Commissioning funds used to pay for GP basics

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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 HSJ investigation reveals.

HSJ’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.

A further £1.6m went on practice refurbishments including new floors and carpets, car parks and decorating.

In most cases primary care trusts approved the spending on the basis that it was within vaguely defined rules governing how different income streams can be spent.

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.

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 has 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.

King’s Fund senior fellow Nick Goodwin, who is leading the think tank’s inquiry into GP quality, said the spending uncovered by HSJ showed there was a “fudge” around what was considered a “core” GP service.

He said: “There is an issue there. But there is also an issue around trust and judgement.

“This spending should be transparent and open for the public to scrutinise.”

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 (see file on right).

Asked to justify why her practice spent more than £15,000 in one year on items including waiting room seating and digital thermometers, a GP practice manager in the North East told HSJ: “We just were given some money to spend.

“If we didn’t spend it, it would have only have gone into a black hole; on a lot of deep carpets at the PCT HQ.”

She said the seating was an additional benefit for patients that would not have been bought without the extra funds and she disputed that items such as thermometers and vaccine fridges should be funded out of the practice’s contract income.

She said: “People have the perception the GP income is enormous, but it isn’t. They are extremely clever people. If they decided to go into industry they could earn a lot more than they do.”

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.”

Commenting on the thousands of commissioning funds that were spent on GP practice floors, doors and chairs, the BMA committee’s chair Laurence Buckman said: “If they had permission from the PCT, then OK. If it’s within the [PCT’s] rules, all I would say is: it looks odd. The [surpluses] were meant to be spent on patient services.”

He said the ability of GPs to draw on additional NHS funds to pay for improvements to their privately-owned premises was long established and it was possible the commissioning surplus had been treated in a similar way.

He said: “Many of those things you might regard as a legitimate business expense have been funded by [PCT] improvement grants.

“Some have been enormous - £1m [for an individual GP] – and they end up in your [the GP’s] pension. I don’t think it’s right or wrong; it’s just part of GP payment.”

Steve Gilvin, director of primary care commissioning for the inner north east London commissioning sector who oversaw GP applications for NHS City and Hackney said the variation in what some PCTs approved and other rejected was often due to different historic approaches to what constituted a core service local practices were expected to meet.

He said: “About 12 years ago no practice was doing spirometry. So as practices started developing that area, we paid practices the cost of purchasing equipment as a one-off investment. But we felt by the time we got to PBC we’d done that.”

“But other equipment like blood pressure monitor we think of as standard equipment every practice should have.”

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.”