Reflections - looking back at the year that was

My Aussie sojourn ,at least physically speaking began almost a year ago to the day.

Mentally of course, I had been toying with the idea for a good 6 months prior. In fact, when we flew to Australia early November last year I had already had my AMC application approved.

After a 3 week holiday here, having met friends and made new ones and having looked at potential places to work in we went back and I remember vividly how I told my wife she had 1 month to decide what she wanted to do. I was already in Australia mentally and just needed the go ahead from my wife as she had her family in UK and it was a very big move for her.

The rest as they say is history. It still took us 5 months to get everything sorted and I flew out, alone at first in the first week of May.

Looking back these are my reflections on how things have gone. How I would do a few things differently and what I would look for were I thinking of moving Down Under now. Call it a Primer on emigrating to Australia (for GPs that is)

First decision: go through and agent or DIY??

We wanted to make sure we were ready to move and wanted to see what the country we were proposing to relocate to was like first hand. So, we decided on a DIY approach. I did contact agents and only used them to shortlist potential places (so I knew where to go and look!). Others, the vast majority I am told are perfectly happy to never visit before hand and just accept positions via an agency

Pros and cons: Obviously if you go through an agent they do all the legwork for you including help with applications like the hideously complicated AMC one and you get the job sorted and only then leave UK. Saves on the first trip but also gives you freedom about resigning from current position in UK etc only when everything else is sorted. Cons- you have no idea where you are going (having said that lots on help is available online like Facebook groups and other online forums)

If you go DIY like me then prior to leaving you know exactly where you are going and have already met you employer, colleagues etc and having this knowledge helps in looking for houses, schools etc. but obviously a scouting trip to Australia isn't cheap. We took it as a holiday first and foremost and even if I had decided to not move, I wouldn't have any regrets on that front as we did have a fantastic holiday!

But, I am dismayed at how agents are being portrayed in online fora and facebook in particular.

I think there are now enough UK Drs in Australia who have their own surgeries and are now looking at Social Media to recruit UK GPs. These people in particular are portraying Agents as some sort of money grabbing Fly by Night operatives. 

I have heard sentiments to this effect- ''agents send you to horrible places''. ''Agents charge $25K for a visa'' and other such non sense. First of all if you are planning to emigrate, you- the emigre pay the agent nothing at all- even on successful placement and secondly; your agent is often your one and only contact in Australia. 

An agent may interview and negotiate with several people for 1 position and only get payed by the employer once the candidate takes up the position. They do a hell of a lot more than just find you a job. They help with all aspects of immigration and their role doesn't end when you land a job. My agent was in contact with me even after I started working and only signed off after my 3 months were over. I did deal with my practice through her on various issues after I started working as I felt it was a much better way of doing things and my agent was aware on the Employer's behaviour at all times as well. I know of several people who negotiate with one place and then change their mind and go elsewhere. Think of the agent- they may spend months with you and you can go elsewhere and they get paid nothing!

Its a demand and supply situation. Currently, Australia needs Drs therefore Australian employer's bear the cost. Never look a gift horse in the mouth!

If someone offers you a job via Social Media and you like it, by all means accept it. But I can guarantee you one thing: No GP owner of a surgery can give you the help and guidance a Recruitment agent can. I did my applications myself for reasons mentioned earlier. But several people I know did absolutely nothing. They just sent CVs to their agents who then did the applications for them and this can be several hours of your life. Above all remember that Recruitment Agents are recognized and regulated. 

An owner of a surgery may offer to help you but they are not recognised immigration or recruitment agents. So, choose wisely!

My advice to potential employers wishing to recruit via Social Media would be this: Negotiate a better price with the agents. If you have done the leg work in finding a Dr, the agent now only has to help with the process. So offer them say $15K instead of $25K but don't for heaven's sake tell your prospective client to go it alone. It's nerve wracking trying to emigrate and the support provided by Recruitment Agents is needed!

When I open my own surgery this would be my preferred strategy.

What should I ask at an interview? This is a question often posed to me when someone is planning to come over. Again, my advice is this: it's you who are interviewing the Employer not the other way round. They need you, not vice versa. Actually, they are not even your employer- they are your sponsor and you are an independent contractor (think of them as agents managing your appointments, billings etc)

So what should you ask?

My checklist:

1) Percentage billings is obvious. But, again think carefully. I was offered 60% in one place and 65% at another. So 5% difference? Actually 11.5%- the 60% was inclusive of GST whereas the 65% has GST at 10% on top which equates to 71.5% of gross billings

2) Patient numbers- this is the biggest issue and hard to negotiate but well worth trying to sort out prior to arrival. Percentage billings mean nothing if the numbers don't stack up. 100% of zero is still zero and 60% in a busy place may well be more than 65% in a less busy place. In my view you need 150-200 patients per week for a Full Time Equivalent (FTE) Dr in a bulk billing practice. So ask how may FTE Drs they have and how many patients they see a week (Weekends are extra and excluded from this calculation)

3) Minimum Income Guarantee(MIG): Obviously the higher the better. But, what happens when this period ends? A practice may entice you with higher MIG but again if the patient numbers are not there, after this period ends, what happens? 

4) Review date: Usually there is a period mostly of 3 months or so when the MIG ends. Then, its up to you really. However, in your contract I suggest a more formal review be put in place and clauses for extending this period if need be also stipulated. Why? Read on!

I end on a warning note and apologies in advance if I ramble on a bit but I am interested in Health Economics- a sad side effect of being involved with a CCG and thus my views are tainted! Those of you who have read my previous posts will understand. 

In Australia at the moment there is rapid expansion in GP services. Here, GPs are broadly divided into 2 types- the traditional UK model which would equate roughly to the mixed billing model. 

The other, more relevant one to us is the Bulk billing model. These are called Medical Centres and are not the same as traditional GPs who just happen to charge less! Medical Centres are mushrooming- current trend is to have one in every shopping mall. This has far reaching implications with regards to points 2-4 above.

Medical Centres compete with each other on 1 thing solely- service provision. Convenience of location and opening hours are obvious. But less waiting times is also very important. Medical Centres are more like UK Walk in Centres- several patients a day are new. When there is lot of competition, the centre with least waiting times may win customers. With DWS restrictions and a virtually unlimited supply of UK Drs this is what I believe is happening. 

People are on a recruitment spree- if your pockets are deep enough to pay for the Agent fee and the initial MIG period then you can employ as many Drs as you want. This allows you to promote your Centre and extend the opening hours- 12 hrs a day 7 days a week is not unusual.

More Drs are required to fill in this rota particularly over weekends. But, during the week the numbers simply don't stack up 

After your MIG ends and there are no patients what will you do? Work longer, more unsocial hours and weekends- the main reason for coming here is lifestyle and this will be the first casualty. The Centre looses nothing. Lets say everyone is on 60% billings and the centre does 10,000 dollars worth of business in a day- the owners cut is 4000 regardless of the number of Drs. Logic says it would be better if it was 5 Drs billing 2K each, but it could be 10 Drs billing 1K each and the centre still earns the same amount. Why do they do it? It gives patients better access (Zero waiting times) and also DWS positions have been taken and if the area becomes non DWS the Centre now has an edge compared to say another centre who can cannot now recruit (Aussie trained Drs don't work in Bulk Billing Medical Centres period!) 

So I would suggest Drs put a clause in their agreement. When MIG ends there will be a review of patient numbers. If the patient numbers don't add up and you can in no way earn more if not as much as your MIG then the centre is failing in its contractual duty to provide you with patients and thus MIG should be extended. If everyone else is earning enough and only you aren't then clearly it's your fault- but I don't see that happening!

Let me know your thoughts, particularly if you like me have emigrated recently. If you don't agree with my views please do criticize.

Australia- Clarity of Vision

Arrived in Australia on 5th May after flying roughly 19,000 Kms.

So this is my experience literally so far and so faaaar!

As part of visa requirements for coming to work in Australia I had to obtain medical insurance for myself and family. As UK citizens we are entitled to reciprocal care with Medicare but its easier to do that after arrival.

So, amongst the first things I did on landing in Australia was to visit the local Medicare office to get my reciprocal card. I quickly realised how streamlined and unambiguous the system is as opposed to the UK where the same system of reciprocal care exists. In Australia I cannot access healthcare without my medicare card (can do via the BUPA cover I got for my 457 visa, have free emergency treatment or pay personally). Moreover, my entitlements are stored on my Medicare card which I need to access any service and they are not down to the whims of a GP. Also, I can access care without having to see a GP for everything.

I needed a new pair of glasses so I went to see an optician. Turned out an eye test and consultation were actually covered by medicare so I got this for free and then only paid for my prescription glasses- at no point was a referral to a GP or a referral from a GP requested.

Take a typical scenario: relatives from UK visit family in Australia and someone falls sick. They go to see a GP. The GP will charge them if they don't have a Medicare card and then they will have to claim it back under the reciprocal care agreements. At no point will the GP be pressurised to see or treat the patient for free. Moreover, not only is the GP paid, medicare will claim the money back from the NHS in UK (that is what reciprocal care is all about).

Now, reverse the scenario: Australian visits family in UK and falls sick. Family member will ring and demand an emergency appointment with their own GP. Said GP will have to see the patient as a Temporary Resident. The guidance is to only provide emergency treatment but family will demand everything including prescriptions for routine items. Either the GP refuses and only provides emergency treatment in which case his own patient (the UK family member) is upset and may complain or he does a FP10 script (a NHS subsidised script as opposed to a private one). If he does an FP10, the UK taxpayer foots the bill! (In Australia regardless of who wrote the script, the prescription benefits are stored on the Medicare card and you pay accordingly to the chemist).

In either case, no reciprocal care has occurred. There is no way the GP can record or the NHS claim from Medicare Australia for the visit to the GP (Note that  the reverse occurs). If the patient goes to A&E(even for non emergency scenario), gets a prescription or has an investigation, no reciprocal claim is being made as the GP has done the referral. In fact the BMA guidance states explicitly that it is not the GPs job to highlight on the referral or test form that the patient is under reciprocal care or even not entitled to NHS treatment (if they are from a country with no reciprocal arrangements) and that such checks must be done by the Hospital Trust. The BBC ran a programme on NHS fraud and highlighted that these checks don't  occur in almost any Trust in UK and as a result millions on pounds are lost every year. Details here on a similar report

It also highlighted that other EU countries are very good at claiming their costs back- Brits go to Europe and fall sick and NHS has to pay. EU citizens come to UK, get treatment and the  NHS can't be bothered to claim!

Add to this the huge number of patients from countries with no reciprocal arrangements. Now, as a taxpayer are you happy that your Govt is wasting your money on people who have no entitlement to care whilst simultaneously cutting down services available to you? (As if to highlight the issue recently this post from an American Dr visiting the UK was published. Have a look here)

Finally, another typical situation which I come across here daily and can't help thinking how wrong we've got it in UK. I work in Wollongong, which is a big University town with lots of overseas students and in UK I worked in Coventry which has a big and expanding University and lots of overseas students.

In Australia, overseas students have to have medical insurance and treatment is not covered by Medicare.

If the Uni expands and more students arrive there is no problem. Surgeries will hire more Drs and Medicare budgets are not squeezed. If the referrals are higher -say to psychologists or sexual health etc no one points fingers at the GPs or tries to performance manage them. The GP is free to practice in a safe and sound clinical environment as opposed to a monetary one.

Equally if practice numbers are low for Dementia, CVD, strokes etc as would be expected for a younger population that comes with a University Practice, Medicare doesn't come chasing the GP. In Coventry the University practices got a visit from NHS England for this very reason (low prevalence of certain diseases). And their funding was being threatened as 100s of patients were being removed from their lists (Payment to GPs is capitation based and Temporary Residents earn the practice a lot less than permanent patients. Are foreign students permanent or temporary?) This is the type of crazy admin work GPs in UK have to deal with on a daily basis.

In UK, foreign students pay a much higher fee and are  therefore  entitled to free NHS treatment. Fair enough, I think.

But only if part of that higher fee is transferred to the NHS. Otherwise the taxpayer is footing the bill for the Universities and the Universities love overseas students because they charge them higher fees. So in a city like Coventry, more overseas students means less NHS budget for the local taxpaying population. Fair you think?

Any health care system will have advantages and disadvantages. All systems are prone to misuse/abuse but in Australia I think there is a clear vision- your entitlements are clearly defined and carried by you on your medicare card. No one can sidestep that. Sure, there are losers and winners but the rules are clear. Medical professionals do not have to juggle financial, ethical, moral and clinical decisions. If the Govt wants to make cuts it simply changes the benefits available via your card. For example if you have diabetes you can get 5 visits to allied health professionals in a year (podiatrist, physio, dietitian etc). If the Govt decided to save and reduce costs they would simply reduce that number to say 4/year. Or if they thought diabetes is under diagnosed/treated etc it could increase the benefits. The GP doesn't bear the wrath of the patient nor is there any ambiguity as with all NICE guidelines for example (they recommend a treatment algorithmn and then say its up to the clinician's decision and patient choice should be respected). Look at the contradictory advice regarding glucose testing strips from NICE and DVLA for example. NHS would love you to stick to NICE guidance, but if a patient has a hypo at the wheel and you have not given enough testing strips as recommended by DVLA you get sued or struck off. A ridiculous situation to practice medicine in.

In UK, the Govt leaves everything, deliberately I feel a bit muddy. You are not entitled to free care if you're not from a country with reciprocal agreements but it's up to the GP to see them as a temporary resident and if the GP feels its appropriate they can register the patient. The NHS charter says tests, referrals etc must be paid for but the BMA advises against it to GPs. When things go wrong the Regulatory bodies- GMC etc will use the higher moral ground and stick to BMA guidance. But, in order to drive costs down the Govt uses all its might to make you go against BMA advice- the erstwhile PCT and now NHSE, CQC, NHS Choices, the complaints procedure for the NHS all make it impossible for frontline staff to follow the BMA guidance. In short, its clear as mud.

This kind of muddy thinking pervades all spheres of UK Govt and policy. When Coventry built a new Super Hospital the number of parking spaces were reduced as compared to the old Hospital because more parking spaces were against the Govt's 'Green Agenda'. Now, the hospital is notoriously congested and when the Air Ambulance lands or takes off even Ambulances are queuing just outside the hospital and the local residents are fed up. The Hospital has put up several bids to ease the parking problems and all have failed. 

Take this 'Green Agenda' a bit further. UK Govt says its committed to reducing ownership of cars and would like people to use public transport and greener cars. Yet, when the depression hit, one of the premier policies of the Govt to get us out of it was the car scrappage scheme which put thousands of new cars on the road. 

Equally if you follow this logic of less people buying cars and using public transport instead being good for the country, then all British car manufacturers will go bust. British car manufacturers are either at the Luxury end of the market(JLR, Rolls Royce etc) or bespoke sports cars- Morgan, TVR, Bristol etc. All these cars are distinctly eco-unfriendly. Is the govt prepared to see them go under? When JLR hired new people in Coventry this was greeted by Ministers as a step forward and a sign on investor confidence returning in UK. Surely, they should have been lamenting the fact that more gas guzzling, CO2 spewing cars were going to be manufactured?

I feel things in Australia are much clearer. They may not be to your liking but they are clearer. Australia has a big land mass and Australians drive long distances over roads that are often uneven. Ergo, they drive big cars and houses, garages, parking spaces etc are built to accommodate this. In Wollongong, in order to promote public transport we don't have congestion charging or prohibitive parking charges. Instead, in true Aussie style we have the The Gong Shuttle- a free bus service that connects all the major spots and the University. It runs a schedule that is better than any paid for variety in Coventry and also runs on Public Holidays and weekends (see schedule here).
Australians love the outdoors and the vast majority live by the coast. So, in Wollongong the council is spending money on running free swimming pools, public baths, free beaches with life guards (see here for details) and is also spending millions on a cycling/running path running some 20 odd kms. 

What exactly does UK stand for currently? I actually struggled to come up with an answer to that. I would have thought that education and the English language itself,  and the NHS would surely be in the top 10. Yet, Councils are busy closing down public libraries, toy libraries and Schools have had a freeze on funding and the NHS is facing massive cuts.

Time to ask- what exactly does being a Brit mean? What values, institutions etc would you like to preserve? And time to get voting my friends!  

Part 3- Melbourne

A trip to Australia wouldn't be complete without some wildlife shots! Visited a small farmhouse with some animals. Aryan loved it and we finally got to see some live Kangaroos(saw lots of Roadkill!!!)

Pics are a random assortment of what we saw.

Arrived in Melbourne and met some close friends after many years. He's a GP near melbourne and got talking about our Health Systems. He was surprised to hear how much non clinical stuff we GPs in UK have to do and was also shocked to hear that we have no system of checking for eligibility. In Australia no one gets through without a Medicare card. I was surprised to hear that they have literally next to no admin work to do. Seemed a very relaxed and clinically driven environment to work in. 15 min appointments, no telephone triage, visits etc. If you choose to work at weekends or OOHs you get paid 1.5-2 times regular rates. What's not to like? Why I wonder do we choose to performance manage GPs and lumber them with mountains and paperwork and then complain that they do not spend enough time treating patients?

Melbourne Skyline

With my friend took the Great ocean Drive to the 12 Apostles. Stayed at Apollo Bay and visited Lorne. Pretty seaside resorts both. Lorne is popular with 'Schoolies' and they were out in force when we arrived. Enjoyed the cafe lifestyle and Aryan loved the beach and play facilities that all Australian cities seem to have. Stayed in another lovely apartment.

12 Apostles

The Apartment at Apollo Bay

After that it was back to blighty unfortnately. Our trip gave us plenty to mull over. The lifestyle and opportunities on offer were hard to overlook and the Health System and job offers were equally tough to ignore.  Having found family and friends there too was an added bonus.

Waiting to board the A380 didn't seem glamorous anymore the second time round. More like cattle waiting to be herded onto a lorry!

Waiting to Board at Melbourne Airport

Next blog- The Big Question. To emigrate or not?

Part 2 of Australian Adventure- Sydney to The Gold Coast

Drove from Sydney to Surfer's Paradise along the Pacific Highway. Distances are in Kms but the speed limit was 90 Km/Hr and in many places there was construction going on to build bypasses  avoiding towns and temporary speed limit of  70km/hr were in place.

Wherever possible we took the designated scenic routes;  so we took our time- the whole point of driving! We had a Holden Commodore- an Aussie built 'large car'. 3.6lt Aussie muscle-very comfortable and great suspension for the roads and a huge boot which easily swallowed our luggage and baby stuff. We were very impressed with the  car- sad to hear its ceasing production soon. A couple of Aussie Motel owners were very impressed that I had chosen to rent one of these.

Must mention the highway- everyone follows the speed limit. 90km/hr means just that. Signs warn 'Speed cameras anywhere, anytime' and Police hand out on the spot penalties and fines. Saw some patrol cars but even on deserted roads everyone stuck to the legal limit. Made for a much more relaxed driving experience. In fact everywhere we went people were much more law abiding. No graffiti, litter, drinking on the beaches or public places etc. Again we were impressed and it was noticeable on a short stay. Nor did it feel oppressive like a police state.

Nambucca Heads on the Pacific highway

View from Motel
A typical Aussie motel- room with separate kitchen and a balcony. Much easier to live in than a typical hotel room especially with Aryan. He always had space to play and run around. In the little Gazebo was a BBQ and the owners were very friendly and helpful- again an Aussie trait if Motel Owners are anything to go by

Aparthotel Q1 Resort, Surfer's Paradise- Very swish!

View from 21st Floor Balcony

At the Beach Surfer's Paradise

Q1 Resort Pool

View from the Observation Deck on the  78th Floor

So, we loved the drive and arriving in Surfer's Paradise and especially the apartment at Q1 Resort was magical. 

The promised lifestyle and weather were all present in abundance and its easy to see why people fall in love with the place. We returned not via the pacific highway but on the inner roads which were better in many ways. After a short stay in Kiama which was highly recommended by my cousin we headed on to Melbourne to visit friends and from there to the 12 Apostles and then sadly back home to blighty!

Part 3- Melbourne

Our Australian Adventure- part 1 Getting there!

Packed and ready to go

On the plane- Birmingham -Dubai with Emirates

Dubai from the Air

The A380 beofre boarding. From Dubai to Sydney. 14 long hours!

Sydney Airport. After 24 hrs in the air and almost 36 hours later. Gruelling

First impressions- much smaller than we thought. Comparable to Birmingham Airport. People are much more friendly and there are lots of languages being spoken; most we can't recognise!

Next Blog: Sydney and the Gold Coast

Costs and Outcomes- NHS v/s Medicare

So how exactly does the Australian system compare vis a vis the NHS?

Does giving Drs complete freedom make them irresponsible clinicians? Do costs skyrocket?

What about outcomes- how do they compare?

Exact comparisons are of course well nigh impossible but people have made a stab at comparing health systems- each one invariably comes out with a different outcome but have a look at the link below. It talks about the most efficient health systems. I think the gym analogy ends here for several reasons:

• The health industry is much more regulated.
• Though there may be competition most countries will map Drs to demand. In UK the average GP has 1800-2000 patients registered with them. In Australia, the govt earmarks Areas of Need (AON) and District of workforce shortage (DWS) where it tries to match numbers of Drs to demand and actively directs Drs where there is a shortage. So unlike a gym when GP surgeries exist close to each other the number of patients is sufficient for both to exist.

Bloomberg has used what it calls 'Efficient health Care' as a means of judging success- this is based on several parametes including life expectancy and per capita costs. UK is number 14 on the chart. And Australia? No. 7. For a full list see here (Updated 2/12/14 the link has been updated and some rankings/figures are now different)

So clearly a capitation based system cannot be said to be superior in principle. There is some merit in saying that a free market economy model does lead to spiraling costs as in the USA (ranked 46) but this is an Insurance lead model and not a levy on income based model like medicare.

But, is it that important? Even UK is not badly placed and 14 isn't too bad. However, there are some compounding problems which I feel will widen this gap to the detriment of UK. UK has an ageing population and though Australia is aging too it is a)younger to begin with and b)growing older more slowly. The median age (Median age is the age that divides a population into two numerically equal groups - that is, half the people are younger than this age and half are older) of Australia is 37.5 and of the UK 40.5 (For a full list see here)

If that wasn't enough the projected number of people over the age of 65 in 2020 stands at over 19% for UK and just under 16% for Australia. Even in 2050 Australia will have less over 65s than UK (see here).

Remember what I said about 10% of your population using up 90% of resources? Well, the vast majority of those reside in the over 65 age group. So, if a country has a higher burden of over 65s and this is projected to grow; where should said country concentrate its resources? But, just at this crucial juncture the NHS has embarked on a project to save £20 billion by 2020!!

A recent kings Fund report states :From 2012 to 2032 the populations of 65-84 year olds and the over 85s are set to increase by 39 and 106 per cent respectively whereas 0-14 and 15-64 year olds are set to increase by 11 per cent and 7 per cent respectively.

That means the work force will shrink and those requiring increasing support will increase exponentially. Whilst the report states that the elderly still make a net contribution to the economy even after taking the increased health care costs it is clear that health care costs do go up. 

At precisely this time the NHS is faced with low staff morale and reduced staffing levels. The RCN(Royal College of Nursing) has identified 68,880 NHS posts marked for cuts by 2015; of these 24,836 have already gone, of which 4,837 are nurses, midwives or health visitors, and 4,042 are healthcare assistants. 

Five Psychiartry consultants from my local hospital have upped sticks and gone to Canada- this at a time when a dementia epidemic is predicted! And the number of Drs requesting Certificates of good Standing from the GMC (a surrogate marker for Drs intending to migrate) is going up.

As a clinician I can't help but feel alarmed at these changes. And as a potential patient? Is this why we are going to work longer, pay more in NHS contributions, taxes etc? The focus seems to be on short term gains and a longer strategic vision seems to be missing. 

This I must point out is not an inherent fault of the Capitation based system. It does, in my view lead to the wide variation in primary care that is evident in UK and some people think the NHS reforms were motivated by a desire to dismantle this. 

If true, it seems an unnecessarily convoluted way of doing things and may have potentially disastrous and unintended consequences

I started by ending an analogy. I'll end by starting another. The NHS reforms centered around making Drs commissioners and putting them in charge of budgets instead of managers. The presumption I guess was that as clinicians they would make sound clinical decisions and commission more cost effective services based on their local population needs. 

But is there any evidence that this is the case? You could argue that its too soon to say. But the effects of this reorganisation itself; seem to me atleast, to be having the opposite effect.

So the analogy? If we assume the NHS was the military and apply the same principle- ministers, managers, manufracturers are messing up the budget so lets give control to the soldiers. Therefore like CCGs commanders from the 3 services lead and control expenses, acquisitions, deployment etc. Makes sense? 

Now in this scenario, can you imagine a Commander from any service going up to Parliament and willingly accepting cuts? Or actually making bigger savings than targeted (for 2011/12 the NHS delivered a surplus of over £2billion!) and then accepting even bigger cuts year on year? This is exactly what Drs as commissioners are doing (my personal opinion again). So they may make cuts in troop sizes (NHS is loosing frontline staff so an apt comparison), reduce services altogether like close bases (akin to closing hospitals or A&E departments). Is that what  the armed forces do? or the police chiefs??

No- they have budget cuts imposed on them. They protest loudly and spell out the dangers of those cuts that they foresee. Then they try and deliver what they can. They are candid with the public- the police chiefs come out and say openly that due to cuts there will be less bobbies on the street for example.

But, when it comes to the NHS,  politicians promise a world class health system to the public. Yet, they allocate a budget which makes it impossible to deliver this, leave alone investing for the future. And the Commissioner Drs? Do they protest like the Police chiefs or Army generals? No! they act like they believe the cuts are justified themselves and make compromises to deliver what they have been asked to. This erodes patient confidence in their GP. This to my mind is the biggest debacle of the whole situation. If the Govt is unwilling or indeed simply unable to spend what it takes to deliver a world class health system then it should be candid about this with the public. 

We as Drs should demand more funding and expenditure per capita if that is what is required (and evidence I have presented above would indicate that it is). We are always told that there isn't an infinite pot of money- in fact there is! The spend on NHS as a percentage of GDP is not only tiny but shrinking. 

The govt will shout form the rooftops that spending per capita on NHS is increasing year on year. However, as a percentage of GDP it is falling!

Don't believe me? Look here at the figures  for yourselves. 

I ask again- with an ageing and growing population should the Govt spend more or less on the NHS as a percentage of GDP? And as Drs what is your duty to your patients. Think long and hard before you answer that if you're a Dr.

Next blog- I visit Australia!

The Australian model- fee for service

So what is the Australian model? This is called a fee for service (FFS) system. 

Keeping the gym analogy going- if the UK capitation system is like a monthly direct debit, the FFS model is like paying a fee each time you use the gym but with no monthly payments. Obviously, you pay according to the services you use. 

Many advantages are immediately apparent: it costs nothing to those who don't use the gym. Light users don't subsidise heavy users. If demand goes up, the gym owners simply invest in more facilities, equipment,staff etc. The gym owners have no incentive to try and squeeze profits by providing inferior services or trying to curtail use of their facilities. In fact, they are more than happy to oblige their customers as they are competing with other gyms 

So what about the disadvantages? Firstly, continuity of care is a casualty. People are free to go wherever they like and are not registered with any one practice or doctor (no monthly direct debit). 

Secondly, since people pay a fee to get in, the assumption is they will want something for it so mere reassurance or an offer to review later doesn't work as it does in a capitation based system. Drs feel obliged to investigate or prescribe in such a system. Also from a business point of view it is inherently more risky- you invest in a new service or staff and patients leave to join a new practice across the road. 

Also there is a risk of spiralling costs- there is no cap. Patients demand more and more and business just keeps expanding to fill the demand putting the whole economy at risk. 

But, patients are not gym goers and most people like to see one Dr and value continuity of care. So what is the evidence? Is there evidence that Australia or Canada spend huge amounts on health care? And what about outcomes. Who fares better?

In my next post I will evaluate the evidence to see if any of the assertions are indeed true. 

Australia - An NHS GP abroad

I am a GP in UK and have been practicing for about 5 years now.

In the UK we have a capitation based system for GPs. This was a hard concept  for me to grasp when I first started. A senior colleague and friend explained it to me with this analogy:

It's like a gym membership. People sign up and you get paid a fixed sum for everyone who signs up. You then actually make a profit from the people who sign up but don't use your facilities. 

People who actually use the gym cost the gym owners money. A gym can try and extract some revenue from them by offering them extra services like cafeterias, saunas, physiotherapy,massages etc.

GP surgeries are exactly the same. They get paid a certain amount for providing 'core services' and then they can bid for certain 'extras' called enhanced services or offer other services from their premises like insurance medicals or travel vaccines. 

But the bulk of the income comes from the 'core contract'. Traditionally, GP profit again comes from patients who are registered with the practice but never use the service- the general wisdom is that 10% of your patients will use about 90% of your resources. 

Now, it becomes obvious that a gym in order to maximise profits has to do the minimum possible for the people who do turn up to the gym and yet keep them happy. 

Obviously, if more and more of the members who paid their dues started turning up or the number of people who do turn up started demanding more services then the profit margin of the gym would be affected. In order to resolve this gyms can put up their prices. 

But, the GP contract is centrally negotiated and GPs cannot charge more capitation fee. With an ageing population and increasing demands from the worried well it is obvious that the number of people using the service is increasing. But, If the capitation fee doesn't increase in line with this increasing demand then GP surgeries are bound to suffer. 

This has been going on in the UK for the past several years and puts Drs in a very awkward position and often affects the whole health economy. This is also responsible for the wide variation seen across GP surgeries in the UK. Consider a simple scenario:  a GP surgery sees a big increase in number of patients with diabetes registered with them. A logical response for them would be to hire a diabetic nurse specialist to support these patients-initiate insulin, carry out regular checks, educate them regarding diet, exercise etc. In this way they could keep referrals to the hospital or other services to a minimum and cost the exchequer less money. 

As a clinician this is obvious. But as a businessman? (Think what a gym owner would do in a similar situation) A practice will not be compensated for hiring this staff member or for upskilling their existing staff. 

On the other hand, if the practice chooses to refer every patient requiring insulin to the hospital it will cost them nothing! Thus, they can affectively have a nurse with lesser training and on a lower pay scale or even an Health Care Assistant instead of a nurse and have a higher profit than compared to another practice who chooses to have the requisite skills in house. From a business point of view the approach of the first practice makes sense and that is what a gym owner would do. But, does that make sense in a health context? 

More importantly, as a GP principal having to make these decisions where monetary considerations conflict with your clinical judgement, training and desire and need to serve your patients how does it affect your morale? How does it impact on that holy of holies- The Doctor/patient relationship?

This blog is an account of my journey from here on.

I have been grappling with these issues for some time now. When the government announced that they were giving powers to the GPs to commission services instead of the PCTs I was naive enough to believe this would change things. Surely, GPs would look at the needs of their populations and ensure appropriate services were available to all patients. But, this too has turned out to be a mockery of the original proposal- GPs are in charge of commissioning services from hospitals but have no say in how GP surgeries are run. Since 90% of NHS consultations occur in GP surgeries it is obvious that this change cannot and will not change grass root GP practice and the conflicts I alluded to that GPs particularly principals face will continue.

I am not alone in being disillusioned thus. Apparently, there is a veritable stampede of NHS Drs emigrating to places like Australia, Canada and increasingly the Middle East. 

Some time ago, I decided to explore my options and for various reasons settled on Australia as a potential destination for me and my family. 

First I did try and understand their health and GP system. The Australian and indeed the Canadian system is a fee for service model. More about this in my next post