To think that the plan to nationalise GPs is a good thing?

[XantheBreeze]

GPs are apparently up in arms about potential plans to nationalise GP practices.
Many people might not realise that GPs and their practices have always been ‘private’ and not part of the NHS but contracts with it as they didn’t want to lose their independence (and high pay) at the birth of the NHS in 1948.

With all the talk of Tories wanting to privatise the NHS, and the recent rogue behaviour of some GPs deciding they prefer not to see patients unless they deem it necessary, AIBU to think this would be a good idea?

FWIW, some of the reasons volumes are up here is that waiting lists for secondary are up and some of the interim demands fall on primary, secondary have ttried to throw some care over the wall and the aggregate burden of patients with COVID and 'long Covid' seems to exceed the results of the excess mortality arising from Government incompetence. Relatively aging population effects have progressed by two years.

Don't bother telling the populist press, Government and their bot army who are busy progressing their own agenda attacking primary care.

Have started seeing some posts on professional primary care fora that seem to be overseas bots trying to sew discord about vaccination, wearing PPE with incoherently changing the subject to the next controversial topic using odd language and a complete lack of understanding of UK health care. I'm surprised they bother as discord generation about primary care is a domestic success story.

You're of course right @Zilla1.

Personally I think the "nationalisation" debate is moot. This will come to a head in the next few years simply due to GP shortages - something will need to happen and they can't magic up Doctors from nowhere.

If they try to nationalise many/most GP Partners will either drop their workload by 30-40pc or drop out completely and go private (how did the dentist thing work out?) and we're not even addressing things like the fact that purchasing the GP buildings estate will cost billions (our practice building which we own is worth just under 2 million).

GPs are relatively innovative and used to running businesses. I have personally set up a Private GP service from scratch - it's really not that difficult and I'd be more than happy to assist other GPs with policies etc for CQC (well maybe not in my direct area as competition ) and you'd be surprised at how many people are happy to pay over £100 for a same day consult for something simple like a tonsillitis.

The only thing holding back private GP in the UK is the fact that, problems aside, NHS GP has generally been okay for most people.

So as the service now struggles due to staffing and sometimes unrealistic expectations for the £150 budget, private GP will rise.

I think the premise of the OP is wrong. The GPs that I've spoken to aren't up in arms about this, mainly they find it funny and would welcome a change.

LMCs are actively pursuing for a new contract...

www.gponline.com/lmcs-reject-outdated-gms-contract-demand-move-item-service-payments/article/1734263

• I don't think GPs are retiring in pensions of £1700 per year.

They are not. It’s either been presented badly or disingenuously.

Somebody in the NHS pension scheme, earning £100k like the example given, contributes 13.5% of their salary pre tax. In exchange they get 1/58 of £100k per year to add to their final defined benefit pension: £1,724.

So after ten years they’d accumulate an index linked annual pension, paid every year on retirement, of £17,240. After 20 years that’s almost £35k per year. Not bad, eh?

The PP suggested that a GP has to contribute 30% of his or her salary to get this but I surmise that she’s talking about GP practice partners paying their own employer contribution in addition to the ‘employee’ contribution. And why shouldn’t they? It’s one of the costs of running a business.*

I'm not sure what's disingenuous about my argument?

For that £35k after 20 years service, the GP partner on £100k will have paid £600k. Since you can't claim your NHS pension until 68 (at present) they will need to live til they're 85 just to get their contributions back! Frankly, after the stress of being a GP partner for 20 years, I don't rate their chances 😂

@privateandnhsgp

we're not even addressing things like the fact that purchasing the GP buildings estate will cost billions (our practice building which we own is worth just under 2 million

Is there even an obligation for them to buy your building or could they set up the nationalised GP services in other sites? Or perhaps the nationalised NHS would rent your buildings from you if they needed them.

There's no obligation at all, because nothing has been decided. But most areas don't have the infrastructure to deliver large scale primary care to the entire population overnight so you'd have to use some of the premises in the short term at least.

You could centralise things a bit more in bigger hubs, but patients would have to travel further and that's a real problem for e.g. the elderly who are big service users. I'm not saying it's not doable but there would be a whole lot of pain involved. It would be a vote loser.

In terms of renting the buildings, well that's what happens now - GP owners receive a notional cost rent for use of the property that goes into the practice pot - non building owners don't get this. It was arranged this way to keep the risk and liability with GPs, but it turns out that property investment worked out rather well in the UK.

But I wouldn't bother renting to a national GP service unless the terms were very favourable - I'd just sell up and make it somebody else's problem - after all, it wouldn't be my business anymore.

The other big issue is that our contracts (GMS Contract) is a guaranteed contract in perpetuity. So cancelling it would potentially have some legal issues - the current plan of making it so shit that GPs give it up voluntarily is better from a legal standpoint but slow.

So despite what they think, HMG don't hold all the cards.

I'm not sure what's disingenuous about my argument?

For that £35k after 20 years service, the GP partner on £100k will have paid £600k. Since you can't claim your NHS pension until 68 (at present) they will need to live til they're 85 just to get their contributions back! Frankly, after the stress of being a GP partner for 20 years, I don't rate their chances

You’re still being disingenuous I’m afraid. In your earlier post you might not have realised that you were presenting your pension entitlement as being only £1700 per year after you retired, rather than £1700 of index-linked retirement income accumulated for each year you work, so I’ll let that one go.

You are certainly not immune from obfuscation though. A salaried GP on £100k pays 13.5% (pre tax, so saving tax at 40% on the contribution; real cost £8,100 per year, not £13,500 per year) per year in exchange for £1724 of index linked retirement income for every year she works in the NHS.

After 20 years (and I know that she won’t start on £100k, this is an example), she will have accumulated £35k per annum of index linked retirement income at a cost to her of £162k.

To buy an annuity, increasing with RPI, paying £35k per year, you would need £1m at today’s rates. £1m instead of £162k. The NHS scheme doesn’t look too shabby, now, does it? Especially because the NHS pension scheme comes with bells and whistles like death in service benefit, spousal pension etc., which personal pensions and annuities (at least at that price) do not.

If you are a GP partner extracting the same amount from the partnership, then you will pay £8,100 per year, net, in exchange for your £1,724 accumulation of retirement income for every year you work. As a partner in the partnership, you will also pay the employer contribution. Of course you will. Who do you think should be paying it for you? You are the employer and you enjoy the risks of enterprise as well as the rewards, which can be substantial. GP partners tend to earn much more than salaried GPs, on average. But you’ll get a discount on that employer contribution as well, because it’s an allowable expense against your partnership income.

So don’t pretend that you are getting a bad bargain. Your pension is a brilliant bargain. Your supposed £30k annual cost is really £18k because of the tax advantages. Over 20 years, the cost to you is £360k. In exchange, when you retire, and assuming that you live to the predicted age for women born in the same year as you, let’s say 20 years until you are 88, you will receive £700k of pension, and that’s before index linking. Double your money.

I’m sure that many people would happily swap their own inferior pension arrangements for yours.

Have not looked at the figures and without wanting to appear disingenuous, I expect the contributions to a money purchase scheme when invested would be smaller than the withdrawals decades later unless the investment is put under the mattress. If it were such a good deal then why are doctors withdrawing (yes I know about the marginal tax rates and penalties)? If being a GP is such a sinecure and licence to sit behind a screen, work PT and print money then why are young doctors leaving the profession, practices handing back contracts and why can't we recruit GPs, PNs and ANPs? These are real signals.

@Iamthewombat

I'm not sure what's disingenuous about my argument?

For that £35k after 20 years service, the GP partner on £100k will have paid £600k. Since you can't claim your NHS pension until 68 (at present) they will need to live til they're 85 just to get their contributions back! Frankly, after the stress of being a GP partner for 20 years, I don't rate their chances

You’re still being disingenuous I’m afraid. In your earlier post you might not have realised that you were presenting your pension entitlement as being only £1700 per year after you retired, rather than £1700 of index-linked retirement income accumulated for each year you work, so I’ll let that one go.

You are certainly not immune from obfuscation though. A salaried GP on £100k pays 13.5% (pre tax, so saving tax at 40% on the contribution; real cost £8,100 per year, not £13,500 per year) per year in exchange for £1724 of index linked retirement income for every year she works in the NHS.

After 20 years (and I know that she won’t start on £100k, this is an example), she will have accumulated £35k per annum of index linked retirement income at a cost to her of £162k.

To buy an annuity, increasing with RPI, paying £35k per year, you would need £1m at today’s rates. £1m instead of £162k. The NHS scheme doesn’t look too shabby, now, does it? Especially because the NHS pension scheme comes with bells and whistles like death in service benefit, spousal pension etc., which personal pensions and annuities (at least at that price) do not.

If you are a GP partner extracting the same amount from the partnership, then you will pay £8,100 per year, net, in exchange for your £1,724 accumulation of retirement income for every year you work. As a partner in the partnership, you will also pay the employer contribution. Of course you will. Who do you think should be paying it for you? You are the employer and you enjoy the risks of enterprise as well as the rewards, which can be substantial. GP partners tend to earn much more than salaried GPs, on average. But you’ll get a discount on that employer contribution as well, because it’s an allowable expense against your partnership income.

So don’t pretend that you are getting a bad bargain. Your pension is a brilliant bargain. Your supposed £30k annual cost is really £18k because of the tax advantages. Over 20 years, the cost to you is £360k. In exchange, when you retire, and assuming that you live to the predicted age for women born in the same year as you, let’s say 20 years until you are 88, you will receive £700k of pension, and that’s before index linking. Double your money.

I’m sure that many people would happily swap their own inferior pension arrangements for yours.

Thank you for setting this out so clearly.

@Zilla1

Have not looked at the figures and without wanting to appear disingenuous, I expect the contributions to a money purchase scheme when invested would be smaller than the withdrawals decades later unless the investment is put under the mattress. If it were such a good deal then why are doctors withdrawing (yes I know about the marginal tax rates and penalties)? If being a GP is such a sinecure and licence to sit behind a screen, work PT and print money then why are young doctors leaving the profession, practices handing back contracts and why can't we recruit GPs, PNs and ANPs? These are real signals.

Because the workload is unmanageable and they don't feel they can provide proper patient care.

Not because the pension scheme isn't generous enough. 🙄😆

Have not looked at the figures no, you really haven’t have you?

and without wanting to appear disingenuous, I expect the contributions to a money purchase scheme when invested would be smaller than the withdrawals decades later unless the investment is put under the mattress.

But you still need £1m of retirement savings to buy that £35k per annum of index linked income at the age of 68, rather than £162k paid into the NHS pension scheme over 20 years. That is the point.

It would have to be pretty spectacular investment growth over 20 years to more than quintuple £162k invested evenly throughout those 20 years, wouldn’t it? Even if you put the full £162k in on day one. Wouldn’t happen. You would have to invest way, way more in a money purchase scheme.

@HootOwl I agree with you and apologies, I wasn't trying to say we couldn't recruit because the pension scheme wasn't sufficiently generous. I was making the point that there are concrete signals in response to circumstances that people who understand things are making about their own finances and careers beyond the firm assertions of not-a-GPs.

If GPs are handing back contracts, young GPs are leaving the profession entirely and so on then that is a signal.

@Iamthewombat so an approach of comparing £360k with £700k and ignoring investment returns is better and not disingenuous by your standards. Spot on. You've convinced me. Have you thought of applying for one of the vacancies Boris has in his office? I expect there's a market for your alternative facts. If not, Trump may be running for 2024 and in need of your expertise.

I was making the point that there are concrete signals in response to circumstances that people who understand things are making about their own finances and careers beyond the firm assertions of not-a-GPs

Not going down without a fight, I see.

Somebody upthread hijacked the discussion to whine about how unfair it was that hospital consultants (not GPs) had to ‘pay to go to work’. I showed that that argument was nonsense.

That other posters, themselves GPs, chose to chime in to complain that the GP pension scheme was poor value, when it really isn’t , as I explain above, is on them. Post self-serving half truths about the NHS pension scheme and I’ll refute them. You don’t have to be a GP to do that. I’m fact, it is clear that I know more about the workings of the NHS scheme than some (not all) of the GPs on the thread.

[quote Zilla1]@Iamthewombat so an approach of comparing £360k with £700k and ignoring investment returns is better and not disingenuous by your standards. Spot on. You've convinced me. Have you thought of applying for one of the vacancies Boris has in his office? I expect there's a market for your alternative facts. If not, Trump may be running for 2024 and in need of your expertise.[/quote]
Oh dear. The truth hurts, doesn’t it? Face it. You have a fantastic pension scheme, better than anybody else not working in the public sector could hope to get. Why do you insist on denying it? It weakens your overall argument because it makes you sound less credible.

Up until two years ago i worked in a job that meant i heard a lot about long term health strategy and the main theme then was that the current GP model is unsustainable and they are looking at other options.

Many people do not realise that GP's do not exist is all health care systems - you go direct to relevant specialists.

Nationalising them seems the first step to this.

Yes I can see you think you are the expert in pension schemes though perhaps less so in what I have posted. When have I said in any of my posts that the pension scheme isn't generous? I did say that GPs are making real world decisions which they are. I said your comparison of contributions and payments is in its own way as disingenuos as you feel other PPs have been.

Well there have been NHS run practices in living memory. Not many but enough to indicate that they were far less productive than the independent contractors.

The current model is based on a large capitation payment and payments to incentivise specific work, like vaccinations. The capitation model means it is easy to register with a Gp practice. Most people are registered with a Gp which is a strong benefit to the NHS. It is basically the core requirement of a primary care system. But that economic model often causes problems with access.

As to incentive payments. These can run to high demand. It was GPs and pharmacies that delivered the huge volume of vaccinations very very quickly for covid. The Government models for mass vaccination centres didn’t work here or in other countries and weren’t ready in time for the roll out of vaccines despite months of planning. GP and pharmacies mobilised in weeks.

@LemonTT Yes, locally there are some practices managed under a SPV run by local acute - Sometimes when the practice handed back the contract but often when the practices failed and no suitable partnership or company was willing to take on the locality so probably not a statistically representative sample.

You're right about the vaccinations too. Our PCN delivered c30,000 vaccinations, more than acute and local massvac for the area. Acute got the vaccine first but their management lost interest as soon as they got the first dose into their staff and families and non-patient facing staff, skeleton ran the service and told their staff to come to the PCN Massvac didn't get the volumes.

IMO, as with most things, nationalisation would be possible if government decided it was a priority as would privatisation to MNCs/corporates. Whether the costs would be outweighed by the benefits and whether it would lead to an overall improvement are subjective. I doubt it myself though suspect either nationalisation or corporatisation would benefit GPs financially and disadvantage the majority of patients. Judging by the political tenor and the populist press, the government seem to think there is political milage to be made from kicking primary care so it looks like their 2011 reforms have achieved their true objectives.

@Zilla1

Yes I can see you think you are the expert in pension schemes though perhaps less so in what I have posted. When have I said in any of my posts that the pension scheme isn't generous? I did say that GPs are making real world decisions which they are. I said your comparison of contributions and payments is in its own way as disingenuos as you feel other PPs have been.

Here’s a real life test of your assertion that a GP partner contributing £360k over 20 years is getting a poor bargain in exchange for £700k - before index linking - over the twenty years post retirement at 68 (and quite likely longer; we are all living longer and actuaries are not idiots).

Index linking at 3% would increase that £35k a year to £45k a year by year ten post retirement. It’s a lot more than £700k in total.

Here is the test: How many GP partners have decided not to join the NHS scheme because they think that their £18k a year will do much better, or even just as well, invested in a personal pension?

What’s that? None, you say? Why is that, I wonder?

@Iamthewombat I was trying not to get involved in the pension discussion and have name changed but a HELL of a lot of GP partners are no longer bothering with the pension scheme.

Many would like to still be in it and would re join if they could reduce their contribution rates (without reducing their pensionable by reducing their hours) as they understand the value of it but they want to avoid AA issues. We can't advise either way only give them all the projections, facts and figures but we see a lot of partners leaving/not joining in the first place. It's silly in my opinion and I would LOVE to be in such a good scheme but alas.

(I am a specialist accountant for GPs / NHS pension scheme so these are things I deal with daily for a bit of context).

Our gp is diabolical. My dd had a huge bite on her leg, getting bigger. I called and was told to send an online form the next morning. I did so at 7am the next day. With photos uploaded. On the form it asks when is ok to call so I said any time except (time and time). Of course they called me then. I then called back - they weren't available. I called again. They weren't available. I called again and they weren't available. Each time waiting 45 mins on hold. Then I get an email with no way to reply saying 'we're full up for the day'. We took her to the hospital in the end which I didn't want to do. She'd been bitten by a tick. She's only 4.

Now you can't even fill an online form in as they've removed it. Just have to wait on hold to be told nothing they can do.

Ok, noted, thanks but they are leaving the NHS scheme because they are worried about the tax consequences of breaching the lifetime allowance rather than because they think that they are hard done by and could get better investment returns elsewhere.

(Always nice to hear from another accountant!)

Just to add, I wasn't saying that the GP partnership pension wasn't worth having, although I see how it comes across that way.

It's just that a bonus of nationalising the GP service would be that GPs would fall in line with hospital consultants in terms of their pension contributions. Why would you want to contribute 13.5% twice as a GP partner when you only have to pay it once as a hospital consultant for the exact same benefits.

I think there will be a lot of benefits to GPs of nationalising (in many ways, but not all), but far less for patients.

For all those who are saying "well at least it means they'll have to see patients again", I think you'll find it's not for the want of trying, and that bringing terms and conditions in line with NHS hospital T&Cs isn't going to be the fix you hope it will.

’This is a precursor to privatisation.’

This ^

100% agree with this happening.

Too many GPs have been swinging the lead for the last 2 years now, and I have a better chance of sitting in McDonalds eating a fillet o fish with the Queen than I have of getting a GP appointment at my practice.

I had a blood test the other week and asked the nurse when the doctors were going to get back to normal and start seeing people again. She said (a bit sharply,) 'they never stopped! They've been seeing people all along.'

I thought 'oh you bloody liar! I don't know one single person who has seen the GP since February 2020!'

About time they were called into question, and sorted out. They are the ONLY ONES who have not resumed seeing people .