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.
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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