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Are GP partners getting greedy?

Some partners are systematically underpaying their practice staff and keeping profits for themselves, argues healthcare management consultant Steve Williams. But GPC member Dr Terry John counters that GPs are just adapting to tough financial realities.

Some partners are systematically underpaying their practice staff and keeping profits for themselves, argues healthcare management consultant Steve Williams. But GPC member Dr Terry John counters that GPs are just adapting to tough financial realities.


Practice staff have been able to join the NHS pension scheme since 1997. A popular misconception is that this then makes them NHS employees.

This could not be further from the truth. Another misconception is that have all been paid according to the Whitley pay scale as per their NHS colleagues. Again not true.

And then there's the assumption that general practice has now seamlessly replaced the Whitley scale with Agenda for Change. If only this were true.

GPs may elect to voluntarily adopt Agenda for Change, but they are not obliged to. As a result, annual pay rises for staff pay vary widely.

A survey of over 15% of practices by First Practice Management found the number of bonuses paid to staff fell significantly in 2006/7.

While nationally pay increased by 4%, areas such as London, the South East and the Midlands all showed overall percentage decreases. Another recent survey, by Independent Nurse magazine, revealed substantial disquiet among nurses over their salaries and bonuses.

Some GPs would prefer to employ someone who does not wish to elect to join the NHS pension scheme, because this will mean that no employer's contribution will have to be paid by the practice.

A review of current payrolls revealed that fewer than 40% of staff were members of the NHS pension scheme. This could in part be a result of the age of staff and the part-time nature of their work, but it does suggest staff are not being actively encouraged to join.

There are many GPs who do award discretionary pay awards to staff irrespective of the economic climate, but conversely there are many others who simply refuse to be drawn into a debate on realistic pay increments.

'Some GPs are exploiting practice staff for their own personal profit'

GPs have also been creating fewer partnerships each year, and instead recruiting salaried GPs and junior clinical staff such as healthcare assistants. Those who are employed are not guaranteed the luxury of a pay rise each year unless their employment contract explicitly says so. The expression ‘at the employer's discretion' is enough to prevent an industrial tribunal.

It is easy to simply say it has not been possible to fund pay increases because of the recent pay freezes – and recommendation of another pay freeze for the coming year. But although practice staff are appraised under arrangements for the QOF, how much money from the quality framework gets re-invested back into that practice?

Staff contribute to achievement in at least some of these aspiration payments, but there is no direct mechanism to ensure they are adequately rewarded for their efforts.

Practice staff are the backbone of primary care and make a significant contribution to the running of the NHS. Years of failure to recognise them as part of the NHS has brought a stark variation in pay rates across the country.

Many GPs do value their staff and ensure proper pay and conditions. But those that knowingly avoid giving reasonable cost of living increases to bolster the bottom line are taking advantage of current legislative arrangements and exploiting staff for their own personal profit.

Practice staff work under difficult circumstances at times and if an administrator were to have achieved their targets and receive a positive appraisal, they would expect to be rewarded. We are not talking much here. A 2% increase on a salary of £20,000 is only £400 per year or just over £33 per month.

What we need is the Government to recognise the full contribution practice staff make to the NHS. Let them be formally governed by Agenda for Change. Let them be part of the NHS family, not just the forgotten children.

Steve Williams is an independent healthcare management consultant specialising in general practice who has worked as associate tutor for the Institute of Health Policy Studies at the University of Southampton.


Two staffing issues are currently sparking fierce debate among GPs. One is the accusation that partners are deliberately reducing practice nurse pay.

The second is concern they are increasingly unwilling to appoint junior partners, and are exploiting salaried GPs.

The claims over practice nurse pay result from a misunderstanding of the official pay statistics, and can be easily dismissed.

The rumour GPs have cut the pay of their nurses was started by the Department of Health in evidence to the Doctors' and Dentists' Review Board. It was apparently based on research done by the Personal Social Services Research Unit (PSSRU).

But the figures do not take into account discussions which took place in 2004, when Agenda for Change was introduced.

There was a debate within the Royal College of Nurses and the BMA about the appropriate banding for practice nurses, and in particular the level that would be most appropriate for transfer from practice nurses' clinical grade F.

The level settled on was level 6. But the PSSRU has since accepted a review of Agenda for Change concluding the more correct banding was level 5. New practice nurses now fall into this band, carrying a lower basic salary, but this realignment has no effect on the salaries of existing nurses.

It's therefore straightforwardly incorrect to accuse GPs of cutting the pay they are awarding.

The issue over salaried GPs is more complex. When I talk to salaried GPs, the main complaint I hear is about availability of partnerships, rather than the accusations from some quarters that they are being exploited in their posts.

'There may not be adequate funds for new partnerships'

The partners I know comply with the salaried contract and get doctors without difficulty. I've heard of a few cases of principals who offer a poor deal - these either get no takers or a succession of unhappy doctors who leave so quickly that the principal is forced to see the light.

The salaried contract is there for all to use and in my experience tampering with the contract gets a principal nowhere.

But when we look at job adverts in the medical press, it's clear there are more salaried options than partnerships, and doctors are quite worried by this trend.

There is also sympathy for the jobs applicants, with over a hundred applications for each advertised partnership.

General practice is constantly changing, and we are now living in an era when greater flexibility is required in every profession.

The current issue over salaried GPs is one that has arisen since the arrival of the new contract. In 1990's Your Choices for the Future survey, a large percentage of doctors said they preferred to remain salaried and negotiators were concerned to solve the problems experienced by principals.

But an unintended consequence of the new contract was the present situation where appointing a new partner does not in itself attract extra resources from the PCT.

Commentators have alleged greed on the part of principals; they will not appoint new partners so as not to share practice profits. I am not sure this is the case.

For many doctors, there is an anxiety about the future of general practice – and a constant struggle with PCTs to retain appropriate resources.

As funding diminishes, contracts are placed elsewhere and turnover falls, it may be impossible to guarantee present levels of remuneration. So the scenario we are seeing may not be one of greed and selfishness, but a worry that, with business under such pressure, there may not be adequate funds to allow partnerships to expand.

But we all realise a future with a mainly salaried or sessional workforce would not be good. We should be encouraging doctors in partnerships to appoint new partners because of the many advantages.

The sharing it allows of financial responsibilities and the opportunity for succession planning will help guarantee the future of general practice.

Dr Terry John is a GPC member and a GP in East London


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