‘Elephants in the room’ outed as general practice fees and ownership models

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‘Elephants in the room’ outed as general practice fees and ownership models

Virginia
McMillan
HERD OF ELEPHANTS
The GP fee and primary care funding seen as hindering moves to improve health system [photo: Benh Lieu Song]
Whenever a new service is asked of it, general practice and primary care, not unreasonably, want to know “where is the funding?” Private general

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The fully-funded model has not worked - just have a close look at the issues inherent in the NHS. The UK has had this model since 1948 and although the ideals behind this system as espoused by Nye Bevan remain desirable, the issue is that the system is inefficient and access is (increasingly) difficult. Salaried systems are inefficient because they are never incentivized to be efficient. The simple fact in New Zealand is that, along with other systems, cost escalation is inevitable. If the level of Government funding or subsidization fails to maintain its value in the face of both General and medical inflation, the costs for sustaining the system will be passed to the user or the provider will simply go out of business. Government has failed to maintain the value of funding for Primary Care let alone provide sufficient funding for Primary Care services in the first place. After the 1 December 2018 "increase" to cover the reduced cost of access for CSC holders and dependents (which was by all measures inadequate to cover the actual cost of the service), the health spend on Primary Care amounts to 1.46% of Government spending on health. In the UK it is 8.1% (which is regarded as inadequate in the UK) and 30.2% in Australia. And yet in Australia the average out-of-pocket expenditure on personal health is considerably greater than in NZ. It is neither the business model or co-payments that are the issue, it is the lack of funding and a consistent failure to maintain the value of the funding that remain the core issues. The thing about academics is they live in an idealized world where they are sheltered from the realities and can express opinions without having to deal with the consequences.

Good luck finding a qualified GP prepared to work 40 hours a week for $124,000 pa (the current top pay scale for 40 hours in the RDA MECA).  This is an hourly rate of $59.62.  This shows exactly how much the services of a primary care doctor are valued by Prof Gauld. Senior medical officers accept that rate (or not as the case currently is) as it is rationalised as being part of their training path to higher incomes as specialists or GP's.  If that becomes the top rate that could ever be earned as a GP then the supply of GP's will dry up - immediately.  

I think you are looking at the wrong contract. The right one is ASMS/DHB contract. Top rate $230000.

It's all the extras also Richard! An extra 3% "step" annually on top of inflation as a reflection of increased experience. 6.5 weeks annual leave, 2.5 weeks study leave and $20k study/conference/holiday/CME budget, very generous superannuation package, 3/10ths non patient contact time, sabbatical leave, morning and afternoon tea, lunch, 8-4, no management responsibilities unless you want them. 

I'd leap at it. However that's coming from a GP ghetto region, some other GPs may not be so keen. 

I think if we could link ourselves to the ASMS contract and conditions we'd be mad not to. 

Top rate may be  $230,000.  There are several  hundred staff over that   level of remuneration up to $1,150,000per annum  . That  is  a turnover in  General  practice  for maybe  4,000 patients .Yet  GPs  employ  receptionists, practice managers, nurses , cleaners  etcand pay  through  the nose for  the coutries  prevalent  PMS whic invariably falls over with  every   upgrade costing thousands of more dollars to fix. 

Whanganui  PHO  has 4 managers being paid around $200,000 each for their time. It  also  employs  5 Fulltime equivalent   Quit coaches working 200 hours a week  who helped around 130 people stop smoking in the 6months Jan-June 2018 for $170,000. The last DHB  audit of the PHO  stated the PHO paid General Practices  a total of $18,000 for a year  for their services helping an un reported number of smokers to stop.

Whanganui PHO  is " clinically" led . The Annual report for 2017/18  gives little information  about where the millions of dollars the PHO  received is actually spent and what is actually achieved.

 

 

 

Top rate may be  $230,000.  There are several  hundred staff over that   level of remuneration up to $1,150,000per annum  . That  is  a turnover in  General  practice  for maybe  4,000 patients .Yet  GPs  employ  receptionists, practice managers, nurses , cleaners  etcand pay  through  the nose for  the coutries  prevalent  PMS whic invariably falls over with  every   upgrade costing thousands of more dollars to fix. 

Whanganui  PHO  has 4 managers being paid around $200,000 each for their time. It  also  employs  5 Fulltime equivalent   Quit coaches working 200 hours a week  who helped around 130 people stop smoking in the 6months Jan-June 2018 for $170,000. The last DHB  audit of the PHO  stated the PHO paid General Practices  a total of $18,000 for a year  for their services helping an un reported number of smokers to stop.

Whanganui PHO  is " clinically" led . The Annual report for 2017/18  gives little information  about where the millions of dollars the PHO  received is actually spent and what is actually achieved.

 

 

 

Fair point. But does anyone believe that's what they'll actually be prepared to pay GP's? 

Oh blessed are the highly salaried cocooned academics with soft clean hands...The inequities across many regions are such that a lot of us would work for the salaries paid to our hospital colleagues and their conditions but simple maths dictates that if we were to work for those conditions the number of GPs would need to be doubled overnight. I certainly wouldn't be doing paperwork until midnight anymore, that would be in my 8-4 like most of the specialists I know, I wouldn't be taking it home!

Just who runs the practices? Who sorts the day to day issues? How much extra are we paid for this? Would we be paid a fair price should we sell?

The problem is we just don't bloody trust the Government any more. Our funding has not remotely kept pace with inflation let alone health inflation. We never get any reimbursement for compliance costs. All we get is an abundance of contempt and lip service.

Sadly we have had NO representation and most would argue PHOs have been a failure for General Practice with us handing over IPAs and losing everything in return.

Sadly we wouldn't be in this sad and sorry state and the profession would be an attractive one for young doctors had successive Governments not treated us with such contempt and invested in the sector. Good luck finding doctors to salary where I work, most of them are jostling for the exit door.

Brains also soft and clean.

https://www.wessexlmcs.com/email13433 

This was posted by Chris Reid (northland gp) and recent contender for our leader at the college.  its a good reid.  It highlights the rot that sets when private primary care becomes a public good. The rot is real and it not only kills people (gp suicide) it is also responsible for the nhs currently tottering on the edge of being privatised by the tories. And this is the swimming pool they want us to jump into. 

tui advert please .... yeah right. 

for non facebookees 

 

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/770916/gp-partnership-review-final-report.pdf

Forget the elephants, what about a title "University Academics devalue GPs and push political agenda based on misinterpreted statistics"?

The 2016/17 survey quoted in the NZMJ paper reported that ONLY 14% of the population found GP costs a problem, so 86% don't see cost as an issue!  However 28% reported unmet health needs so the academics should have focused on the real issue of access to GP services caused by an under-supply, shorter consultations driven by artificially low fees and poor GP access to psychologists, imaging and secondary services. 

Why would GPs welcome any scheme that denied them the right to charge a shortfall fee given successive Governments' inability to match medical inflation (or even normal inflation) or curtail the cancer of management intrusion into clinical matters?  At present DHBs employ about 2 managers/admin per doctor they employ (often to write reports no-one reads), so can we really afford a few thousand more managers, all on 6 figure salaries? 

Using the NHS failure in primary care as a model just doesn't make sense, we should look at where many of our trained GPs end up, Australia, where GP services are valued. What incentives are there for the academics' students to want to work in General Practice in NZ if they will have to achieve more in 10-15 minutes with less access to investigations and specialist services than a SMO, but will earn no more than them and have no specialist salary step (or better "rights"), even with Vocational Registration?

We do one thing very well in medicine - export highly qualified GPs to places that value them. 

If these academics want "all NZers to have equal access to the same standards of treatment", the inequities of different services (and costs) based on which practice type, PHO or DHB one does or does not belong to have to be abolished. They are however right that the current DHB/PHO arrangements are not appropriate. However the inefficient communist system is not the answer, we need to learn to use the private system better, ranging from the the private GP practice to the private hospital (eg for low tech surgery), combined with national public "centres of excellence" as we already do for paediatric oncology and spinal injury, not the current inefficient duplication in 20 DHBs.

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Access thebmj.com - Image removed.

Why are so many doctors quitting the NHS?—it’s time to ask the right questions

January 25, 2019

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The mayday call is out—urgent action is required

 

“Never let a good crisis go to waste” 

— Winston Churchill

A recent report by the General Medical Council (GMC) lays out, in detail, the crisis that has been unfolding for many years in our healthcare professionals—a crisis that is now seeing the workforce at breaking point. [1] As the GMC puts it, this is the most critical juncture in the history of the NHS, and one that deserves our utmost attention. Why are so many doctors quitting the NHS? How do we reinvigorate one of the noblest workforces on whom so many lives depend?

Despite a relatively rosy outlook at the start of the journey—medicine remains a popular career choice with a surplus of students applying for a place, and the announcement of five new medical schools in England—there is a worrying exodus that is gaining momentum. In 2017, 57.4% of Foundation Year 2 doctors did not enter higher-training posts and 9000 doctors quit the NHS entirely. [1] In 2011, when career-destination surveys were first conducted, 71.3% of FY2 doctors progressed into higher training-posts. By 2016 this had dropped to 50.4% and last year the rates had plummeted further to 42.6%. [2] The rate of decline is near exponential. Added to this is a growing culture of quitting both across the specialties and across the generations. [1]

A multitude of factors have been put forward to try to explain what is causing the exodus. [3] Changes to junior doctors’ salaries, hours-worked, a reduced investment in training, inflexibility with schedules, lack of consistent teamwork, and an understaffed service all contribute. [4] But perhaps what underpins it all, driving the discontent and dissatisfaction, is a lack of feeling valued and supported. Three out of ten doctors have said they feel unsupported by management each week, and that they feel the mentoring provided to them as part of their role has decreased. [1] 

.........[Sorry guys, you will need a subscription to BMJ to read more, We do not have permission to reuse their content - Editor]

 

Small business ownership is not complex in comparison to the bureaucracy that is required to run DHBs and Govt. It is efficient, nimble and generally highly optimised because waste is felt very quickly and sharply in the owners pocket .

As for buying up general practices and the DHBs ? running them?

Has anyone told the property team at the DHBs they will need to add another 900 odd sites, in multiple, remote locations to their property portfolio. They will need to manage the leases, and all the capital costs if they are dim enough to try and own the buildings.

What about the accountants at the DHBs, have they been talked to about the funding costs of funding thousands and thousands of extra staff and what that might do to their balance sheets?  Who is going to pick up the operating cash flow that is going to be a one-off hit when transitioning from small businesses carrying this cost to the DHBs

Has the HR department been talked to about how and who is going to manage the HR requirements for thousands of extra staff, plus all the additional managers, professional development budgets, annual leave requirements etc. They are going to be thrilled.

What about the IT department at the DHBs. Are they going to pick up the hardware and software requirements for all these sites, they can't even look after their own kit properly, let alone take on the requirements of staff working multiple remote locations. 

Good grief. It's not just about salaries, that is the least of the issues. This is bonkers.

If we extend this nonsense to pharmacy, they will need to also pick up the cost of owning the drugs from the small business owners who currently hold this risk - they are doing to put another $100m on their balance sheets just to do this alone.

Rocks in heads .........

Absolutely Anna! I've got a really off the wall, crazy idea...how about they take a deep breath and fund General Practice properly with a single, fair, targeted funding formula that's been corrected for the last fifteen years of dishonest underfunding. You might then get GPs staying in the sector and recommending it as a career!

This is also a generational war. The one’s behind us are NOT going to sacrifice marriage, children and friends on the altar of Medicine. 

https://www.statnews.com/2019/01/28/medicine-culture-change-retain-talented-physicians/