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Gold, incentives and meh

Gerada to 'start dialogue' on GPs' independent contractor status in new NHS England role

Professor Clare Gerada’s new role at NHS England will see her tackle a range of ‘thorny’ issues - including the controversial question of whether GPs should retain their independent contractor status - the RCGP chair has told Pulse.

In an exclusive interview just days after her appointment was announced, Professor Gerada outlined some of her goals as the new clinical chair for primary care transformation in London - a paid, one-day-a-week position she will take on when she steps down as college chair in November.

She said she wanted to discuss how to best deliver integrated care, which will include her ideas for integrated care co-operatives, groups formed of primary, secondary and community care clinicans.

This could also involve examining GPs’ independent contractor status, she added, and moving away from the health service that was designed in the post-war years.

She said: ‘My priority for my first year is around talking to the profession about how we can best deliver services that are in the best interests of our patients and keeping the best elements of general practice – first contact care, GPs’ fingers on the patients’ pulse.’

Professor Gerada said integration was the best way of delivering services in the patient’s best interests and she wanted to start a ‘dialogue’ about how integration should look.

Her own preferred model for integration is ‘integrated care co-operatives’, a concept she explained at an RCGP event on federations last week, which would ‘bring together all relevant health care providers - within a contiguous and geographically bound authority area - as not-for-profit organisations with resources allocated and distributed according to the best needs of the population’.

However, in order to achieve this, ‘it may be that we have to look at some thorny issues’, she added. ‘We may have to examine the independent contractor status and decide what the pros and the cons of it are.’

She added: ‘I am not coming into my new job saying we need to get rid of the independent contractor status – I’m categorically not saying that. I am just saying let’s start to discuss these things and see where it takes us.’

The integrated care co-operatives would not necessarily mean GPs giving up their independent contractor status, she said, but they would make it ‘harder - and I am not 100% sure what the advantages are, although that’s not to say there aren’t advantages’.

Professor Gerada, who has been chair of the RCGP since November 2010, will also take forward NHS England’s ‘call to action’ on reforming GP services as part of her new job.

 

Readers' comments (29)

  • No Pre-determined outcome there then ...

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  • >we need to get rid of the independent contractor status.

    No she wouldn't want that. Her practice model of a few partners running a large number of salaried GPs works perfectly to her satisfaction......................!

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  • thanks Anonymous 11.56pm

    I wondered how long it would be before someone claimed I had a conflict of interest - and that this was determining my thinking and views! How would i be better off if we didn't have partnerships? I don't know - what I know is that I am committed to general practice - I love the profession and believe it too be the back bone of any health service. I want to improve and protect my profession so that we can improve the care we provide to patients - and I believe the ICS has done its time. (PS I wrote about this in 2009 way before my own practice had expanded)

    http://www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z-policy/Changing_Partnerships.ashx

    I use my own practice as a barometer of what is going on - and can categorically say I have never suggested anything, at any time, merely because I would personally gain.

    Clare

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  • From my point of view organisations where the buck stops with a clinician seem to provide better quality to patients and more efficiency to the NHS than organisations where the buck stops with a manager, large NHS organisation or large private company.
    .
    GP V OOH. Mental health V Medical Admissions. Old DNs V Serco DNs etc

    I can't really imagine things working with every GP working 4 hour BMA sessions as an employee/ not putting their own time into QOF/ reports for admission prevention etc.

    This is only anecdotal though, so would like to hear what other people think. It would be more likely to work if there were enough GPs around to make reasonable competition for employment opportunities, but outside London that is just not the case.

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  • Vinci Ho

    ' I have never claimed to have a monopoly of wisdom but one thing I've learned from this job is you should always try to do the right thing,not the easy thing. Let the day to day judgements come and go , be prepared to be JUDGED BY HISTORY.'
    Question is what is the 'right' thing? What is the 'easy' thing?
    Who said this? Tony Blair on Iraq War 2003......

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  • Perhaps it is better to be salaried - with leave and health and safety. The independent status [IS] means imposed contracts,escalating workloads with no means of escape, depression and burn out. Witness the exodus from the IS, through retirement and OZ. Salaried means health and safety sick, annual and study! leave. I think having worked in the NHS for almost 40 years it is time to leave IS. I think structured time, even though more regulated might save us from burn out.

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  • Are we really "independent" contractors?

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  • I do think Clare realises what is good for London may not fit the rest of the country which is why Berkshire where I practice had good OOH care pre2004 and post. 111 has caused chaos at our A+E whilst the OOH call volume has decreased. Where GPs were talking and looking after patient 111 has sent them to less qualified staff in A+E -genius.
    I'm ready to give up responsibility for my building staff and getting the job done and demanding pay, rest, study leave, annual leave and not crawling in whilst sick as no one else can cover my on call.
    Let them win over our complacent alive bodies. Take up clinical jobs only.----unfortunately we know it'll cost more.

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  • Vinci Ho

    So everybody goes salaried , that will be happy days???
    If a government does not really care and want to play radical and ruthless , you really think it would not be able to find a way to impose on us???

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  • Practice size and clinical targets are currently money driven. Salaried service would be management driven. If population and targets and GP numbers remain the same, this could only be tackled with more GPs on lower pay or shorter appointments times...

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  • I agree with anonymous 9.07am.
    I also think that losing independent status would attract more junior doctors into general practice, because it is more similar to what they are used to (PAYE, etc). It would remove much of the financial risk and disparity.
    Arguments in favour of IS include autonomy and sense of ownership, which is personally satisfying, and has made GPs prepared to go the extra mile. However, this has been exploited and unappreciated by the government, almost to the point of destruction.
    I think Clare Gerada is right to suggest that we consider an alternative.

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  • At the same Federation meeting last week Clare Gerada said gave the impression that young GPs did not want partnerships. From an organisation with just 4 partners employing many dozens of salaried Drs this seems a bit rich- the partnerships are not being given. The PMS contract and 2003 GMS contract led a whole generation of older GPS to start employing salaried Drs as opposed to offering partnership- a situation which continues to this day. This has led to in many moderately sized practices where one now commonly finds 2 or 3 partners employing another 4-8 Drs.
    This has led to a weakened and divided profession which has absolutely no hope of defending the concept of partnership or practice working, and will ultimately will be to the detriment of patients as we are all either coerced by NHSE or local CCG's or sleepwalk into giving up partnerships and become employed by organisations such as Dr Gerada's in the guise of local networks.

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  • Many young drs would love to have a partnership but
    but models like Clares that keep hundreds of salaried drs suppressed from this aspiration is partially to blame for the self destruct mentality.

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  • Many of us have a suspicion that independent contractor status is a 'dead Man walking'.

    Whether by accident or design it is hard to be sure?

    Let's see now......

    Accident? We need to consider,as bloggers have commented, there were indeed financial advantages in the 2004 contract to employ salaried doctors in the subsequent year or two when profits were relatively high, prior to the relentless financial attrition since then -- this has prevented a generation of younger doctors obtaining partnership status, most of whom no longer want to do so I presume given the predicament the profession currently finds itself in. In other words, the perverse disincentive against employing young partners may indeed have contributed to the current recruitment difficulties, now that many partnerships wish to take on new/replacement partners.

    Design? We need to consider the following. Government/DOH have heaped vitriol through tabloid poodle press. Increased work load eg QOF, responsibility eg CCG involvement, bureaucracy, box ticking. Increased risk accrued by pressure to reduce referrals. Reduced resources -- taking away PMS cash this year the latest example. More favorable APMS contracts favouring private sector. CQC, revalidation, Professor Field appointed to lead yet another raft of monitoring -- the latest plank in government GP bashing. Is all this designed to make GP partners give up their independent contractor status?

    Anyway, some predictions --

    There will be a pretense of engaging practices in reasonable discussion and negotiation.

    At the same time the government will continue to ignore the outcome of negotiations completely as they did last year, then impose unacceptable contracts and working conditions on GP partnerships.

    The requirements for reporting, revalidation and monitoring will relentlessly rise, all monitoring bodies, individuals and organisations dancing to the government tune

    Many practices, especially smaller ones, will close because it is cheaper for the government to let them do so rather than buying them out. Some GPs will loose their health, livelihood and go bankrupt.

    The private sector will be given vastly more favourable contracts to pick up the pieces which will ultimately cost a great deal more even in the short to medium term (just look at the funding for some APMS contracts per head).

    The NHS will evolve rapidly into a health maintenance organisation model which with hindsight we will realise was the vision all along.

    Politicians will have achieved their goal, bypassing the democratic process and debate as they did so successfully with the last White Paper.

    Welcome to the modern NHS, or should I say Welcome to America?

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  • Keep GPs independent...we are good at what we do and being independent is a strong motivator to work hard for our patients. Cannot imaging I would work 11 hours a day if I was salaried !!

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  • It's nice of Prof Gerada to come here and comment.

    I'm afraid I don't buy it though - you may argue till the cows some home but there is a clear conflict of interest there. How can a co-director of 13 practices run by 200 salaried doctors have absolutely no conflict when remodelling the service in which she has her business. Even if there is no financial gain, there will be a political gain, or at least you will be pushing her views above the others as the last article about single handed GPs clearly show.

    I don't practice in London (thank god!) but London LMC should really object to this biased appointment. I feel RCGP is harvesting a toxic culture within it now where it's senior most members are using it as a political springboard, as seen here and by Prof Field.

    I probably will resign my membership next year.

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  • Perhaps naively, I fear the loss of independent contractor status risks losing far more than it gains, and may come with unintended consequences. My greatest concern would be that salaried GPs have no motivation to stay wedded to one practice/population for 30 yrs, which brings with it real continuity of care. Good general practice is more than just making one-off diagnoses and referrals, isn’t it? Find a way to achieve that level of continuity with another model and I’ll stop being so concerned about the future/value of General Practice.

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  • That this debate is fuelled from within seems like the divide and rule strategists at Whitehall/Tory HQ have played a splendid hand. Bravo.

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  • To underestimate the financial advantages to the country of GP partnerships, is naïve to the extreme.

    For the last ten months, my partners and I have been working an extra clinical session per week in order to provide a half decent service at a time of recruitment problems. None of us wanted to do this but we all felt it was our duty to our patients. Do you honestly think we would have the same mentality as salaried GPs? This is just a tiny example of the commitment differences and to ignore them is both ignorant and insulting to GP principals in normal sized practices ( ie not managing directors of huge empires)

    I agree with the sentiments that the previous contract and the influx of salaried GPs is what got us into this mess in the first place. The end result will be an entirely salaried workforce with slightly less workload but a lot worse pay and terms and conditions. Patients will not be satisfied either because if you pay people peanuts you get monkeys. GPs are no different.

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  • Sold down the river. Thanks Clare!

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  • Thanks anonymous 10:52! Nicely analysed. Why are the governments itching to get rid of the traditional general practice?

    If we answer this question, we would find out if its for the best interest of the public or for the benefit of the 'private sector managers'.

    In traditional general practice, which I dare say is unique in the whole world, the GPs manage care; in the new model(s), we would be managed by the 'private sector' and hence the politicians in the background. It's a struggle for power over management.

    What will happen to the patients? People must take responsibility of their own health like in the US, and must buy sufficient insurance. The 'post-war' "socialistic" NHS system to provide free care for everyone (and obviously too expensive for any government), must be erased from the page of history anyway ... It's just the scenario that has been put together by all the leading parties in the UK. Very clever, no party is to be blamed by people, hence losing votes, but in fact it's the GPs to be blamed because they have failed to provide care in the same way they have done all these years. A good question to ask is "why now? Why us?"

    I have no criticism to Dr Gerada's views; I just think she needs to have a look around the different healthcare systems around the world to have a better idea of the route she is taking. There are plenty of examples of the system she is trying to design, it's not unique and not innovative. Integrated care after all is going to be managed by 'Family Doctors' who wouldn't be GPs in the sense they are now, ie with management skills and sufficient clinical and upfront involvement.

    Please Clare, wake up and see we are losing our heritage of 'post-war NHS'; it's not just a reform, but is a termination of a fair system of health provision for all, though not really free, but at least free at the point of delivery. And that is what makes a difference!

    I wouldn't accuse Clare, as a respectful colleague of mine, of being politically driven or of having interest in any of the suggested changes, but I shall urge her to think twice before allowing the politicians to picture a Eutopia for her and leave her alone with her vision, half way alone.

    God bless you all and God bless America!

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  • A salaried service, the road to serfdom.

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  • I have no doubt that Comrade Clare's Soviet ideals will deliver us to be property of the state ... Apart, of course, from GP Mandarins like herself who will reinforce their position within the oligarchy. Live long and prosper!

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  • Having started to work with nhs England and our local ccg I have finally realised that you will never find that one person that understands what and how things need to change. Most nhs England bods are so detached from primary care it's a joke

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  • They could not afford to make us salaried as they would have to buy our properties that house the surgeries or take over the responsibility of our leases.

    I think the plan is to make our surgeries non viable, destabilise us, leave us with the debts taken out in good faith, and allow big business to set up a huge super surgery in each town. No choice for patients.

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  • 9.14 -They won't be paying for it. Buildings will be bought and you will sell because the contract and pay will make it impossible to continue with Health Corp opening on Sundays near you and cherry picking your 'valuable' patients. The ones remaining loyal to you will be the ones who actually know how good you are because they see you regularly but cost you so much. They won't take residential homes nursing homes on either. You cannot believe that the protection of property and goodwill from patients will save you. The public who need us lose out, the public that shout loudest about being busy and NEED evening and weekend appointments won't care until they age get chronically ill and Health Corp will have gone through another reorganisation and dump them or raise their costs too high.

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  • Salaried is really what we are. To me that is an imposed contract.
    Salaried maybe not attractive but it has health and safety, regulated hours worked and patients seen in a day. The EU sees to that. The silver tsunami of multimorbidity and dementia means we will have plenty of work. The world is short of doctors. Really. If we stood up to the Govt. they would have no where to go. The nation needs its doctors.

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  • I'm not sure how much employee protection GPs will have even if General Practice becomes a salaried service.
    I don't remember overly much employment protection when I was a hossy doc.
    Clearly the EWTD has come in since then but you can 'voluntarily' opt out of that. I can imagine a scenario where there is a wholesale 'voluntary' opt out in order to maintain a reasonable income in the private sector.
    If only doctors would recognise their power as a collective and act like one.
    COI Retired

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  • all interesting conversations. What people seem to neglect is what is happening in response to restrictions imposed by there various interested parties. The locum rates are going through the roof. 27% of matriculating GP's are out right leaving the NHS... and locum doctors. choosing their own hours, have not administrative role, are making more money then partners without the headache of being one. This will quickly leave the NHS high and dry for regular working doctors, and no incentive for anyone to even bother aspiring to be a partner. If everyone goes salaried, and make the lousy 110k or less. would you choose £100 an hour locum job or your trust job for about 40£ an hour... in the end it comes down to chickens and your families...

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