[Closed] NHS Costs

I think they sum up the missed appointments, lump them together and say that means there is x days/weeks/months of missed appointments which equates to x doctors/nurse/hospitals that aren't at full capacity which cost Xmillions

All of which is making some dramatic and incorrect assumptions - but that's politics and statistics for you.

If 10% of your appointments are not attended then you need to have capacity for those patients who could have filled the appointments. If it costs a fixed amount to run a surgery for a year or x-thousand appointments a year but only 90% of those show then it costs more to per appointment than if they were all taken by patients.

Mike - But if each day is oversubscribed by 10% - which it generally seems to be for the Doctor to be running late, it wouldnt be possible for all the patients to attend anyway, without the Doctor working late.

@mikew - you've been away too long; what you do is understaff on the assumption that x% won't attend and then abuse the good will of your staff, expecting them to work longer on the well-attended sessions and/or whenever there's a complicated patient or two that delays things

there's no real loss - it just has to be presented that way by managers in order to save face

The 'price' of missed appointments in Primary/Secondary care is either simply a worse service for other patients or, as Mike says, the need to create extra capacity to see them in a timely way. Limited resources in the NHS mean it is often the former.

I've got no problems with the £ approach to displaying how much it costs the NHS. It's just PR, really. EDIT: Though if the PR was entirely successful, and patients all turned up, there would be chaos!

You could argue that the capacity lost in most GP surgeries was not there in the first place, though, given the chronic over-booking of most clinics. A bit like airlines who overbook flights on the basis that a percentage of passengers will not turn up on the day.

If you can be certain to be oversubscribed by exactly the right amount then it might work but if people cancel their appointments you can reallocate and fit more in on the day.

Martin - Your last paragraph is how I see the situation based on waiting times to make appointments and the waiting times in the surgery before being called.
Mike - I'm pretty sure it would take long to get a 'feel' for what percentage of appointments are missed at each surgery. - Every company I have worked for builds a bit of redundancy into their business model - assuming 100% efficientcly would be daft ?

This "cost" is a bit of a fallacy as Doctors will allow for some patients to not turn up and will overbook.

It's amazing what assumptions are made when designing and planning health care stuff.

This "cost" is a bit of a fallacy as Doctors will allow for some patients to not turn up and will overbook

You do realise most GPs are working their asses off, seeing extra patients here there and everywhere, because the [b]demand is so high.[/b] (and not because someone has coldly calculated an expected no-show % and accounted for this!)..?!!

DrP

It's OK, Mr Cameron has promised to get an extra 5,000 people through an 8 year GP training program by 2020 so we have enough of them by then.

It's laughable!
I quote to my patients "it's like building nests for 5000 Dodos"

Today Jeremy Hunt signalled a 'new deal' and 5,000 extra GPs to be made available over the course of this Government to enable the Conservative vision of 8am-8pm 7-day a week routine GP access. He suggested half of medical school applicants would have to become GPs to achieve this with no detailed plans on how to make this happen. (1)

David Cameron later confirmed these plans to create a 'seven-day' health service. He cited 'different shift patterns' and an increased reliance on technology based consulting like Skype and email consultations. (2)

Both the RCGP (3) and BMA (4) responses are available.

In response we feel the following points need to be made and clarified.

7-day access to GPs currently exists and is functioning in the form of current out of hours (OOH) service.
Moving to an 8am-8pm 7-day a week ROUTINE GP service from current 8am-6.30pm provision would amount to 60% increase in current work provision.
Currently primary care receives less than 8% of the NHS budget (total of ~£100 billion) of ~£8 billion (2)
There are just over 32,000 GPs in England providing over 340 million consultations a year at current 8am-6.30pm service provision. (5)
The Government has ALREADY pledged to commit at least £8 billion funds (by 2020) in addition to £22 billion efficiency savings to make the CURRENT £30 billion shortfall in NHS (not primary care) funding. This has been commented by NHS England chief Simon Stevens as money needed just to keep the NHS running rather than funds to expand services. These plans would make the NHS budget ~£86 billion - a reduction in actual funding.

The planned increase of 5,000 GPs (if an increase from current GP numbers) would lead to only a ~13.5% increase in GP workforce (over the next five years) which are being asked to provide a 60% increase in work provision with an overall reduction in funding.

Simply the numbers do not add up. Neither the 'new deal' or where 5,000 GPs will be sourced from has been detailed and without this information both politicians are simply creating sound bites which are being pushed to create headlines with no substance.

From [url= http://www.resilientgp.org/5k-gps/ ]Resiliant GP[/url]..

DrP

[i]politicians are simply creating sound bites which are being pushed to create headlines with no substance.[/i]

It got them a majority and that was all they cared about 🙁

DrP - Member

(and not because someone has coldly calculated an expected no-show % and accounted for this!)

I'm not going against your basic point but my outpatient's clinic absolutely does plan for a no-show rate... Just once, everyone actually turned up and it was total chaos, we didn't really fit in the waiting room never mind have enough doctors etc.

Not the hospital's fault of course but the fault of habitual no-shows, they usuall have a 25% absentee rate which is just appalling. Though this fact was lost on most people at the clinic, and no doubt some of the most furious people have no-showed in the past.

Would be very interested to know if a statistic exists that gives a breakdown of what these appointments are actually for. I can't help feeling, and probably have mentioned on here, that more education is needed for health matters and this should start at school.

I do think however that the NHS is guilty of the 'we know best' attitude. People need to be encouraged and cajoled to learn how their body works and that it's in their best interests.

A good starting point is my current favourite person who happens to be a GP not afraid of controversy:

http://drmalcolmkendrick.org/

Just once, everyone actually turned up and it was total chaos, we didn't really fit in the waiting room never mind have enough doctors etc.

Sounds very familiar. Something like that came up on a new hospital build we are working with sometimes things get overlooked.

I suppose that kind of policy is likely to be trust specific.

Locally, it's not uncommon to overbook fracture clinics at a rate of 4:1 (i.e 4 patients for each appointment).
Why..because that's the only way people get seen.
We waited with my lad for hours when he snapped his arm in half and was waiting for follow up. I did, however, get to see Jordan (Or Katie Price..whatever) in the waiting room too. Her kids played nicely.

DrP

mikewsmith - Member

Something like that came up on a new hospital build we are working with sometimes things get overlooked.

This is a very old hospital. TBH I thought it all made perfect sense, it's just unfortunate that unreliable people are unreliably unreliable. In this particular case, it's the sort of clinic where workload is fairly stable, not accident/response but longterm so more reasonable to plan in this way, pretty different from fractures etc.

How easy is it for patients to cancel/postpone an appointment if they need to? How long is reasonable to be left hanging on the phone at the patient's expense?

At the moment a lot of practices in Oz do online appointments and appointment management so it's really easy.

Does anyone else think that having completely free GP appointments is daft?

Part of the problem with the NHS is that as demand is effectively unlimited it is rationed by queues.

If you could do something to put a price on the services (with exceptions for those who can't afford to pay and can prove it) then you would start to deal with this problem.

No political party could possibly get away with saying this as it has seemingly become a fundamental right that all must have access to healthcare that is free in the UK. I think this is barmy.

In other countries with better public health systems like France healthcare is not free to all users as you pay for it through a Mutuelle (kind of collective insurance which covers a varying proportion of the cost but means some types of care will cost you something)

Marcus,

Your not running to time issue is probably separate from the possibility of overbooking. As I understand it this is caused by perhaps 3 types of patient:

(i) the "oh can you just look at..."

These are patients who come in with one condition and use their allotted time for that and then mention something else (often the something else is actually more serious so can't be "please book a new appointment"). Decision - delay all patients by 5-10 minutes or risk this patient not getting the help they need when they need it.

(ii) the "thinks their dr is their social worker..."

Thats probably an unfair description, but the doc is perhaps the only person who actually listens to them and seems to be interested in their well being. They might have addiction issues, mental health issues, dementia, or just be lonely. Decision: If you have an 80 yr old granny who's struggling to cope with the loss of her husband when the clock says "time up" - do you kick them out?

(iii) "oh shit I need to fix this NOW or the patient might die, today"

Whilst most patients in a GP surgery are not in life threatening situations it only takes one patient to walk in with signs of a heart attack, meningitis, septisemia or probably a load of other conditions and they can forget the appointment book. Decision: make all the patients run late with no hope of catching up, or let the patient wait for an ambulance in the waiting room?

Overbooking only works if you have a predictable stream of visitors who can be allocated to any available resource, it also works best if you have a turn up and be seen approach rather than formal appointments - because you have no way of predicting if the first or last appointment will be the no show, and even if it is the first you can't move forward all the people who turn up just-in-time.

NewRetroTom - Member

Does anyone else think that having completely free GP appointments is daft?

No. Charging for GP access will inevitably mean that people who need to see a GP, don't. The worst thing you can do for practically all medical conditions is delay diagnosis, it makes the prognosis worse, it often makes treatment harder and more expensive or even impossible (and more urgent, increasing time stress on providers) and it increases the economic loss due to illness.

An example close to my heart- if you're a t1 diabetic in America, you're far more likely to suffer preventable long-term complications than in the UK, simply because you're less likely to access preventative healthcare. And dealing with diabetic complications 30 years down the road- retinopathy, circulatory issues, nerve damage, heart and kidney issues general impaired health once the damage is done etc, is far more expensive than just helping a patient maintain good control. That's ignoring the economic and societal impact of having people who should be fit, being unfit

Course, free GP access has negatives too. But they're not negatives that ruin or end lives. You know how a penny of prevention is worth a pound of cure? If you're the person paying for both, it makes sense to give away pennies worth of prevention.

NewRetroTom - Member
Does anyone else think that having completely free GP appointments is daft?

NewRetroTom - Member
Does anyone else think that having completely free GP appointments is daft?

no.

I had an appointment at my GP for a Glucose tolerance test which would mean my going bloods, drinking a sugary drink, hanging around fr 2 hours then giving more blood to compare. Turned up 5 minutes late, appointment was cancelled, which was interesting as every time I've attended this clinic my appointments have been between 15 and 25 minutes late. I guess it's ok to keep patients hanging around, less so for their staff to be kept waiting. Or that they would be able to charge the NHS for my DNA, re book me then charge again for the attendance.
So to answer the OP, GPs charge because they're a business and charging for DNAs is money for nothing.
EDIT - DNA -> Did Not Attend

I fully accept that Dr's generally work hard - probably much harder than I would be willing to. And this hard work is with cancelled appointments. Do Dr's actually want all appointments to turn up or are they happy with a few missed appointments to allow them to claw some time back ?

Charging for GP access will inevitably mean that people who need to see a GP, don't.

As things stand, GP appointments cost time, not cash. If you cleared out the system of the people who are not "$10 ill", you'd perhaps free up some capacity to deal with the people who are not "2 hours out of my working day ill".

Don't know. 😕

Yep NorthWind
I think a lot of people in the UK need to actually try the US style of medicine - where having a sick kid can mean having to sell your house, the Dr gives you choices... medicine a) costs £10 and will probably work say 60% or medicine b) costs £100 and will work.
What do you want to pay? And yes, missed appointments will cost you.

Complex topic with no easy solution. To pick up your DNA experience BigButSlimmerBloke - if you were in for a blood test its probably a 10 minute appointment? you are 50% of the time late knocking next punters late? Not unreasonable at all really.
As per Poly earlier there are multiple reasons clinics get delayed but sitting twiddling thumbs hoping you turn up and doing 10min work in 3 minutes left of allocation isn't fair to you, other patients or practitioner surely?
I do Occ Health , usually 1hr or 45 min appointments - if your 15min late you get rebooked unless there is capacity in my schedule as otherwise everyone else is affected by over run from your appointment.

Northwind

I'm absolutely not suggesting we move to a US style health care system as I think that is daft too in other ways and unquestionably leads to some terrible outcomes.

I think the current focus on just the supply side is insane. As long as we stick with this approach the NHS will be permanently in the much media hyped "crisis" (which actually means reasonably good outcomes for the vast majority patients but the NHS being a stressful and under-resourced workplace).

If we keep the current approach we'll end up spending a higher and higher proportion of GDP on the NHS without getting any improvement.

NewRetroTom - Member

Northwind

I'm absolutely not suggesting we move to a US style health care system as I think that is daft too in other ways and unquestionably leads to some terrible outcomes.

The problems I highlighted with GP access and long term treatment/costs etc aren't specific to a full US style system- they're intrinsic to any system that has barriers to early diagnosis and preventative care, which is exactly what you'd get if you charge for GP appointments. Even if all other aspects of treatment were free you're putting them all behind a paywall.

It's not impossible it could have a net benefit, I think. But it's definitely not daft to offer it for free, there'd be persuasive arguments for that even if it wasn't how we already do it.

Things like payments are sledgehammers, blunt instruments that may help part of the problem but don't really address the real issues. As someone said above, education is a better approach, specific measures to deal with the frequent fliers or improving the general health of the population.

Prevention is one of the best things that have to deal with it, GP's are actually one of the tools in prevention that can help to reduce the impact on the NHS as a whole.

[i]Does anyone else think that having completely free GP appointments is daft?[/i]

Apart for the fact that this is how the NHS works, can you imagine the cost of having to implement Pay&Bill into the NHS? Not just the IT but the whole process etc.

For example; whenever anyone brings up charging foreigners for care, it actually means putting a system that can charge everybody but will only be used to charge a very small percentage of patients.

Imagine how much you'd have to charge for a GP appointment, just to cover the cost of Pay&Bill, £10 or probably far, far more.

Charging for GP access will inevitably mean that people who need to see a GP, don't.

This. It is really difficult. If you charge a nominal fee then a certain amount of people won't pay it in any case in the same way as you get free prescriptions, they'll get free appointments. There would be no incentive unless you made the system complex so that they paid for missed appointments - even then you would have people who could not pay.

There would then also be people who would have small issues who didn't go to see the GP until they became big issues. I know a fair few people who have had serious diseases diagnosed as a result of what, on the face of it, was just an annoying symptom that could be ignored - things like coughs that have persisted or unexplained weight loss.

Education is probably the best answer - explaining to people where they should go for help with certain issues and why they won't prescribed antibiotics for a cold or that they should just go and buy ibuprofen rather than getting it on prescription.

Prevention is one of the best things that have to deal with it, GP's are actually one of the tools in prevention that can help to reduce the impact on the NHS as a whole.

Indeed.
If you were to read the "NHS five year forward view" (riveting..) there's a lot of weight put on 'preventing preventable diseases'.
I can see why - reducing obesity/smoking/sugary pop NOW, is sure to pay off with reduction in health needs in the future.

However, it does also paint a picture of "gold plated plasters" and "diamond encrusted cancer treatments", but with significant funding reductions....Hmmm...

DrP

You do realise most GPs are working their asses off, seeing extra patients here there and everywhere, because the demand is so high. (and not because someone has coldly calculated an expected no-show % and accounted for this!)..?!!

DrP

Mine spends at least 1 day a week moonlighting as a hospital doctor at the local hospital. I have even seen him as a GP, he refered me to hospital. On arrival my appointment was with my GP as a hospital doctor. How can that possibly be a good use of resources?

Prevention is one of the best things that have to deal with it, GP's are actually one of the tools in prevention that can help to reduce the impact on the NHS as a whole.

Indeed.
If you were to read the "NHS five year forward view" (riveting..) there's a lot of weight put on 'preventing preventable diseases'.
I can see why - reducing obesity/smoking/sugary pop NOW, is sure to pay off with reduction in health needs in the future.

However, it does also paint a picture of "gold plated plasters" and "diamond encrusted cancer treatments", but with significant funding reductions....Hmmm...

DrP

Indeed, both in how dull a read it is and what it aims to do.

"Missed" appointments cost our local multi-Partner GP surgery so much that:

- their automated service for cancelling an appointment in advance has been broken for more than a year
- on Saturdays you can't even speak to a receptionist to tell them in advance you're late / can't make it because "we don't open the phones on Saturdays"
- even though it's nigh on impossible to pro actively cancel an appointment they will text you and write to you to tell you missed it

The whole system is set up to introduce waste at every possible opportunity.

There are some truly horrible attitudes towards the workers of the NHS displayed in this thread.

If you are late for your appointment then your appointment probably didn't mean that much to you are you are probably not that ill - maybe not even ill enough to warrant seeing a GP.

If the GP is running late it's probably because someone much more unwell than you needed extra time with the Dr.

As for the costs an cancelled appointments thing - in my work I charge people who cancel appointments at very short notice or who dont show up. The NHS doesn't get to do that, but has to provide cover for the people who have not been able to get an appointment due to some waster not turing up.

If the GP is running late it's probably because someone much more unwell than you needed extra time with the Dr.

what if you have the first appointment of the day and they are over 30 mins late? its happened to me more than once...

what if you have the first appointment of the day and they are over 30 mins late? its happened to me more than once...

They were probably just eating their cornflakes and waiting for their coffee machine.

Alternatively, they might actually have been dealing with urgent hospital referrals, out visiting a patient, dealing with a patient on the phone, but your right most probably just tossing it off to annoy you.

To be fair it is annoying that Practices do not advise how far behind the clinic is running.

As to hospital clinic appointments, they do not over subscribe because people wont turn up. Unfortunately some of it is due to shocking back office systems that double book appointments etc. However mostly becuase the Dr only has 10mins allotted time, and sometimes that just isnt long enough.

You do realise most GPs are working their asses off, seeing extra patients here there and everywhere, because the demand is so high. (and not because someone has coldly calculated an expected no-show % and accounted for this!)..?!!

DrP

If you are late for your appointment then your appointment probably didn't mean that much to you are you are probably not that ill - maybe not even ill enough to warrant seeing a GP.

what if you have the first appointment of the day and they are over 30 mins late? its happened to me more than once...

Or maybe they were just late or inefficient? Who knows? And if we did know, what would it tell us?

Not sure I would go the the GP is I was really sick, the wait for an appointement is too long at 3 days - even the emergency appointments are booked out. I'd go to AE which is what I htink many people are doing now.

If you can get to A&E under your own steam them you probably shouldn't be going to A&E....

If you can get to A&E under your own steam them you probably shouldn't be going to A&E....

Come on now don't be silly.

Back in December I started getting a chest infection. GP wouldnt be able to see me for 3 days. So rather than waiting 3 days, by which point I would have probably have ended up being taken to hospital by ambulance, I just drove myself to A&E and was given Anti's.

Was it the 'correct' referral path to take, no it wasnt, but because the NHS is currently flawed then it was the most logical thing to do.

[i]If you can get to A&E under your own steam them you probably shouldn't be going to A&E....[/i]

I've ended up in plaster 4 times in my life with broken/suspected broken arm bones and I've been stitched 3 times. I got myself there for each of these occasions.

Only times I didn't make it there under my own steam was when I had a ruptured appendix and when I broke my hip.

I think there's a lot of non-life threatening injuries that require 'emergency' care that people can make their own way to hospital with.

Back in December I started getting a chest infection. GP wouldnt be able to see me for 3 days. So rather than waiting 3 days, by which point I would have probably have ended up being taken to hospital by ambulance, I just drove myself to A&E and was given Anti's.

And you know that it was a bacterial chest infection based on which tests? I suspect that you probably had a viral chest infection and you just got better by yourself.

I've ended up in plaster 4 times in my life with broken/suspected broken arm bones and I've been stitched 3 times. I got myself there for each of these occasions.

That's what minor injuries is for.

my local hospital doesn't have a minor injuries...

If you can get to A&E under your own steam

Not sure about that. Concussion? I've cycled directly to hospital after coming off my bike and smacking my head hard. Pretty sure that was acceptable. The doctor who saw me certainly thought so though that was about 10 years ago so maybe minor injuries would be the place now.

FWIW, more recently when I sliced open my knee in a very annoying off, I went to the minor injuries clinic and got seen faster than I would have in A&E.

Not sure about that. Concussion? I've cycled directly to hospital after coming off my bike and smacking my head hard

my local hospital doesn't have a minor injuries...

Go to the one that does then.

[i]Pretty sure that riding a bike concussed is stupid.[/i]

You'd have to be concussed to ride a bike when... Oh.

[i]Go to the one that does then. [/i]

So what's a reasonable distance for me to drive with a broken arm or a profusely bleeding head wound, in your professional opinion?

Yeah, I agree but as pointed out above, it seemed reasonable at the time (and the headache had only just started - peaked nicely about 2 hours into my wait at A&E)

RE GPs doing other work..

Mine spends at least 1 day a week moonlighting as a hospital doctor at the local hospital. I have even seen him as a GP, he refered me to hospital. On arrival my appointment was with my GP as a hospital doctor. How can that possibly be a good use of resources?

A lot of GPs are 'portfolio doctors' - using other skills/qualities in other areas of the NHS - clinical work/commissioning/private stuff.

Why - because leading an interested and varied life leads to better job satisfaction. No one can 'force' them to work solely as a GP.

DrP

wanmankylung - Member

If you can get to A&E under your own steam them you probably shouldn't be going to A&E....

What a load of bollocks. Sorry but no other response possible. Every time I've been in A&E I got there myself. Probably should have called an ambulance for the broken hip, mind. And no question that I was in the wrong place.

So what's a reasonable distance for me to drive with a broken arm or a profusely bleeding head wound, in your professional opinion?

The answer to that question is simple - no distance at all. What you did would probably have got you banned had you been caught.

What a load of bollocks. Sorry but no other response possible. Every time I've been in A&E I got there myself. Probably should have called an ambulance for the broken hip, mind. And no question that I was in the wrong place.

In that case you are clearly an idiot.

[i]What you did would probably have got you banned had you been caught.[/i]

It's a good job I chose not to drive and went to the local hospital then, eh.

If you insist.

That's what minor injuries is for.

my local hospital doesn't have a minor injuries...

Go to the one that does then.

Maybe NHS Scotland just works better?

wanmankylung - Member

In that case you are clearly an idiot.

Because you know all the details, obviously. Have a word, you're spouting nonsense and calling people idiots for correcting you despite not having the slightest idea yourself. Tons of A&E cases are walk-ins.

whenever anyone brings up charging foreigners for care, it actually means putting a system that can charge everybody but will only be used to charge a very small percentage of patients

FYI, the NHS does charge foreign patients. If you don't pay up then they'll tell the border agency and they won't let you back into the country until you settle your bill. And the bill has 50% added on top of what the treatment should have actually cost. The more foreigners use the nhs, the better off it is thanks to the out-of-towners tax!

True, but if it was planned treatment then they'd be charged up front. Personally I'd rather we treated people who need lifesaving care rather then making them wait while they check their bank balance/eligibility.

In any case, it's not as if no other businesses (hotels, restaurants, US hospitals) charge you on 'check out' rather than for everything as it happens.