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GPs used NHS commissioning surplus to fund basic practice costs and alternative medicine

GPs have been able to boost their take-home pay by using commissioning funds rather than their general contractors’ income to buy basic medical equipment and fund practice refurbishments, an investigation by Nursing Times’ sister title has revealed.

Health Service Journal’s analysis shows almost £1m of commissioning surpluses generated through practice based commissioning were spent on basic general practice kit such as stethoscopes, otoscopes and waiting room chairs.

Surpluses were also spent on controversial complementary therapies, including aromatherapy and homeopathy.

Across 29 primary care trust areas GPs bid to spent a further £2.5m on practice refurbishments including new floors and carpets, car parks and decorating.

GPs were able to bid to spend the surpluses under the previous government’s policy of practice based commissioning. Their bids, in most cases, were approved by primary care trusts on the basis they conformed to vaguely defined rules which said the spending should “benefit patients locally”.

However, the fact that GPs were able to spend commissioning funds on core GP services and equipment meant they had less need to draw on the income they receive as contractors to the NHS, potentially boosting their profits.

As private contractors to the NHS, GPs are expected to fund their standard business expenses out of their practice income, which in 2008-9 stood at a gross £258,600 per practice partner.

The revelation comes as the British Medical Association and others have warned that GPs must not be seen to personally benefit financially from making surpluses on the commissioning budget.

Royal College of GPs chair Clare Gerada said: “It’s important commissioning savings are used for additional services. Savings need to be invested into services for patients, not in day to day running costs of the practice, such as otoscopes.

“If the system puts conflicts of interests in place, GPs must be protected [from that]. There has to be the right spirit around this, or GPs are going to suffer. It sounds like an MPs’ expenses type thing, and that’s what we’ve got to avoid.”

Under the previous government’s policy of practice based commissioning, GP groups or individual practices were allowed to determine how a proportion of their indicative budget surpluses were spent, subject to PCT authorisation that the spending would “benefit patients locally”.

HSJ obtained the details of GP spending proposals from 50 PCT areas, covering more than 650 practices or practice groups.

In 21 of the PCT areas, spending proposals were for additional services such as foot clinics, or, where savings were particularly small, one-off schemes such as buying gym vouchers for overweight patients.

But in 29 PCT areas, around half of all proposals were for practice refurbishments or items considered essential to providing basic primary medical care or meeting quality and outcomes framework targets, which are usually funded from core practice income.

These included: blood pressure monitors for use in the practice, spirometers, standard scales, thermometers, equipment for removing warts, ophthalmoscopes and stethoscopes.

Although some PCTs rejected such proposals, many approved them.

National Association of Primary Care chair Johnny Marshall told HSJ: “I would have expected the PCTs to oversee the process in terms of making sure the spirit as well as the letter of the rules is applied.

“Some things are clearly part of [providing the general medical services contract]. I would be concerned that equipment that is part of delivering core GMS is having to be funded in this way.”

He said defining “core GP kit” was a “grey” area, but in common with other GPs who spoke to HSJ, he believed all the items mentioned above clearly fell into that category.

GPs also planned to use commissioning surpluses to fund practice refurbishments.

These included two practice staff kitchens in County Durham, more than 25 separate applications for new carpets and floors, three improvements to car parks, including an £8,900 resurfacing in Great Yarmouth and Waveney, and more than 20 applications for waiting room furniture. This included one for a fish tank - which was rejected by NHS Norfolk.

HSJ is publishing details on all such claims online today.

Richard Vautrey, deputy chair of the British Medical Association’s GPs committee, denied practices had benefited personally from spending commissioning funds in this way.

He said: “If they bought an otoscope, that’s not going to make a difference to a profit margin, but it may make a difference to a trainee who is using an old one.”

However Unison head of health Karen Jennings said the ability of GPs to use commissioning surpluses to pay for equipment and refurbishments that could be seen as standard legitimate expenses was a concern.

“The new system needs to have safeguards to stop consortia from making profits, or dishing out bonuses, by cutting the level and number of services they provide. This is the only way these consortia can generate a surplus in the current financial climate, which means that patient care will suffer.”

HSJ’s investigation also revealed that a number of GPs bid to use the commissioning surplus to fund alternative therapies, including acupuncture, the Alexander Technique and neuro-linguistic programming.

One funding proposal made to NHS Portsmouth by an anonymous GP was to extend the GP’s existing private homeopathic clinic to NHS patients. In their application, the GP offered as evidence of the effectiveness of the clinic by saying they had treated one patient with flatulence who received “substantial benefits” and a “lonely” patient who had been “cured”.

That application was rejected.

Edzard Ernst, professor of complementary medicine at the Peninsula Medical School, which assesses the evidence base for alternative medicines said although there was some “good evidence” for acupuncture, yoga and osteopathy, this was limited to very specific patient groups.

There was no good evidence for homeopathy or neuro-linguistic programming, he said.

He told HSJ the GP bids “all seems very hit and miss, and it indicates the existence of double standards within the NHS: Evidence based medicine for conventional medicine and random choice for complementary medicine.”

A spokeswoman for the Department of Health said: “Any freed-up resources from practice based commissioning have to be reinvested in patient care and the use of freed-up resources would need to be agreed with the relevant PCT.”

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Readers' comments (14)

  • I suspect this is the the thin end of the wedge when it comes to what GPs can use money for. The GPs I worked with used the surplusses in a very intriguing way and boasted that they had found a way to to buy second houmes and cars -even to pay off their mortgages.
    Are we sure the NHS dwindlng coffers are safe in their hands??

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  • I agree although I think the thin end of the wedge happened the minute GP's became fundholders. Remember this is tax payers money. GP's should be salaried the same as nurses and other NHS employees. In particular because out of hours services, which have, by and large stopped, would incur additional fees. My guess is that if GP's were given extra pay to run saturday morning/early morning and evening sessions, these services would be reinstated very quickly.
    GP's can suit themselves, and whilst many are consciencious, honest and hardworking, the system has allowed for abuse. As a nurse, I know the long hours, on call etc Doctors used to have to contend with, however the pendulum has swung too far in the other direction. Many GP's I know are now part time and still much better off than the nurses who support the service. This is a luxury tax payers cannot afford.

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  • can this system give rise to abuse so that GPs are cutting costs at the expense of patient care in order to make savings for other spending?

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  • So what will happen if a hospital does say 500 operations of a certain kind and PCTs buy these - 200 from one, 200 from another and 100 from another. The GPs commission and they're asked if they want to buy 1 operation each. How does that work? It's obvious the GP is going to say 'oh, last year I only needed one for mrs so and so down the road but I don't think i'll need any this year'. And so the hospital ends up having none of those ops commissioned, even though they know they'll need to do around 500. Do they then stop doing them? The GPs are going to want to save money so why commission something they don't think they'll need? It doesn't make any sense to me. And what about all the bureaucracy involved in doing this, I can see many bureaucrats in the GP practices to do all this commissioning. And if they're not going to benefit from it then what is the point of it all anyway? Am I the only one to think this?

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  • So what can we, the humble nurses do about this? At a time when scrutiny is the byword - e.g. MP's expenses scandal, bankers bonuses; is it not now time for the work of GP fundholders to be scrutinised. After all they are not a private business - their funding does come out of the public purse. Recent proposals to enable GP's to float funds on the stockmarket makes me despair even more. Predicted profits could 'net individual family doctors a windfall of almost £1m'. If they are already being accused of identifying a loophole to line their own pockets, who is going to be able to scrutinise this further descent into the abyss of more for the rich and less for the poor.
    There is strong evidence to suggest that the 'gentlemans club' known as the government will only serve the needs of people who hold the purse strings. It is seriously scary to think that GPs who control stocks and shares to fund their practices will be able to influence so much more than just the health of their patients.
    This is the type of practice that leads to greater splits between the haves and have nots and history has proven... to anarchy and revolution! You have been warned.

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  • A European newspaper reported this am that one of the world's most influential bank chiefs is questioning the future of his international bank in the City. Having just invested millions in a brand new purpose-built state of the art building. if they withdraw, 7000 jobs go with them and will set the ball rolling for other large enterprises to follow suit to go and establish themselves in countries with more profitable and stable economies and which are far more attractive to them and their employees.

    We need these enterprises to bring us revenue and wealth (bonuses and all) which also has a bearing on Government income and spending including that spent on health services. without them we will be left to stew and sink back into the abyss of the dark ages. There are many other lands where the grass is far greener where these businesses can thrive if we no longer continue to attract them and look after them.

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  • Perhaps we do need these enterprises to create secure investment, however, my question was, are GP's the best people to do this with tax payers money. If there are such high returns to be had, then why don't govt investors with expertise in this area invest, rather than asking GP's who, as far as I am aware, have no experience or investment banking. My other point was that it is clearly open to abuse. It will also create a health care system where the patients of GP's who gain successful returns on their investments will have a better service than others less successful.
    How will this be governed and how can we all challenge any inequalities of care services. The mind fairly bogles at the thought.

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  • Maybe it would be good to let GPs do the commissioning and leave the practice of medicine to the specialists.

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  • I hope NT and its sister journal are going to explore this story because the tales of fraud, corruption and financial mismanagement I hear from G.P. colleagues make ones hair stand up on end.

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  • It seems that very few in positions of power are immune to stories of abuse - now even members of the former French government who were highly esteemed and in positions of trust.

    Who next?

    General management was introduced to the NHS in the 1980s because the government wished to relieve clinicians of their admin. duties so that they could devote more of their time to providing expert patient care however they were also relieved of much of their decision making responsibilities leaving them with their hands tied to carry out this care to the best of their ability. they were considered by the government to be good at their own jobs but not necessarily so experiences at managing resources such as budgets.

    so what comes next?

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  • this is going to be an absolute disaster
    rip the nhs!!!!!!

    never mind though the gp's will be stinking rich..who does that remind you of...bankers maybe!!!

    hope your so proud who ever voted in this shambles of a govt

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  • even if the gps become 'stinking' rich this is no guarantee to better care. they need more training not higher pay.

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  • One of the reasons given for the PCT commissioning / split was the conflict of interest of being commissioners and providers and the need to allow competition. I'm not sure how this rests at all with GP commissioning given they must be commissioning themselves!

    I can't help but wonder if the GPs are being set up for a fall.

    The GPs will have to be very careful to avoid a GP expenses scandal.

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  • The issue of being both commissioners and providers of care conflict of interest is still not addressed or settled.
    Neither is the fact that the funding bodies know nothing of what GP's actually do with the funds given them by government except by the numbers that are produced at the end of the year.
    The other issue that seems not-ta;lked about is the fact that governemnt is prepared and intends to incentivise GP's to reduce their referrals to specialists, completely regardless of the need and clinical indications. Some GP's have spoken up and pointed out the distinct and premeditated lack of ethics in this, however the governemnt is remarkably quiet on this.

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