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Could Government control solve GP jobs crisis?

A return of the Medical Practices Committee might not be popular, but it would be better at distributing partnerships than market forces, says GPC chair Dr Laurence Buckman. But Dr Richard Fieldhouse says the MPC didn't work first time around and the push to restore it is just another attempt by the BMA to exert control over the medical profession

A return of the Medical Practices Committee might not be popular, but it would be better at distributing partnerships than market forces, says GPC chair Dr Laurence Buckman. But Dr Richard Fieldhouse says the MPC didn't work first time around and the push to restore it is just another attempt by the BMA to exert control over the medical profession



It has been a central political belief for the past 20 years that local market forces and individual primary care organisations decide what kind of medical workforce they require. The result is we now have new GPs, trained at great expense to the taxpayer, who do not have any definite prospect of a job, and nobody controls where they go, so neither practices, patients nor the public sees a benefit. This way of working has failed and a rethink is needed. It is in the interests of the NHS and its patients that the Government takes a much clearer role in the planning of workforce distribution.

Once upon a time GPs were distributed by the Medical Practices Committee - an unloved but very effective body that described areas as designated (where you received additional funds to open a surgery), open (where you could expand at will), restricted (where it was difficult to take on extra partners) and closed (where someone had to die or retire before the practice could take on another partner).

These categories varied from time to time and also depended on the provision of a basic practice allowance that each new GP brought with them to the partnership. The BPA money was intended to meet the costs of having a partner as well as acting as an incentive to take on GPs. The MPC produced a spread of GPs throughout the UK and enabled practices to take on partners. It also stopped GPs flocking to popular areas - and was regularly criticised for doing this. However, it did at least mean that underdoctored areas had a constant supply of new GPs and that new GPs had jobs.

Why can't we just recreate this model? There are several problems: first, practices are now the operating entity of GMS GPs and individuals have no money attached to them apart from seniority pay. There could only be a BPA for the entire practice although this could depend on the numbers of partners in the practice. Second, the labelling of areas would be much harder now as populations are weighted by need rather than simply raw numbers.

There is no doubt that needier people require greater numbers of doctors. Third, we now have a concept of skill-mix firmly embedded into the NHS. Skill-mixing has made practices look differently at who works for them and many consider it a way of maintaining practice income at a time when many GPs have had pay cuts for three years. What was once done by GPs alone is now delivered by other health professionals and what is left for GPs to do becomes feasible with fewer doctors. This makes predicting how many GPs are required much more complicated.

But by reintroducing the functions of the MPC, we would be able to encourage practices to take on doctors as part of the business in places where we need more GPs, as well as giving practices a financial incentive to do so. Without incentives, practices will not see a reason to expand unless they are under enormous pressure of work. Joining practices into loose units (such as federations) might enable them to bid to the MPC together to make a case for more GPs, and they could then share the additional GPs between them. If this process were well regulated, it could be matched to training outputs so that the gap between numbers of GPs in training and partnerships available could be narrowed.

It is up to us to persuade the Government to make it possible for the GP workforce to expand to give patients the GP-delivered service they need - and use the talents of all the trained and underemployed GPs out there - without forcing the remaining GPs to fund it themselves.

Dr Laurence Buckman is chair of the GPC and a GP in Finchley, north-west London



No. But that's not to say that there isn't a problem with the GP jobs market. Indeed, it's a mess. The market currently consists of three main players. GP principals who have - or should have - control over resources and responsibility for patient care. Then we have employed GPs - same responsibility but no control. And finally locums, comprising 25% of all GPs, who just have responsibility over patient care, not resources, and wildly varying degrees of control over their own job market.

When the MPC was in place, all new GP posts were sanctioned by the Government to ensure that a particular area wasn't overdoctored. This was meant to make sure deprived areas got their fair share of GP partners. But life isn't fair and punitive action rarely brings positive outcomes.

The logical scrapping of the MPC allowed for an open market in terms of the GP workforce and for the creation of salaried GP posts, with the greater flexibility they bring. That can only be a good thing. What should then have happened is that these employed GPs should have had their own representative organisation - or, better still, a trade union. Instead, the employers union (the BMA) decided against this in order to guard its monopoly, to become the only trade union in Europe to represent both employers and employees. Which is impossible. Douglas Adams said the knack of flying is learning how to throw yourself at the ground and miss, and the BMA has been applying the same logic to representing employers and employees - funny on paper, impossible in practice.

Had the BMA done the right thing and acknowledged its contradictory position, we wouldn't be in this mess. Salaried GPs are being exploited left, right and centre, thanks mainly to an unenforceable

paper-tiger contract (and if the BMA is still saying the model contract is proof of its commitment to salaried GPs, then it has lost the plot). And locums are now staring down the double barrels of a revalidation shotgun. Quite rightly they have to achieve the same evidence as their practice-based colleagues, but they're now having to participate in a process that requires significant resources despite decades of absolutely no investment from their 'representative' organisation.

A new MPC won't get us out of this, and creating desperate measures to a simple problem only highlights the BMA's myopia. It needs to do what every parent needs to do in order for their offspring to survive in the real world. It needs to let go - to empower salaried GPs, not enslave them. An equally resourced independent trade union is needed to ensure sufficient investment is made to develop the role of non-principal GPs to a level equal to that of partners.

In short, the BMA should be empowering the profession, not emasculating it.

Dr Richard Fieldhouse is chief executive of the National Association of Sessional GPs

Yes No Dr Laurence Buckman Dr Richard Fieldhouse

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