

  1. I’ve got it.

    We convert doctors’ waiting rooms into the Gong Show. Patients have 30 seconds to state their ailment. If no gong goes, they get to see a GP. Otherwise it is the Walk of Shame ( or shark tank ).

  2. Your recipe would encourage many short appointments so that’s possibly not the best solution either. Perhaps it would be better to reward by patient treatments and allow these amounts to accumulate over a period to group payments due for that patient.

  3. Nice snark with ‘lawyers’ there 🙂
    Wasn’t it Heinlein who considered lawyering an unskilled activity?

    I like Ottokring’s suggestion, bhut with one chabge: if the doctor cannot correctly identify the ailment, they’re the one in the tank.

  4. It is pretty absurd – that there were going to be backlogs to clear once lockdowns were eased was possibly the most obvious consequence, but from what I can tell most parts of the NHS have done the square root of f**k all to plan for it.

    Fun anecdote: Mrs Yeoman’s GP was the source of the quote about “GP’s surgeries being swamped with a tsunami of patients” (or whatever) earlier in the year. Whilst they’re seeing people face-to-face again, only between their normal weekday opening hours, and are closed entirely on Wednesday afternoons.

  5. Part of the problem are the hypochondriac / von Munchausen syndrome by proxy and “it’s free so i’m going to use it” (and they do, at every opportunity) patients too.

  6. Of all the dozen or so acquaintances diagnosed with brain tumours over the last twenty years, all had several gp consultations for chronic severe headaches, all but one was diagnosed on a routine visit to an optician and one in A&E with symptoms so severe a neurologist had a look. I conclude most gps can’t or don’t examine fundi routinely and their competence questioned: time to deduct pay for every missed diagnosis.

  7. If there are problem patients who over-present, punish them somehow. Don’t punish everybody with over-exclusionary rationing or fees.

    (There is a modern tendency to avoid seeking out the guilty and then punishing everybody. I hark back to being kept in after school when someone had done something, graffiti maybe, and they didn’t know who. I hated it then and I still do. Someone stabs an MP, and everybody loses the right to net anonymity..)

  8. On the jobbing tradesmen front. They let women in. No profession can survive that and retain its gravitas and authority. Women are all first names and friendy-friendy. That counts for everything. Teachers. MPs. Lawyers. Whether that is a bad thing per se I wouldn’t know, but there is no authority or gravitas any more in those trades.

  9. if there had been health insurance in Ambrose Bierce’s day, this entry would have appeared in the Devil’s Dictionary

    “Capitation fees” – physicians getting paid based on the amount of care they deny to their patients.

  10. This will run afoul of Goodhart’s law: Any observed statistical regularity will tend to collapse once pressure is placed upon it for control purposes.

    Instead, eliminate the system of “registering” for a GP (you aren’t registered with a plumber, are you?) and give everybody a stack of vouchers which they can use at any GP. Each voucher would feature a portrait of the Monarch on one side and a prominent historical figure on the reverse.

  11. The radical solution would be to get patients pay for a consultation. Hysterical cries of “Free at point of use….”

  12. It does seem unbalanced that prescriptions aren’t free but consultations are. A fiver out of pocket would discourage enough of the “worried well” (hypochondriacs, the lonely) to free up some space.

    But GPs are a three pipe problem. Would ceasing to hector patients on their lifestyle, or spending more of the consultation 8 minutes on advice about smoking, drinking, eating chocolate etc lengthen or shorten the queues?

  13. (There is a modern tendency to avoid seeking out the guilty and then punishing everybody. I hark back to being kept in after school when someone had done something, graffiti maybe, and they didn’t know who. I hated it then and I still do. Someone stabs an MP, and everybody loses the right to net anonymity..)

    Yes, I recall that happening at my school. I nipped it in the bud by refusing to comply. When challenged the following day as to why I had not attended detention, I told the teacher concerned that she knew full well who the troublemakers were and that it was up to her to deal with them directly, not expecting the rest of the class to do it for her. Surprisingly, it worked and I wasn’t taken to task for it. Had she put me into detention for standing my ground, well, I was prepared to take that on the chin, but she didn’t.

  14. If you pay doctors according to the number of patients on their books, they have an incentive to accumulate the healthy and reject the sick.

  15. It does seem unbalanced that prescriptions aren’t free but consultations are. A fiver out of pocket would discourage enough of the “worried well” (hypochondriacs, the lonely) to free up some space.

    The French do it the opposite way around. So you rock up at the GP surgery, wait your turn and pay for the consultation. If you need a prescription, it’s free at point of use.

  16. Longrider

    But in general you have the secondary insurance and so you don’t actually pay anything in the end….

  17. Is the capitation formula really based solely on numbers of patients without any correction for age? I suspect that the typical male university student never sees his GP except for initial registration over three years of undergraduate study. Are the GPs in the core areas of university towns mining gold?

  18. I note that Philip and Diogenes have no problem with keeping me in after school. I don’t attend the GP willingly. The experience of fighting the gate dragon and then sitting with sick peopple is no fun for me. I don’t want to pay. If there is a problem patient, identify themn and make THEM pay.

  19. “Capitation fees” – physicians getting paid based on the amount of care they deny to their patients.

    Pretty much. They’re paid by the NHS and the NHS doesn’t want patients clogging up its systems.

  20. “Women are all first names and friendy-friendy. That counts for everything.”

    My father always felt that the problem was precisely the opposite: that (perhaps out of a sense they have to compensate for exactly that preconception) they were too concerned with being what they imagine to be “businesslike”: i.e., brusque and offhand. As he said, having a good personal relationship with your clients is businesslike; treating them like something you stepped in hardly encourages them to recommend you to all their friends.

    Outside of his firm, I haven’t had much to do with lawyers, but (with one or two notable exceptions), it’s certainly been my experience with doctors.

  21. FFS! We know what the answer is. What the rest of Europe has. Health insurance. You pay your insurance, you have the medical care you’ve paid for. The state pays for those can’t pay the insurance.
    But it’s never going to happen. Vested interests. It would require dismantling the holy cow of the NHS & all its legions of administrators. GP’s would actually have to work for a living.
    I spent a year in the UK a while back. While my father was in the process of expiring. I saw how well the NHS treated him. I did actually need to see a doctor for myself ( a very rare occurrence). I went to France for the day. I’ve learned to be a lot less stupid than the Brits.

  22. @Sam Duncan
    I’ve long treated doctors, lawyers, all “professionals” as what they are. Servants. Can’t say they like it very much but they get used to it. It’s not as if they have an option. I’m not going to change so they have to. Works marvels.

  23. @rhoda and @longrider,

    In my experience, I never minded being punished when I was guilty and caught, but felt a deep grievance when I was punished for someone else’s misdemeanours. (Although I once was filled with glee when a toe-rag copped it for something I’d done!) It was a very long time ago.

  24. The Meissen Bison
    October 22, 2021 at 8:46 am
    Your recipe would encourage many short appointments so that’s possibly not the best solution either. Perhaps it would be better to reward by patient treatments and allow these amounts to accumulate over a period to group payments due for that patient.

    It works OK in France. 25€ to see a GP paid cash/cheque/credit card before consultation starts. Patient is reimbursed by l’Assurance Maladie (70%) and top-up private insurance if they have.

    ‘… many short appointments…’. The point so frequently missed by those who say this sort of thing, is where there is competition, and certainly in France there is, if you get short changed by one GP you go to another as, unlike in the UK, you are not tied to ‘your’ GP. The docs know this. The same applies to other areas of health care in France… no-see/treat patient, no-get paid.

  25. Ljh,

    “Of all the dozen or so acquaintances diagnosed with brain tumours over the last twenty years, all had several gp consultations for chronic severe headaches, all but one was diagnosed on a routine visit to an optician and one in A&E with symptoms so severe a neurologist had a look. I conclude most gps can’t or don’t examine fundi routinely and their competence questioned: time to deduct pay for every missed diagnosis.”

    Think about what GPs do all day. It’s things like handing out antibiotics for throat infections, talking to old ladies about their hip troubles, telling people with a cold to go home and rest, and for a lot of stuff, referring people.

    Like, I’m a software developer. Once upon a time, people taught me all sorts of things, but over time I’ve forgotten them. I would struggle to do COBOL on ICL VME because I haven’t done it in 20 years. There’s still a few guys doing COBOL on ICL VME and know it like the back of their hands still. Doctors are the same. They might have been taught about lumps at university, but if they aren’t doing them regularly, it’s going to get lost.

    It’s why we should get rid of GPs and just have more specialist units that you go to. And I don’t mean “specialists” as in doctors with decades of experience, but units focussed on some part of the body that the public go to, and as early as possible, we train people into them. Itchy arse? Go to the Arse Unit. Lump? Go to the Lump Unit. Hearing problem? Go to the ENT unit.

    We already do this with eyes. We have opticians and then eye hospitals. My GPs involvement was that the optician referred to him and he referred to the eye hospital. Could have been removed entirely. Opticians are pretty great and so are the eye hospital, because that’s all they do all day. Opticians are like the first line, and also do some diagnostic tests that might mean you go to the eye hospital, where you meet people who have done nothing but eyes for 20 years of their life. Their examinations of what is wrong are going to be pretty much instinct at that point. They’re going to know the difference between X and Y eye condition because of some subtle difference in symptoms. You have a concentrated unit, so it’s worth spending money on diagnostic equipment that would be ridiculous for a GP to have. Your GP doesn’t know the difference between glaucoma and ocular hypertension and can’t even diagnose it because he doesn’t know those conditions and doesn’t have a camera that expands a tiny portion of the eye to the size of a PC monitor, or various sensor equipment.

  26. Bloke on M4,

    But if you could go straight to the specialist, where would all those people with fibromyalgia or long covid go?

  27. @Andrew M. Hate to tell you but as a non-hypochondriac suffer of post-viral fatigue I can tell you (a) the symptoms are real, (b) diagnosis is by exclusion which involves a lot of visits, and (c) NHS screw ups on recommended treatments mean the NHS is useless. My ex-GP fastened on the idea I was a depressed alcoholic which was causing my problems therefore I needed to exercise and socialise (in non-drinks settings) which are the things that kill energy levels and can see me in bed for days. [I’ve very slightly elevated liver enzymes in blood btw but hardly drink alcohol, but GP thought I was lying about that..]

    The high rate of presentation from women with FM/Long Covid/CFS/ME etc is interesting. For many it’s very real but I do think there are some who are lumped in as the case criteria were so loose anyone could qualify. Thankfully that’s changed for ME but as noted above, GPs are so generalist as to be mostly useless.

    PS – my current GP practice knows to not let me near the ex-GP as he can’t diagnose his way out of a paper bag and I had to complain about his jumping to conclusions. Luckily they’ve a competent friendly, open to debate, female GP I can see but she only works three days a week… 🙂

  28. @John B

    I have no issue with any of what you say but Tim was not suggesting (if I understood him correctly) that GP lists be done away with. I have experience of living and working in both France and Germany where the money follows the treatments and where the patient is the customer: this seems an altogether more sensible way of working.

  29. It’s a problem with GPs and MPs for that matter that when they meet their patients or constituents, they are inevitably meeting a large proportion of moaners and complainers. They learn to despise their customers. And they despise us all, innocent and guilty alike. Given any event or crisis which seems opportune, they will try to avoid meeting the unwashed. They all despise us. They despise us all.

  30. Bloke in North Korea (Germany province)

    Ljh, either you have a vast number of acquaintances or a reasonable number of acquaintances of interest to mysterious foreign security agencies.

    “It’s why we should get rid of GPs and just have more specialist units that you go to. And I don’t mean “specialists” as in doctors with decades of experience, but units focussed on some part of the body that the public go to, and as early as possible, we train people into them. Itchy arse? Go to the Arse Unit. Lump? Go to the Lump Unit. Hearing problem? Go to the ENT unit.”

    This is more or less the German system. Most arse, lump, other specialists are in private practice (some with license to see the 80% unwashed publicly insured, which is how healthcare is rationed) and the proportion of specialists is fairly high. So you don’t have the English system of having to be referred to one of the top 8 lump specialists in the country and be made to wait sufficient months for your lump to get bigger, but can go to whichever of the many hundreds of lump specialists has a slot.

  31. It’s why we should get rid of GPs and just have more specialist units that you go to. And I don’t mean “specialists” as in doctors with decades of experience, but units focussed on some part of the body that the public go to,

    This is how it works in quite a few places.
    They don’t do away with GPs entirely though.

    Skin problem? Goto dermatologist
    Eye problem? Goto eye person
    General health problems or just feeling crap? See GP for either general treatment or a push in the right direction.

    Works wonders in my experience.

  32. Rhoda

    I fail to see how my suggestion is punishing the innocent. It is how the 2 other medical systems I have experienced operate. In France I had an ear infection, so I visited an Oto-rhino doctor, waited a few minutes in an empty room and saw the guy. It cost about 10 francs, partially reimbursed by my insurance. In Amsterdam, with a similar complaint, I made an appointment with the GP, sat a few moments in an empty room and had a consultation with her. It cost a couple of euros and I left with a prescription. Now, in the UK, if I did get an appointment with a GP, I would have to stand for maybe 30 minutes in a queue on the pavement outside the surgery. Which of these 3 systems punishes the innocent?

  33. Diogenes, I suspect you’d get the worst of both worlds. Queue outside, then pay. Because name notwithstanding, the NHS is not a service. The essential fix, mentioned by a few here, is to link the money to the patient’s choice. But that kind of reform requires a brave politician to introduce a bold reform, and that ain’t gonna happen until it’s broken enough that the public wake up.

  34. Seem to me that more nurse practitioners doing what is essentially a triage role with limited ability to offer treatment without referral to a specialist, would also provide another path into medicine that allows people to accumulate real world experience as they progress rather than forcing insane working conditions on junior doctors

  35. There’s no easy solution. Remember the principle of the market is that you get what you pay for.

    If you pay by appointments seen, you’ll get people being unnecessarily told to return for prescription renewal, dose changes, checking progress etc. If you pay strictly by number of consultations, you’ll get a lot of one minute visits to sign a piece of paper. If you pay by time spent, you’ll get hour-long consultations to discuss trivial details.

    Ultimately, you have to trust the doctors to do the right thing.

  36. @Allan Peakhall
    It’s worse than that. The male students won’t switch to another GP after they have left, not until they need a doctor, which could be 10 years down the line. Literally money for nothing, year after year.

  37. Long term NHS needs to be gone.

    For now tell the GP hacks to go back to doing what they did before con-vid powergrab. Or no money.

    Plus get names of all practices trying to scam and have a random 1 out of 20 visited by a lovely team that will crash in and beat the shite out of the Practice. Doctors, nurses, practice managers, receptionist, cleaners–the fucking lot of them. Beat them until they beg and then beat them some more for begging.

  38. Ultimately, you have to trust the doctors to do the right thing.

    Ahhahahahahaaa!
    Good one!
    I haven’t laughed so hard in a long time.

    Doctors (particularly GPs) in this country are a bad mixture of self-serving and incompetent. Nurses aren’t much better. Sure there’s the odd one that isn’t, but as a whole, they’re useless.

    Mine, and a lot of people I know have a history with the NHS that involves routine incompetence and extreme difficulty getting past the GP to see someone who might actually be slightly less incompetent with the problem at hand.

  39. BIS nails it.
    Just flipping copy whatever flavour of Bismarkian / Social Insurance Health System we prefer.
    We have examples in Austria, Switzerland, France, Holland, Germany, Japan, Singapore Australia etc etc.
    Its notable that every single one provides 1st world healthcare with better patient outcomes than the flipping Wah!NHS, which provides mostly 2nd world healthcare with occasional islands of competence.
    We’ve got 20+ examples to choose from, just copy what is already proven to work.

  40. @Charles
    Market principles.
    One advantage of the insurance based systems. Insurance companies are going to have a good idea of what typical GP throughput should be. GP’s try gaming the system they have to deal with the people who are paying them. Insurance companies are kept honest because if they’re incentivising GP’s to hold back services, their customers go to another insurer. My experience with health insurance companies is not how reluctant they are to pay but how enthusiastic they are to pay.

  41. The problem with incentives for health insurance (or indeed any insurance) companies is that you only find out how good they are when you claim, so your choice of insurance cannot be influenced by that. Of course, in one sense that’s the same as bying a ham sandwich from Tesco – you may find you don’t like it and cannot take it back. But for lots of small transactions that doesn’t matter, while for rare, expensive transactions it is a very distorting effect (this is why used car salesmen have such a stereotypically bad reputation – for most people buying a car is rare).

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