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GP view: Flu jabs are an important part of how we balance the books

“Part of the problem is a lack of awareness about how GPs are funded”

Flu vaccinations are no better when delivered by GPs, but if surgeries don't deliver enough they may not be able to afford to offer the service at all, says GP Toni Hazell

I know that I’m getting older when flu season seems to come around quicker each year – is it the medical equivalent of policemen seeming younger? Flu vaccinations have become more complicated over the last few years, with different ones depending on age. All the practices I know order their vaccinations very early, but they still don’t seem to get the deliveries in time, which is frustrating for patients and GPs.

Flu vaccinations hit the news last month when a GP surgery sent letters urging patients to have their vaccination done at the GP practice, not the local pharmacy, leading to accusations of unprofessional behaviour and that the GPs concerned were putting money before patient safety.

I can see both sides of the story, and I think part of the problem is a lack of awareness about how GPs are funded. Practices are funded around £80 annually per patient. When you add in incentives such as the Quality and Outcomes Framework that might go up to around £120.

That payment is for all the patient’s primary care needs, including paying for doctors, nurses, administrative staff, heating, lighting and insuring the building, consumables such as printer toner, accountancy fees, and paying a plumber if the sink blocks. Everything except the rent on the building and the IT hardware. It isn’t a huge amount to look after someone for a year and without the subsidy from healthy people who never come to the GP, it would be impossible to run a practice on it.

For the sake of comparison, private GPs might charge £60 for a single 15-minute appointment, and it can easily cost over £1,000 for a year’s worth of medical insurance for a dog or cat. Primary care is good value and the ‘all you can eat’ model of funding saves the NHS a fortune. Many GPs question whether it's sustainable in the long-term, but for now it's what we have.

Set against this background are the fees that we can charge for extra services. If a GP vaccinates a patient against flu, they can claim £10.50 from the NHS. It doesn’t sound like a lot, but that's equivalent to roughly a month’s funding for a patient, so it's a significant payment for a five-minute appointment.

For practices that have a big population of patients who are entitled to flu vaccinations, the payment for giving them is an important part of how the surgery balances the books. If lots of patients from any one practice choose to go to the pharmacy to get their flu vaccination, that is potential funding that the practice won’t be able to receive. They may even lose money, as they have ordered the vaccinations upfront.

Cuts in funding mean cuts in services. I know of practices that are considering cutting some GP time as a direct result of a loss of income from flu clinics, and others who have been left with paid-for vaccines that they can’t use. Some have decided not to offer the flu vaccination in the future, as the cost of staffing extra vaccination surgeries and the risk of being left with unused expired vaccinations is too great.

I haven’t seen the letter in question, but I understand that it implied that the vaccine provided by the GP was somehow superior to that given at a pharmacy. That’s untrue, and I don’t think it's an acceptable insinuation. But we live in times when a lack of funding is driving some GPs to bankruptcy and record numbers of practices are closing as they can’t make ends meet. In that context, asking patients who value their GP surgery to support them financially by having their flu vaccination at the practice doesn’t seem like the worst crime in the world.

Toni Hazell is a GP based in a practice in London

40 Comments

Leon The Apothecary, Student

Thanks for writing these articles Toni. It is very enlightening to know what is going on in "the other place" to steal a term from parliament. In your opinion, what would be the idealistic solution to healthcare in the community in a holistic view?

Edward H Rowan, Locum pharmacist

Welcome to the 21st century, doc. You provide the services that customers want, when and where they want them, they come to you. If not, they don't.

Tarvinder Juss, Locum pharmacist

Re-posted in appropriate place in discussion.

Alexander The Great, Community pharmacist

Yes, Dr Hazell is a fab contributor, dont let us put you off from further ones. Just that this article was a bit sensitive, as she is not aware how much pharmacy is actually suffering. In the area I am in, 4 pharmacies are within 5mins of each other. The surgery next to the drs with 20k patients has a pharmacy attached. It is CLOSING DOWN, why? cos of massive budget cuts and sky high rents. 

Leon The Apothecary, Student

Looking at it pragmatically, how many pharmacies does one need to deliver 20k items? 

Charles Whitfield Bott, Pharmacist Director

Lets look at the numbers, 3000 patients per GP (lots have more) at £120 per year is 360k. 100k for the GP still leaves 260k to pay for the other staff etc.

Not IT or rent to pay and a big fat early pension.

I know who is better off financialy, me or a GP and its not me!

If GPs want to do more flu vacs then give a better service, remember there has been no competion for GPs for years, now that there is some competion in a very small area of their practice they don't like it.

N O, Pharmaceutical Adviser

Actually there is BIG CRY (disappointment) in the GP circle that the per GP figures have exeeded 5000+, so the figure per GP should be £££ 600,000.

Even then, going with your calculations, they still have £ 20,000/month per GP to be spent on -- "" paying for nurses, administrative staff, heating, lighting and insuring the building, consumables such as printer toner, accountancy fees, and paying a plumber if the sink blocks."" 

Yet, they want to keep the £ 10/ per patient of the seasonal flu payments!!!! Which, for discussion sake, would be say 60 % of the 3000 patient population = £18,000/ year = £1500/month. And now lets see what pharmacies are taking away. Let's say 50% of the actual flu vacs = £9,000/ year = £750/month.

Compare this with a NET LOSS of Est. Payment + MURs = £25,600 (for the smallest Pharmacy) + 12% funding cuts + 5 year fixed contract without taking inflation in consideration. + more to come in future CUTS.

Added to this, the Pharmacies are also required to do some FREE stuff like - Home Deliveries, MDS Trays, Specialist Brands @ generic prices so on and so forth.

Oh I forgot, we have to pay for our IT and Rent and Rates and Pension.

So, let's now compare who is actually at the losing end??

Leon The Apothecary, Student

Interesting, do you have some source material?

Alexander The Great, Community pharmacist

We have to pay more for toner costs now that the GP seeing as the majority are EPS now. Not only do we have the print them all, but when we receive it we have to spends HOURS a day sifting through them, booking them in and prioritising deliveries, ordering stock etc

Benie I, Locum pharmacist

What's the toner for ? Thought everything was paperless......

C A, Community pharmacist

In your dreams... the BSA still wants the back of all those >D exempt FP10Ds signed, but don't send the age exempt! it costs them too much money to process and store! 

Ah the joys of yet more EPS sorting!

Leon The Apothecary, Student

Yeah...and they don't process payment off them...

Tony Schofield, Community pharmacist

The main fly in the ointment is that NHSE cannot resist meddling so will PCNs continue after the election? And... how far will we get until the spending plans of both of the main parties are likely to produce a recession probably in 8 months if Corbyn wins and 2 years if Johnson wins

Leon The Apothecary, Student

The thing that is more likely to cause a recession, and in some ways already causing strain, is not knowing which way it is going.

C A, Community pharmacist

I'm not sure that Johnson would make it to 2 years before causing a recession...

Tony Schofield, Community pharmacist

It's fantastic that Dr Hazell has taken the time to explain the vaccination issue from a GP perspective. She is absolutely correct that GP income, along with pharmacy income has declined steadily since 2005. It's not rocket science to conclude that GPs will seek to cling to whatever income source they can just as pharmacies will embrace eagerly any crumb of a new opportunity. The future is surely to have a mature relationship and look at how our mutual and complementary skills can best be used so that patients get the best of all worlds whilst those delivering services make a reasonable living for the skills, risk and investment they all contribute. The new PCN situation and the announcements  that both profession's contracts will be developed together further strengthen this development for the future. My experience has taught me that that which we offer to GPs is not necessarily what they want from us so the quicker we start talking the better.

 

 

C A, Community pharmacist

Hang on Tony isn't a lot of that decline since 2005 due to the DOH realising they had overly "generous" in giving the GPs a >25% uplift with the new contract and doing a bit of a "clawback" (something every pharmacy contractor is familar with). Also didn't primary care just get an extra couple of billion invested in it - was it an average 3.4% uplift over the next 5 years? Compared to pharmacies 0% for the next 5 years?

Reeyah H, Community pharmacist

Let's stay postive. At least the rent and IT hardware is paid for (unlike pharmacy!). 

Leon The Apothecary, Student

Food for thought, if the government want dispensing hubs, would it be willing to put up the cash for them in a similar fashion?

C A, Community pharmacist

And the rates are reimbursed too

Chris Pharmacist, Community pharmacist

A lot of patients I vaccinate have stated that they can't get an appointment or can't make the clinic times offered by GPs meaning some will have gone all winter unprotected. The main issue isn't money but making sure that patients are vaccinated in a timely manner.

I hear your comments regarding cuts to GP services but news for you, the same is happening in pharmacy. The govenment want pharmacies to close and have cut funding significantly to make this happen. We're all in the same boat but at least more patients are being protected from flu over the winter.

A Hussain, Senior Management

Dr Hazell is far fairer than most GP's I've come into contact with when it comes to flu.  As a pharmacist all I hear is how much more convenient it was to come to me.  GP's would get many more patients come to them if they put themselves out more.  And as others have said, surgeries seem to have a number they want to vaccinate and then pack it in when they've reached that even when there is vaccine available to order.

Also it's £10.50 plus any margin on the vaccine purchased!!  ;)

Tired Manager, Community pharmacist

I agree with many of your articles but as stated previously this service was only introduced into community pharmacy due to the inability of GPs to hit the required target... Perhaps a more collaborative approach is required: Our local GP surgery, perhaps old fashioned, likes to do "cattle-market" clinics twice a month through October, November and December and is very happy to send people up to the pharmacy in between as a sort of "mop-up" for those who can't attend. In exchange for this we display their clinic dates in the pharmacy and agree not to vaccinate anyone with an appointment to avoid complication. That way the pharmacy figures are nice and healthy and the surgery has nice full clinics and no wasted vaccines. Simple!

Leon The Apothecary, Student

The target issue does cause unneeded competition. Here, they like PCNs don't they? Make the target for the PCN as a collective.

Adam Hall, Community pharmacist

Fundamentally, flu vaccination was only opened up to Pharmacy because GPs weren't hitting the targets, for many reasons - the most common one that I get is because appointment times are not convenient. GPs are finally becoming honest in admitting to patients they are a business, in exactly the same way as pharmacy is and, like any business, they have had their monopoly challenged by someone able to provide the same (or better) service and as a result 'customers' are voting with their feet.

Toni Hazell, GP

'customers' are welcome to vote with their feet, if they want to. But they may well then see other services cut. The public deserve to be in possession of the full facts before they make their decision. 

 

Alexander The Great, Community pharmacist

Well, the papers tend to say GPs earn over 100k/annum, loads work part-time, patients have to wait 2 weeks to get an appointment. With these "facts", they wont think GPs are struggling as you claim, and cos they cant get appointments, they think you're too busy and dont want to burden you.

Benie I, Locum pharmacist

Finally, at least you're intimating it's all about the money. Should make these new PCNs all the more fun.

Adam Hall, Community pharmacist

Is 'seeing both sides of the story'condoning unprofessional and unethical behaviour? I do hope not!

Kevin Western, Community pharmacist

All this would possibly have a grain of truth if any GP practice that I am aware of had actually met its flu targets instead of ordering enough for a cattle market session at the local meeting hall then forgetting about the rest of its patient list.

Pharmacy doing Flu vaccines has not only reached patients who wouldnt have a vaccine, but forced GPs into doing vaccines at times convenient for patients, not the Practice, and, seemingly, miraculously find appointments to do them... 

I always find it amusing when thje subject of funding cuts comes up from a GP... when was the last reduction in cash paid to GP surgeries? 

If you would like to compare payments/benefits for the two businesses, i'm sure that can be done very easily but i dont think you will like the result.

 

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