Appendix II
Survey of workload and remuneration in
general practitioner and community hospitals
September 2004
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1.
Introduction
192 general practitioners working in community hospitals in the UK were identified from the
community Hospitals Association database and asked to provide information on their
workload and remuneration. All 192 serve community hospital beds, 105 doctors also
perform casualty work.
2.
Total number of hours spent each week working in GP and community hospitals
GPs spend an average of 11 hours a week working in GP and community hospitals (range 10
minutes to 72 hours). A quarter of respondents spend 15 hours or more a week on this work.
3.
Community hospital beds
GPs are remunerated for their work attending community hospital beds in a variety of ways
(Table 1). The most common is through bed fund arrangements (69%).
The contract is most often held by the practice (43%) or individually (38%). 13% hold a
contract with a group of doctors locally and 5% have another arrangement (Table 2).
Only 23% (45/192) of doctors reported being employed on national terms and conditions.
28% said they were not employed on national terms and conditions of service and 47% did
not know (Table 3).
The majority (68%) provide 24-hour cover for their unit. The remainder provide ten to twelve
hour/day cover with other arrangements in place for out of hours (Table 4).
An average of eight hours per week is spent attending community hospital beds. A quarter
spend 11 hours or more per week attending community beds (Table 5).
The average number of times GPs are specially recalled to the hospital to attend beds is 4.3
times/week (Table 6).
The vast majority (85%) make or receive calls relating to community hospital work at times
when they are not carrying out their normal session (Table 7). The number of calls made
range from 0 to 80 (average 4.4) the number received range from 1 to 160 (average 6.4)
(Table 8).
4.
Job weight
The majority of GPs (83%) work without supervision. 91% of GPs provide specialist care that
is usually associated with hospital settings (Tables 9 to 12).
5.
Non-clinical duties (Tables 13 to 15)
In addition to direct patient care:
42% of GPs (80/192) have management responsibilities, of which 35% (28/80) receive
remuneration
37% (71/192) carry out administrative duties, of which 24% (17/71) are remunerated.
28% (54/192) are involved in clinical governance, of which 19% (10/54) are remunerated.
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25% (48/192) have teaching duties, of which 15% (7/48) are remunerated.
17% (33/192) undertake preparation for accreditation, of which fifteen percent (5/33) are
remunerated.
6.
Casualty work
The most common form of remuneration for casualty work is a retainer payment for 24-hour
cover (46%). 27% receive a sessional payment and 26% receive a payment per number of
patients seen (Table 16).
54% hold a practice contract, 30% hold an individual contract and 15% hold a contract with a
group of doctors locally (Table 17).
The average amount of time spent each week on casualty work is eight hours. A quarter spend
nine hours or more on casualty work each week (Table 18).
7.
How do you see your involvement in GP and community hospitals changing as a result
of changes to GMS out-of-hours arrangements? (Tables 19 to 22)
56% of GPs are planning to withdraw from out-of-ours cover and 6% are planning to
withdraw from all community hospital work. A quarter a continuing with present
arrangements for community hospital work.
8.
GP's views on work in community and GP hospitals
Many respondents feel this is an area that has been badly neglected. The work has for a long
time been under-resourced. Doctors in the past have been happy to provide this service to the
community, even though this has involved being on call 'for work of unknown amounts at
unknown times'. Now, however, doctors feel undervalued in the face of increasing demands
from Trusts and this good will is being eroded.
The job itself is changing with early discharge from District General Hospitals (DGH) of
complex cases and 'out of area' patients. Elsewhere the complexity of the work is increasing
as GPs develop special interests. This is inadequately remunerated at current clinical assistant
rates.
A number of respondents describe remuneration significantly below the rate recommended by
the BMA (e.g. 50p per 'point'), others are paid £50 per admission (compared to £3000 per
admission to a DGH). Some report not being paid at all.
A random sample of respondents' comments are presented in Table 24.
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Table 1. Under which system are you remunerated? (More than one may apply) Base =188
Bed fund arrangements
Clinical assistant grade
Contract with Trust/PCT
Per admission
Hospital practitioner grade
Based on Holden formula
Session
Other system
Number
129
37
16
14
12
10
6
17
% of Cases
68.6
19.7
8.5
7.4
6.4
5.3
2.5
9.0
Number
73
83
24
180
%
40.6
46.1
13.3
100.0
Table 2. Is your contract?
Individual
Practice
Group of doctors locally
Total
Table 3. Are you employed on national terms and conditions?
Number
45
54
89
188
Yes
No
Don't know
Total
%
23.9
28.7
47.3
100.0
Table 4. Do you provide 24 hour cover for this unit?
Number
127
61
188
Yes
No
Total
%
67.6
32.4
100.0
Table 5. In a typical week how many hours do you spend attending community hospital beds?
Weekdays between 0800 and 1830
Weeknights between 1630 and 0800
Weekends between 1830 Friday and
0800 Monday
Total
Mean
5.1
1.2
Min
0.2
-
Max
30.0
10.0
25%
2
-
50%
4
1
75%
7.5
1.5
1.6
7.5
0.2
12.5
50.0
3
1
5
2.0
11.0
Table 6. In a typical week how many times are you specially recalled to hospital to attend the
beds?
Mean
4.3
Min
0
Max
120
25%
2
50%
3
69
75%
4
Table 7. Do you normally receive/make telephone calls relating to community hospital work at
times when you are not carrying out your normal session?
Yes
No
Total
Number
159
29
188
%
84.6
15.4
100.0
Table 8. If yes, please estimate?
The number of calls received each week
The number of calls made each week
Mean
6.4
4.4
Min
1
0
Max
160
80
25%
2
2
50%
4
3
Table 9. How often does your work involve being supervised & having your work reviewed?
Never
Sometimes
Very often
Often
Total
Number
158
25
6
2
191
%
82.7
13.1
3.1
1.0
100.0
Table 10. How often does your work involve managing difficult cases without supervision?
Never
Sometimes
Very often
Often
Total
Number
7
85
48
47
187
%
3.7
45.5
25.7
25.1
100.0
Table 11. How often does your work involve providing specialist care usually associated with
hospital settings?
Never
Sometimes
Very often
Often
Total
Number
17
93
41
36
187
%
9.1
49.7
21.9
19.3
100.0
70
75%
6
5
Table 12. How often does your work involve being supervised & having your work reviewed?
Never
Sometimes
Very often
Often
Total
Number
55
75
33
23
186
%
29.6
40.3
17.7
12.4
100.0
Table 13. Which of the following do you undertake as part of your community hospital role?
(More than one may apply) Base =192
Number
84
54
48
80
71
33
Continuing professional development
Clinical governance and audit activities
Teaching
Management responsibilities
Administration
Preparation for accreditation
%
43.7
28.1
25.0
41.7
37.0
17.2
Table 14. For which of the following are you remunerated/do you receive protected time to
undertake? (More than one may apply) Base=192
Number
15
10
7
28
17
5
Continuing professional development
Clinical governance and audit activities
Teaching
Management responsibilities
Administration
Preparation for accreditation
%
7.8
5.2
3.6
14.6
8.9
2.6
Table 15. Do you have access to secretarial support for this work?
Yes
No
Total
Number
41
126
167
%
24.6
75.4
100.0
Table 16. On what basis are you remunerated for casualty work? (More than one may apply)
Base=101
Retainer payment for 24hr cover
Retainer payment for 12 hour cover
Retainer payment for 12 hr cover Monday to Friday
A sessional payment
Payment per number of patients seen
Other system of remuneration
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Number
46
7
8
27
26
21
% of Cases
45.5
6.9
7.9
26.7
25.7
20.8
Table 17. Is your contract for casualty work?
Number
30
53
16
99
Individual
Practice
Group of doctors locally
Total
%
30.3
53.5
16.2
100.0
Table 18. In a typical week how many hours do you spend doing casualty work?
Weekdays between 0800 and 1830
Weeknights between 1630 and 0800
Weekends between 1830 Friday and
0800 Monday
Total
Mean
3.5
2
Min
0
0
Max
25
13
25%
1.0
-
50%
2.0
1.0
75%
4.0
2.0
3
7.7
0
15
40
49
2.5
1.5
4.5
4.0
9.3
Table 19. How many hours, in total, do you spend each week working in GP and community
hospitals?
Mean
11.4
Min
0.16
Max
72
25%
3.5
50%
8
75%
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Table 20. How do you see your involvement in community hospitals changing as a result of
changes to GMS out-of-hours arrangements?
Will withdraw from all community hospital work
Will withdraw from out of hours cover
Will continue with current arrangements for community hospital work
Will undertake more community hospital work
Other
Total
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Number
11
97
48
4
13
173
%
6.4
56.1
27.7
2.3
7.5
100.0
Table 21. How do you see your involvement in community hospitals changing as a result of
changes to GMS out-of-hours arrangements: other responses (n=13)
Bed fund will continue; Cover of other work will possibly be transferred by PCT to other provider.
Awaiting PCT decision on alternative cover.
Don't know.
I suspect the PCT will stop payment for the OOH component of our casualty work. Yet to be
negotiated!
Negotiating new pay scale & NHSQIS quality payments.
New contract already based on NGMS. Started 1.4.04.
Still to negotiate with Health Board.
Uncertain at present but keen to withdraw from OOH.
Waiting to see what PCT propose. Don't want to jeopardise employees status if redundancy is
proposed by PCT.
Will strive for new contract to take into account admissions & continuing care out of hours - must be
properly remunerated.
Will withdraw from out of hour cover. Reluctantly abdicating as my practice & the PCO are ? cover to
GP out of hours.
Will withdraw from out of hours cover & will undertake more community hospital work.
Will withdraw from out of hours cover or will continue with current arrangements for community
hospital work. May be bullied into taking over A&E/minor injuries.
Table 22. How much will this cost the practice?
0
£400
£1,000
£1,700
£2,000
£2,500
£3,000
£3,200
£5,000
£6,000
£7,500
£10,000
£11,000
£12,000
£12,500
£15,000
£18,000
£25,000
£30,000
£36,000
£45,000
£104,033
£120,000
Total
Number
18
2
1
1
1
1
1
1
2
2
1
3
1
4
1
1
1
1
1
1
1
1
1
48
%
37.5
4.2
2.1
2.1
2.1
2.1
2.1
2.1
4.2
4.2
2.1
6.3
2.1
8.3
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
100.0
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Table 23. In what geographical region do you work?
North
Yorkshire and Humberside
East Anglia
Greater London
Rest of the South East
South West
East Midlands
West Midlands
North West
Wales
Scotland
Northern Ireland
Total
Number
9
6
7
2
21
43
8
11
6
18
39
2
172
%
5.2
3.5
4.1
1.2
12.2
25.0
4.7
6.4
3.5
10.5
22.7
1.2
100.0
Table 24. Comments on work undertaken in GP and community hospitals
(10% random sample)
Current rate of pay is totally unsatisfactory. I will not be continuing this work unless it increases
substantially. This would be with great regret, as I enjoy the work & the patients value it VERY
highly. However I can no longer subsidise this service when other work would be as well paid & less
intrusive. It is hard for administrators to understand the ‘hassle factor’ of being on call/available for
work of unknown amounts at unknown times.
(1) Wards. Derisory pay for responsibility & commitment required for the clinical assistant job
which can in winter be over 15 hrs/wk (& up to half of that at weekends or after 6.30pm because of
problems transferring patients in the day). Bed fund scale remuneration only at 50 per ‘point’ instead
of £1.40+.
(2) A&E. No longer a job we do up there – patients usually come to us in the surgery as they know
we will be there. But no local enhanced service agreement for providing this. We are still receiving
our casualty pay which covers this at present but they are of course talking about removing this.
Island practise population 1,400. No out of hours provision possible from mainland except using
locums. Our GP practise presently provides locum flats, heating, lighting, phones etc. for locums out
of hours. This in itself is costly. I currently work a one in two rota with a doctor who has agreed to
join our practice recently. Prior to this I have often been on call 24/7 for periods of weeks on end.
This is unsafe & I refuse to carry on doing this even for holiday cover.
Vastly undervalued & resourced.
We have always seen our community hospital work as important for the community, and not as a
profit-generating activity. Sadly, attitudes at the PCT have changed such that good will by GPs has
evaporated & this combined with the far more demanding & complex cases now transferred to our
community hospital calling for more time, and the lack of consultant support from the DGH means
we will not be sorry to say farewell to this longstanding commitment.
We are hoping to involve the community hospital in (town) with undergraduate teaching. This will
change the role. The new, younger GPs do not use the beds because of the poor pay and continual
phone calls. This unit has some consultant beds covered by a GP practitioner on a sessional basis.
The PCT (so far) have not attempted to review our contract that does include OOH cover - we have
decided to wait for them to realise this fact! We suspect that the management have not applied
themselves to the question of contract. N.B. Our current contract does not count towards our NHS
superannuation. We have always felt that it should.
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Glad to see it go!
Would be best to pay on basis of consultant sessions notionally for work done/responsibility.
Current rate of pay is totally unsatisfactory. I will not be continuing this work unless it increases
substantially. This would be with great regret, as I enjoy the work & the patients value it VERY
highly. However I can no longer subsidise this service when other work would be as well paid & less
intrusive. It is hard for administrators to understand the ‘hassle factor’ of being on call/available for
work of unknown amounts at unknown times.
Just about to retire so am willing to continue past arrangements which have become more
unsatisfactory with dangerous combination of early discharge of complex cases, often not out
patients, without ANY contact with doctors at DGH plus poor out of hours cover – hence my
dropping in at weekends to make sure all is well – a rather unfashionable thing to do these days.
Our contribution to the NHS has long been undervalued. We provide a service for our local
community and NHS Grampian know we are reluctant to reduce our input as the community in
which we live will suffer – this has been used for too long to pay us peanuts. However, I feel the
worm is turning and attitudes amongst my colleagues is hardening. Get us some decent money for the
work and responsibility taken on.
As a result of the change in GP contract & the lack of change in GP hospital contracts there are no
incentives to continue 24hr cover. My colleagues all want to lose OOH. As a result the hospital has
no admissions OOH and little cover – the case mix has become more stable & less acute. As a direct
result I have decided that I cannot continue in practice and have resigned. I cannot face the changes
in practice and income that will result. I anticipate that if matters do not change we will lose approx.
£10,000 just from decreased admissions. The contract for casualty will change …& will reduce
income by a further £5,000 approx. No one appears to realise that the community hospitals needed to
be considered when discussing the new contracts and as a result the pattern of care which involves
community hospital v. intermediate care (Oxford & Anglia definition) will disappear. This will
increase …costs/inappropriate placement of patients. It will reduce the medical/emergency cover in
rural areas significantly & can only result in higher morbidity & mortality for patients in those areas.
However as these areas are large but have small populations the changes will not be noted unless
specifically studies and we need to recognise that the general practitioners who work in those areas
are so anxious to achieve the holy grail of OOH opt out that they have convinced themselves that the
service change will not affect patient care; “If it does, it is not my problem”; as a result those who
best know what the implications are will not stand up and advise those who are planning and
negotiating contracts because they fear that if they did they won’t be able to “opt out”.
Has always been remunerated poorly for the effort involved. Done largely as a favour to the
community. If the pay remains the same but over obligation to provide OOH cover is removed we
will be happy.
Workload is very variable and is unpredictable, in terms of when it occurs & how long it takes. I
have given a very conservative estimate of it in this survey, and have not included my unofficial role
as lead clinician. Audit is badly needed, but there is no time/money to do it.
At present our ‘cost per case’ agreement does not include superannuation and other such benefits –
this is clearly inequitable. There is a total lack of management support in CPD provision for
community hospital work.
What is required is a national contract tied into protocols, governance & outcome evaluation?
Properly remunerated & part of an NHS which values intermediate care & wishes to see it adopted
throughout the service. The BMA have been appalling in its NEGLECT of those working in
community hospitals. Please refer to my MD published 2002, Glasgow University “Community
Hospitals, A Study of Resource Use, Decision Making & Patient Outcome”.
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Due to new contract GPs in area refusing all minor injuries. These are being sent to local minor
injuries unit. This is stretching our resources, as workload has doubled in past 2-3 months.
Cardigan’s nearest DGH is 50 mins journey time. Our clinic is not equipped for more minor injuries
work. Without our practice & minor injuries dept the people of Cardigan would have to travel to
Carmarthen.
Increasing pressure from Trust to take non-registered and more complex cases coupled with their
wish to “enforce” the contract has meant withdrawal from 1st October 2004 when GMS OOH
changes. Unfortunate, regrettable but inevitable
Currently I am paid 2 hospital practitioner sessions though we have negotiated this to increase to 6
sessions with the PCT but have yet to receive any increase! We used to receive bed fund payments
but these appear to have stopped. Although only I am paid for my work all 4 of my partners attend
the hospital & look after their own patients & offer out of hours cover for no remuneration.
Grossly underpaid for disruption. Pattern of work has changed and where we once looked after only
our patients it is now a ‘dump’ for discharges from DGH.
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