GPs’ charges under scrutiny

Older people in residential homes are supposed to receive
general medical services free. But several charities are claiming
that there is confusion over charges for services provided by GPs,
reports Claire Laurent.

When is a GP service not a GP service? When it is provided for
patients in residential homes.

According to a report from a group of charities published
recently,¹ one-third of GPs are charging charitable care
homes extra fees for services to residents.

While GPs are not allowed to charge for what are known as
“general medical services”, they are permitted to charge retainer
fees to care homes for work above and beyond these core NHS
services. These fees are paid from a mix of subsidies from
charities and charges on individual residents.

A Department of Health spokesperson says: “GP services are and
must be free for patients, including residents of nursing homes.
GPs sometimes contract with nursing homes to provide additional
services, for example, training for staff. That is different from
individual, direct patient services, for which GPs should not be
charging their registered patients.”

However, the charities’ report found that while the average
retainer was £41 per person, in some areas this rose to
£150. David Prescott, deputy chief executive of BEN, the Motor
Trades Benevolent Fund, says: “The essential problem for us is that
older people are being asked to pay twice for a NHS service. The
only way we can secure even health services across our residential
service is to retain GPs. But it is an extra cost. In one area it
is £15,000.”

The survey covered sheltered housing, nursing homes and
residential homes. It was carried out by a number of charities
including Help the Aged, the Anchor Trust and the Alzheimers
Society. Altogether, 183 charitable care home providers were
questioned, representing 9,000 residents.

The research showed that 34 per cent of homes were paying fees
to GPs who also receive extra cash from the NHS to care for
residents. All GPs automatically received a NHS fee of £45 for
each patient over the age of 75, whether they live in their own
home or in a care home. However, unlike people living in their own
homes, people in care homes are unable to change their GP or switch
to a GP who does not charge a retainer.

The British Medical Association rejects the claim that GPs are
being paid twice. Andrew Dearden, chairperson of the BMA’s
community care committee, says such charges would be fraudulent:
“They are breaking their contracts and they should be disciplined.
All the retainers I know of don’t pay the GP to do GP work, they
pay them to do extended GP work, non-NHS work, for extra time.”

The problem, according to Dearden, is that doctors and lay
people are unclear as to what constitutes a GP service and what
doesn’t. While it is easy for both the BMA and the government to
talk tough about GPs who break the law, there is confusion about
where the line between “general” and “extra” falls.

Dearden argues that this confusion over what constitutes
services meant that many of the managers questioned in the survey
did not understand the questions or their context. He claims that
one in four of the homes don’t have a written contract with the GP
providing the service. “If managers don’t know what they are paying
for, how do they know they are paying twice? If a manager of a care
home gives anybody thousands of pounds and doesn’t know what they
are paying for they should be sacked.”

Graham Allen is chief executive of the Bakers’ Benevolent
Society, which provides sheltered housing. He believes managers
understood the research questions perfectly well, and says that his
organisation has written contracts with two GP practices that cost
them more than £7,000 a year, one of which “details a number
of benefits we do not currently benefit from”.

The issue of GPs being paid retainer fees first arose with the
closure of large numbers of older people’s care beds in hospitals
resulting in older people, many with complex health needs, being
discharged into nursing and care homes. The retinue of doctors,
nurses, physiotherapists and occupational therapists working in
hospitals promptly disappeared, leaving GPs to pick up
responsibility for people with some challenging needs.

Dearden’s own Cardiff-based GP practice has agreed a local
development scheme with Brotaff Health Authority, under which the
practice is paid £130 per patient (in a residential, care or
nursing home) per year. This, he suggests, is the preferred
solution but as few as one in 20 health authorities has developed
such a scheme. “The shame of it is that the NHS and health
authorities do not see older people in nursing homes as a
priority,” he adds. The Welsh assembly is now looking at whether
such a scheme could be applied across the whole of Wales.

Tessa Harding, head of policy for Help the Aged, says: “We
appreciate where the BMA are coming from, but that’s an argument
between GPs and the NHS or the government. The first and top
priority is to make sure that those very vulnerable and frail older
people actually get the care they need. That’s the NHS’s
responsibility, and people should not under any circumstances be
charged for something that they would get free if they lived
elsewhere – and that the rest of us get free.”

Harding hopes that the newly announced National Service
Framework for Older People will help in the push for change. “In
the NSF the first standard is to ban age discrimination in health
care,” she points out. “This is a classic example.”

¹ Association of Charity Officers, Fees
Paid to GPs for Services to Residents of Care Accommodation for
Older People 2000-1 from 01707 651777.