Rewarding GPs
STOP PRESS - July 11th -
Almost five months to the day after I informed Virgin in writing that their plans to 'reward' GPs for making clinical decisions that increased Virgin's profits was unethical and contrary to BMA and GMC guidelines Virgin have been forced to change their plans.
As the article in Healthcare Republic says:
"... the BMA warned the plan would damage clinical objectivity, because GPs would have a financial incentive to direct patients to other services within the centre."
Which was exactly the point I made to Mark Adams, the CEO of Virgin in lengthy emails from as early as my third day in the job.
In that my concerns directly contradicted Virgin's plans for a rich income stream management chose to dismiss my concerns as 'making a mountain out of a molehill" and when I persisted with my concerns they dismissed me from my job too.
I now ask that the Virgin Group investigate my other concerns about the ethics of Virgin Healthcare's plans and acknowledge publicly that their business plan has gone seiously awry.
7th June 2008
The issue concerning how apparently 'independent' GPs were to be 'rewarded' by Virgin Healthcare is a complex one but there are simple principles behind it.
Having revealed the evidence I had on this and the other matters covered in this web site to The Guardian an article was published on 9th April 2008.
Why the Guardian changed their minds from having said initially this was ‘’a front page story – unless Gordon Brown dies’’ with the possibility of a follow-up in the Sunday Observer to a much shorter story on page 6 will be covered here.
Essentially, the ethos of the NHS involves a relationship between a patient and a GP where the patient can be confident that his or her GP makes clinical decisions based on what is best for the patient, unadulterated by concerns that the GP may have a 'hidden' financial interest in recommending certain treatments.
The General Medical Council web site is quite clear on these issues:
Financial and commercial dealings – paragraphs 72-73
- You must be honest and open in any financial arrangements with patients. In particular: You must inform patients about your fees and charges, wherever possible before asking for their consent to treatment
- You must not exploit patients' vulnerability or lack of medical knowledge when making charges for treatment or services
- If you charge fees, you must tell patients if any part of the fee goes to another healthcare professional. You must act in your patients’ best interests when making referrals and when providing or arranging treatment or care. You must not ask for or accept any inducement, gift or hospitality, which may affect or be seen to affect the way you prescribe for, treat or refer patients.
- You must not offer such inducements to colleagues. If you have financial or commercial interests in organisations providing healthcare or in pharmaceutical or other biomedical companies, these interests must not affect the way you prescribe for, treat or refer patients.
- If you have a financial or commercial interest in an organisation to which you plan to refer a patient for treatment or investigation, you must tell the patient about your interest. When treating NHS patients you must also tell the healthcare purchaser.
So, when I heard that Virgin Healthcare senior management were discussing how to ‘reward’ these GPs I wrote a lengthy email to the CEO, Mark Adams, and concluded:
’’Summary: It may be best to have a simple information card that can be handed to a patient that informs them that their GP has a financial interest in such a referral but that the referral is based entirely on best clinical reasoning and not primarily on that financial interest.
If such a service is also available on the NHS (eg physiotherapy) then the patient should be made aware of this along with waiting list delays.
If the GP concerned is salaried or has no financial interest in the transaction it seems the above advice will not be necessary.’’
In reply to this email Mark Adams seems to have missed the point:
‘’Thanks for your note John and I think that this is a typical NHS grey area. In the way that we currently envisage the practices running where the doctors have no direct control over other businesses in the practice and do not receive a commission per referral, but receive a level of profit based upon the overall profitability of the practice.
In effect, if a doctor referred a patient for a £300 course of private physio treatment I suspect that their share of the eventual profitability of the practice would mean that they were making no more than £3 for this referral.
I agree that it might be useful to produce some small card which refers to the relationship between GPs and Virgin Healthcare but in a non-inflammatory way and also in a style that would not cause us embarrassment if it was picked up by the media or by local GPs or the local PCT.
......
Sarah – I think that this is an issue for the specialist advisors from DLA but we need to be careful that we are not making a mountain out of a molehill. Most GPs already get paid for completing crematorium forms, for carrying out insurance medicals, for signing sick notes and for signing proof of identity for passports. I doubt that there are a series of handouts that GPs currently give to their patients in this regard and given the relatively small amount per referral how significant is this?
Mark Adams’’ (My Italics)
OK, so let me try and ’’unpack’’ this…Firstly, Mark Adams acknowledges that, effectively, GPs will be benefiting financially from the profits they create for Virgin by referring their NHS patients on to privately employed Virgin clinicians.
He defends this by saying that GPs:
’’..do not receive a commission per referral, but receive a level of profit based upon the overall profitability of the practice.’’
So, this means that GPs will receive profits which are largely based on the numbers of NHS patients that are treated privately. In fact GPs were to receive 10% of the overall profits made by Virgin Healthcare.
Now Mr Adams doesn’t see a problem with this because he argues:
‘’Most GPs already get paid for completing crematorium forms, for carrying out insurance medicals, for signing sick notes and for signing proof of identity for passports. I doubt that there are a series of handouts that GPs currently give to their patients in this regard and given the relatively small amount per referral how significant is this?’’
As I pointed out to him in my email by reply:
’Your argument with reference to GPs getting paid for insurance medicals / signing passports etc etc is a different issue really because it is quite clear to the patient that the GP is receiving a payment for this. The situation is transparent. The patient approaches the GP and asks for a service and the GP says 'Yes - this is what it will cost you' - it's a straightforward, transparent, commercial transaction.
The issue with GPs being paid for referrals to other clinicians is that the GMC are concerned that the patient may not be aware that the GP benefits from such a referral (ie the situation is not transparent) and you could end up with a situation where an unscrupulous GP is no longer making decisions based on the patients' best clinical interests but is tempted to refer outside the NHS because there is profit in it.
John Spencer’’
It concerned me at the time that the most senior individual in Virgin Healthcare could confuse and conflate such separate issues.
A GP asking for payment to perform non-clinical duties for which he is not paid by the NHS and a GP being ‘rewarded’ for clinical referrals are clearly very different.
Now, in another paragraph Mr Adams’ says:
‘’I agree that it might be useful to produce some small card which refers to the relationship between GPs and Virgin Healthcare but in a non-inflammatory way and also in a style that would not cause us embarrassment if it was picked up by the media or by local GPs or the local PCT.’’
My question, Mr. Branson, is why is Mr. Adams concerned that such a card could cause ‘’embarrassment’’?
Why is Mr. Adams concerned that the media, local GPs or the local PCT might ‘’pick-up’’ this card?
Surely if Virgin Healthcare were intending to be honest and transparent with the media, local GPs and the local PCT there would be no cause for embarrassment?
A clue may lie in a document called Project Plan Progress published on 14th February 2008:
Strategic Risks and Issues
Risks:
The key risks are;
- The PCT may interfere with service provision at the first Virgin Healthcare Clinic
Does this imply that Virgin's relationship with the PCT was as adversarial one and perhaps VHC's intentions as regards the PCT were less than honest?
Let’s look a little further at the regulations of the BMA (taken directly from their web site) regarding the relationship between private companies and NHS GPs:
May GP practices receive payment for work with private companies?
Practices may receive a fee for services provided or for work done by them, but it is important to note that, other than payment that the practice receives for rent (as detailed above), there must be a clear purpose for this and that purpose must not be in connection with any medical treatment to their own registered patients.
If this is in connection with the provision of medical treatment to registered patients the practices could be deemed in breach of their general medical services (GMS) or personal medical services (PMS) contract for breaking regulation 24 in relation to fees and charges, as they are receiving an indirect fee for their involvement in letting the private company treat and charge their patients.
If, for example, the practice was receiving an administrative fee to help promote the provision of medical services to their registered patients privately, this would be deemed to be in breach of the regulations.
May GPs recommend and/or promote a private service?
By all means a GP is entitled to discuss a patient's private options in the privacy of an individual consultation although any personal financial interest must be clear, and may be inappropriate (see Good Medical Practice). However, these options should be presented along with NHS alternatives where applicable. Within a consultation, it is not for GP practices to advertise or promote any particular private service, as this would be deemed inappropriate.
If a practice rents out space to a private provider of physiotherapy for example, the practice should not promote or encourage that service against any other service. Independence must be maintained between the two entities." (My italics)
So this advice seems in direct contradiction of Virgin Healthcare’s plans to ‘reward’ GPs with 10% of profits.
I wrote an email to the BMA on 12th May asking for clarification on these issues. I am disappointed that they have declined to reply.
Richard McMahon, Clinical Director for Virgin Healthcare has insisted that VHC had already received advice from the General Medical Council, prior to my employment, and that VHC’s plan were approved by them.
I have asked for copies of these emails to be forwarded to me but VHC have declined to do so.
If you are from the GMC or BMA would you be kind enough to respond to these issues and I will publish your reply here.
I will leave the final word to Dr Richard Vautrey, deputy chairman of the BMA's GPs committee who was quoted in The Guardian article on 9th April:
"The intention really is that Virgin will make money out of private elements within the centre. Our concern is that doctors working within the centre may be coerced or encouraged to make referrals or encourage patients to attend these private facilities. The real risk is the opening of Pandora's box, which once it is opened will be very difficult to close."
Mr Vautrey, if you have any more comments now you are aware of the full extent of these issues I would be happy to publish them.
The irony of this entire episode is that Virgin do not need to coerce GPs into their plans by offering financial 'kickbacks'.
GPs would be happy if profits were ploughed back into better clinical training and treaments instead but the commerically experienced crew at Virgin Healthcare are so used to motivating people by rewarding them financially that they cannot see this.
Read next story about Virgin Healthcare.
Read about Branson-Pickle's success in forcing Virgin to change their plans here.
Manchester, UK