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At the heart of general practice since 1960

Is this the beginning of the end for GP partnerships?

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Once considered unassailable, the independent contractor status of GPs is being undermined like never before.

In the most significant intervention to date, the man who could be the next health secretary has suggested that general practice should move towards becoming a largely salaried profession.

It seems Andy Burnham has been bitten by the same Kaiser Permanente bug that has infected NHS England deputy medical director Dr Mike Bewick and former RCGP chair Professor Clare Gerada, raising the prospect of GPs working for an increasing number of large ‘integrated care organisations’.

But abandoning the model of general practice that has been in existence since the formation of the NHS would have wide repercussions.

Independent contractor status is the bedrock of general practice. It enables GPs to be effective advocates for their patients and ensures that they are able to speak out when they witness the NHS failing them.

It also means that general practice is an incredibly lean and efficient service. If the NHS had to pay overtime for all the evenings and weekends that partners work to keep up with the mountains of additional paperwork generated by their practices, then it would quickly bust its finances.

ICOs are likely to be run by foundation trusts employing GP practices as shop windows for their specialist services, meaning a greater shift towards expensive secondary care. They could also be easily packaged and sold off to private healthcare providers, with GPs becoming mere lackeys inside a corporate-run primary care service that is run for the benefit of shareholders and not patients.

And the signs are that Mr Burnham would face considerable opposition from GPs themselves. A recent Pulse survey showing that more than three-quarters of GPs are against ditching their independent status. The GPC has said that it will put off many from joining the general practice if they see that they will not have the same status as now.

But the push towards a salaried profession is not just from on high. As a reporter at Pulse a few years ago, I remember writing story after story about the ‘salaried-partner divide’ and how the partnership shortage was denying young GPs the chance to progress. How times have changed.

Practices across the country are struggling to recruit partners. The next generation of GPs are plumping for salaried or locum positions that offer the freedom to spend time with their families and have time outside the surgery. There is something to be said for the benefits of salaried employment - maternity and paternity pay, sick leave, employment rights. Why take on a stressful partnership that (in some cases) pays less than a salaried position?

So while Mr Burnham may have settled on this idea for his own reasons, don’t be surprised if it catches on. The days of the GP partnership may be numbered.

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Readers' comments (16)

  • Harry Longman

    For all our sakes as patients, I hope you're wrong Nigel. The model is not broken. It is unloved and it needs political leadership to understand the incredible value of the NHS GP model. The rest of the world craves what we have.

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  • Can we trust Burnham after MidStaffs?

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  • Vinci Ho

    Believe in 'Circle of Life' . So often things go around in circles.
    There are certain principles are not to be replaced. Time will tell and judge.

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  • Azeem Majeed

    The independent contractor model has many strengths but as I argued in an editorial in the JRSM (see http://goo.gl/zcYodm), it is not viable without a fairer method of funding primary care.

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  • 'What underlies many of the problems faced by general practitioners is the method by which general practices are funded and the independent contractor model of UK general practice.'
    This is grossly misleading.

    The model has proven robust and cost effective for over 60 years. What is in fact causing most of our problems is government meddling and subjecting primary care to a scorched earth policy of funding, continual reorganisations and a tide of vitriolic propaganda from the tabloid press.

    If we were united and moved to a European model of co-payments and insurance, we could provide unlimited excellent independant care because more work would equal more money. This is how every other business on the planet works, it's just that the government want to sell us to HMOs at the lowest possible price. We will only succeed if GPs are prepared to acknowledge their true value to the NHS and fight for it. Please don't sell us down the river.

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  • Una Coales

    Very well written Nigel. A blast from the past to see the NHS change to a Kaiser Permanente model. I was a med student rotating through a Kaiser clinic in Oregon sitting in with 2 family physicians and I told myself, never! $70k, full time, cover one's own hospital admissions and GP clinics, long days and salaried status. Remember US medical students are saddled with 6 figure debts!

    Just learned today that some US hospitals use the managerial concept of sham peer reviews to get rid of salaried physicians who are making a loss for hospitals, ie prescribing expensive drugs, booking pts for surgery, how long they keep pts as inpatients, etc. This youtube clip from the American Academy of Physicians and Surgeons explains what I fear may come salaried GPs way if they do not ensure profits for a hospital employer. http://youtu.be/LpvYwjwID8g

    It may go some way to explain why 400 US physicians a year commit suicide in the US as they lack control over their job and why some whistleblowers in the US live in fear of state medical board investigations into themselves and not the hospital they blow the whistle on as some sitting on medical boards may have vested commercial interests.

    The solution, Generation Y GPs, is to become independent private GPs (no targets or managerial tactics of ambush meetings, numerator and not denominator, hearsay evidence, etc.).

    I went to visit an older private GP in Chelsea. She looked happy, in control, confident and had no intentions of retiring. Her surgery was very intimate and she was able to offer her self paying patients her full attention and the very best medical care. She updated her clinical knowledge by attending free IDF lectures conducted by NHS consultants doing private sessions in private hospitals so she was well informed as to the best and latest treatments for every condition.

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  • John Glasspool

    A bit irrelevant as we won't have enough to fill he spaces available.

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  • Bob Hodges

    John's right.

    This country does not have enough GPs to staff ANY model of healthcare that would not leave the county bankrupt inside of one parliamentary term. The rate of decline of the available work force and it's productivity is accelerating.

    Everytime I DON'T send a patient to hospital, SOMEONE saves a couple of grand. At present that someone is the taxpayer. Crucially, no one makes any money either.

    The key to this is percentage of GDP spend, not really the proportion of public/private funding. We cannot afford a model that sees hospitals on a PBR type tariff harving control over their own 'front door' and effectively able to ask themselves how much they'd like to earn on any given day.

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  • I would have faith in the independent contractor model if it weren't for the fact that partners keep signing up for locum agencies to moonlight and let down their own patients. I personally would prefer every single GP in the country to be salaried. This would banish the expense on the NHS of agency fees. It would cap costs and would introduce stricter controls on professional standards.

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  • Theresa Eynon

    Having been a partner and now working as a salaried GP (and politician!), I share Nigel's concerns. Politicians, however well-informed, frequently miss the unintended consequences of their actions. Salaried GPs do not need to have the same long-term commitment to the patients and the community they serve. While many if not most take continuity of care seriously, they do not have to. Unlike a partner, they are free to move on at short notice.
    While that can be useful for a portfolio GP, it is not good for patients.
    I am not convinced that the Labour Party have got the message that continuity of care, co-ordinated by a clinician with clout, cuts costs.
    I will be working on this at Conference this weekend!

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