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At the heart of general practice since 1960

Carr-Hill is on track for real reforms

Partners and salaried GPs can work together in complete harmony and to great effect ­ but effort needs to be invested in such a partnership to make a success of it, says Dr John Couch

In the last few years increasing numbers of practices have started employing salaried GPs. This started with PMS and nGMS has added considerably to the growing total. The fact that more newly-qualified GPs want to at least start their careers on a salaried basis has also been a prime factor. The result is that now a majority of teams consist of a mixture of GPs.

My own practice now has seven partners and four salaried doctors. There are advantages ­ but also some disadvantages. For many practices it has been their first experience of employing colleagues. Avoiding disagreements can be a challenge but it essential to meet this and ensure all blend together.

Salaried GPs are generally accommodating but can be sensitive if they feel they are exploited. Even the definition of 'exploited' often varies! As a partner, my own views may be a little biased but I am a firm fan of the new mixed economy.

Partner perspectives

Few GPs are perfect, but most principals would agree that to work with other doctors as partners there needs to be a strong sense of clinical and business responsibility, shared jointly. While there is no doubt that salaried GPs share the former, they are less likely to share the latter. If you do not have a 'stake' in a business you are less motivated to put in 101 per cent effort when needed.

A good example is summarising records. Many practices were forced to do this by the imperatives of QOF. This often necessitated taking notes home to do the work outside normal time, an average list of 1,800 patients taking around 200 hours of GP time. Few practices would have asked a salaried GP to do this ­ at least not unpaid. But the work still needed to be done.

If workload increases I feel I can share the experience with a partner, safe in the knowledge that our mutual exhaustion can be blamed on outside forces, 'a GP's lot'. If one of my employed GPs has a busy day and is similarly exhausted, then technically it is my fault as the employer, not a comfortable feeling. Workload issues are one of the commonest tension points in mixed practices.

As a GP I have always been used to complete openness with my partners. Clinically this is unchanged with salaried colleagues, but I would not wish to discuss financial and other business issues. This creates another barrier.

Salaried GP perspectives

Before the term 'salaried' GP was invented a few practices employed GP assistants. Sadly, a small minority were clearly exploited by their employers. Many current GPs choose a salaried option either because they do not feel ready for partnership or they do not want the extra responsibility and (sometimes) gamble of partnership. There is a concern that a GP employer will make salaried GPs do more of the work while they take more of the profit. A sense of this occurring, whether true or not, will cause upset and anger.

A common problem is that while partners may get involved in more specialist clinical work, salaried GPs are expected to take up the slack of normal consultations. Many salaried GPs have extra skills or would be willing to be trained to take on some specialist roles. This is not always encouraged.

Visits may be another issue. There does not always appear to be a good reason why some GP employers do fewer or no visits while salaried GPs do most or all.

Making it work

While it would be wrong to state that there are always problems in a mixed practice, few work well without mutual effort. There is no exact recipe for success, but many of the following should help.

Good communication is essential but sadly not always the case. There should be some time every working day, no matter how brief, for mutual informal contact, conversation and exchange of ideas.

A regular formal meeting of all GPs is also important. This can include teaching, clinical and non-clinical items. In addition at least one partner should act as the formal contact point between partners and salaried GPs so that more urgent issues can be aired promptly.

For the sake of clarity and accuracy, brief written minutes of meetings and aims should be made and agreed by all to instil a sense of joint ownership.

It is helpful to emphasise that we share a large proportion of 'common ground'. This can be aided by a spirit of openness, honesty, respect and listening. An ability to consider each others' viewpoints certainly helps.

All GPs should feel their workload, pay and conditions are fair. It may help to jointly look at all GPs' clinical and non-clinical workload annually. Unfounded perceptions or inequalities soon become apparent. While there should be an extra reward for being a partner ­ otherwise why bother to become one ­ the salary package should be at least comparable with the going market rate. Incentive schemes rewarding hard work and business success may also be useful. Finally, holiday and study leave should be comparable for all GPs in the team.

One of the biggest problems has been the pressure engendered by the first year of the new contract. This has been uncharted territory for us all and there was a huge amount of work for practices to get through.

Inevitably priorities dictated that many new salaried GPs did not get an ideal start. Now that practice systems are in place to make year two of nGMS smoother, there should be more time to devote to achieving better harmony.

John Couch is a GP in Ashford, Middlesex

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