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Independents' Day

Are fixed-share partnerships a fair way of employing GPs?

In uncertain times, it can be sensible to employ GPs on flexible contracts - as long as they are not substandard, says Dr Charles Alessi. But the GPC's Dr John Canning warns that too often, fixed-share partnerships exploit GPs and may simply be a way of avoiding national insurance payments

In uncertain times, it can be sensible to employ GPs on flexible contracts - as long as they are not substandard, says Dr Charles Alessi. But the GPC's Dr John Canning warns that too often, fixed-share partnerships exploit GPs and may simply be a way of avoiding national insurance payments


General practice is going through some difficult and challenging times - times that are uncertain financially and structurally. Practice-based commissioning has largely failed to ignite the imagination, the entrance of new independent providers into primary care is causing concern and practices are faced with newly emboldened PCTs that are sometimes unilaterally changing the rules of engagement.

How should GP practices respond to such a volatile environment? Many have determined to batten down the hatches and consolidate, and partners are loath to make long-term decisions about their future. Added to this is a great disparity between the jobs available and the number of applicants looking for employment.

The environment has similarities to that of the 1970s and early 80s. There was no threat of new entrants then and no resurgent PCTs, but there was a culture of young doctors being employed as 'partners' on fixed shares in an unregulated way. It was common for GPs to work up to parity over a period of five years or more and at rates of pay that were substantially lower than that of a fixed-share partner today, allowing for inflation. Primary care was far more hierarchical then than the flat management structures that now exist.

So are there advantages to the fixed-term arrangements presently in vogue in primary care? It would be disingenuous to ignore the environment and market forces that I have described. These undoubtedly make it easier to employ doctors under a variety of contractual arrangements.

In the more developed practices, the roles of the partner and fixed-share doctor are fundamentally different. Both comprise a core clinical role dealing directly with patients, and although clinical workload can be managed and responsibilities defined, this is often not done. But partners should also fulfil a far more complex role, covering the business management of the practice with responsibility for steering it through the dangerous waters that are fast developing in primary care. Financial risk-taking is becoming more common - and it is partners who are bearing those risks.

It is also becoming clearer that new skills are needed in the leaders of modern primary care - marketing experience, diplomatic skills and financial acumen are all likely to figure in future advertisements for partnerships.

But we should not rejoice in the lack of partnership opportunities, and there is more we can do now to ease the situation. There needs to be a commitment among both GMS and PMS practices not to exploit fixed-share arrangements by employing doctors using substandard contracts. It should also be possible to mimic the arrangements used by other professions, with an intercalated model of partnership through which doctors who wish to develop skills outside a purely clinical environment are encouraged and nurtured towards becoming partners. Fixed-share contracts could be used over introductory periods to assess the suitability of incumbents to the rigours of partnership (and vice versa) and introduce differing aspects of partnership by mutual arrangement. So marketing, finance, governance and the management of key relationships could be introduced and explored.

Primary care is changing rapidly. There will be those among us who favour the more entrepreneurial models that may well be required for survival, whereas others may prefer to concentrate on purely clinical roles. Despite the transitional difficulties we are going through, general practice will survive and evolve. I look forward to the journey - even if the choppy seas do make me seasick on occasion.

Dr Charles Alessi is a GP in Kingston upon Thames, Surrey, and medical director of the Kingston Co-operative Initiative


General practice is changing and GPs need to face up to those changes. One of the ways some GPs are trying to change is in the way they operate their practice, and how they treat and pay GP colleagues.

Anyone who suggests there is a right way to run general practice is mistaken, but the reverse does not follow - there are wrong ways to run a practice. One of the wrongs GPs can commit is to treat their colleagues unfairly - there is a tendency to exploit other GPs, especially in times of tension and when there is an oversupply of doctors. Regrettably we are in one of those times.

We face not only an apparent oversupply of GPs, with some finding it hard to find work, but also an assault on the whole of general practice. But we can protect the future of the profession if we commit to the fundamental principle that underpins it - a continuing relationship with patients.

A key to the future is the way practices plan and manage their medical workforce. To talk of continuity but not provide it is unacceptable and must not happen if we want the best for our patients. A succession of salaried doctors doing the majority of the work with the expectation that they will move on is not what patients expect and not what we should offer them.

So are partnerships the only answer? Maybe. Currently partnerships offer the best chance of continuity for patients, but even partnerships are open to exploitation and opportunistic corporate governance.

When partners are equal, understand their mutual relationship and respect each other, there should be no problems. But when partners engage fixed-share partners - or, as they are still frequently known, 'salaried partners' - the full partners often use these arrangements as a means of reducing the costs and risks to the practice.

Salaried GPs in GMS contracts have the benefit of a guaranteed contract with minimum standards; they have rights to paid sick and maternity leave, redundancy arrangements and so on. In a fixed-share contract, most of these benefits are at the discretion of the partnership. There are some benefits to a proper fixed-share arrangement, notably that the fixed-share partner has a guaranteed income in the face of falling profits - although in practice the guarantee will be set at a low level.

But the nature of a fixed-share contract prevents the partner from benefiting from any efficiency or quality improvement that leads to a higher profit. Fixed-share partners will also find they have to manage their own tax and national insurance arrangements - which can be particularly difficult in the first couple of years as the GP changes to self-employment - and will need to arrange their own locum and insurance cover.

If the doctor is a fixed-share partner for mutual benefit, these responsibilities may be reasonable. But if the reason, as I suspect is often the case, is to avoid such obligations - or more worryingly to avoid employers' national insurance - this is exploitation and an action not worthy of GPs.

NHS general practice can only survive as a holistic, patient-centred service if its usual method of delivery is through equity partnerships committed to that care. This is GPs' unique selling point and if we don't provide it patients will see no advantage to visiting us rather than polyclinics.

The future of general practice is in your hands. Don't throw it away.

Dr John Canning is a GP in Middlesbrough and chair of the GPC contracts and performance subcommittee

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Financial risk-taking is more common - and it is partners who bear the risk

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Often this is exploitation and an action not worthy of GPs

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