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GPs buried under trusts' workload dump

Lord Darzi: All GP partners should be offered salaried NHS employment

All existing GP partners should be asked if they wish to become employees to the NHS, influential NHS policymaker Professor Lord Ara Darzi has said.

Lord Darzi, a former Labour health minister, said this comes as independent contractor general practice has in some cases hindered the move to primary care at scale.

Following a review, the Imperial College London professor has set out a 10-point plan for the NHS for the 2020s, in which he said general practice was the ‘jewel of the crown’ that must be protected.

As part of this, he said the total NHS expenditure towards primary care, community care and mental health should increase each year to 2030.

His recommendations come ahead of the Government’s own long-term plan for the NHS, due out this year, which will be underpinned by this weekend’s announcement of a £20bn five-year funding increase.

It also comes as the Department of Health and Social Care has launched a review into how the GP partnership model can be 'reinvigorated' to attract and retain more GPs.

Lord Darzi’s report, published by the Institute for Public Policy Research, said that leaving general practice 'in the private sector' has 'in some cases (but not all) - made it harder to move to primary care at scale at pace because it requires small organisations to take on big contracts or come together to form partnerships'.

It said this had 'also put more pressure on GPs – to run a business as well as provide medical care – with levels of stress and dissatisfaction in the UK disproportionately high compared to other countries'.

Lord Darzi went on to say that ‘while some think the partnership model is ideal and will want to retain it, it is not right for everyone’.

And, referencing a Pulse survey of GPs from 2016, the report said: ‘More and more GPs do not want to become partners because of the levels of responsibility and financial risk involved in it as well as the geographical immobility it requires. Evidence suggests that many GPs would be open to moving to a salaried model.

‘That’s why the NHS should welcome general practitioners into the health service, as full employees, on the same basis as their colleagues in hospitals.’

Lord Darzi suggested that ‘this could occur as part of a transition to Integrated Care Trusts’, adding: ‘All existing GPs should be offered salaried employment for their core clinical services. Those that wish to retain their existing contractual arrangements should be allowed to do so – this is likely to be particularly important in rural communities, for example.

‘Overall, these changes would remove the risk and stress that currently exists for many general practitioners.’

The report went on to recommend that general practice nursing, clinical and administrative support services should be funded on a capitation basis, while new funding streams are added to proivide enhanced services 'to sustain the entrepreneurial and innovative characteristics of much of general practice’.

The Pulse 2016 survey of GP partners referred to in Lord Darzi's report saw just over half (51%) saying they would consider a salaried position 'if offered the right deal', and 36% saying they would not.

But in an updated version of the survey, carried out in April this year, the numbers who would accept a salaried role declined marginally to 50%, while the numbers who would would not accept a salaried post went up to 40%.

Commenting on Lord Darzi's recommendations, BMA GP Committee chair Dr Richard Vautrey said: 'This is at odds with the partnership review commissioned by the secretary of state for health and social care and it is that which we will be engaging in.'

Dr Zishan Syed, a GP in Maidstone and Kent LMC representative, said: 'My view is that it is not the independent contractor model that needs remedying but rather the mechanism of funding. A fairer method of funding primary care that gives GPs adequate renumeration like the Australian/New Zealand model would be ideal. 

'The present obsession with pursuing "salaried for all" serves the interests of a few individuals who often are barely involved in frontline care and would happily exploit others with very poor salaries and poor continuity of care for patients. The purchase of all the premises from doctors would be prohibitively expensive.'

The report also recommended abolishing CCGs, replacing them with 10 strategic health and care authorities; merging NHS England with other arms-length NHS bodies including Health Education England; ending compulsive competitive tendering in the NHS; and offering free fast-track British citizenship to all EU citizens currently working in the NHS.

Lord Darzi was a health minister in Gordon Brown's Labour government between 2007 and 2009, when he resigned from the role. He will be most well-known to GPs for his policy to roll out walk-in polyclinics - dubbed Darzi centres - in all areas of London.

Lord Darzi's recommendations for general practice

  • Establish a new ‘right to NHS employment’ for all GPs currently working for the NHS.
  • Allow all existing holders of General Practise contracts (GMS, PMS and APMS) contracts to continue to under these arrangements, if they wish.
  • Create new funding streams to support innovation and enhanced services.
  • Increase the share of total NHS expenditure that goes towards primary care, community care and mental health each year to 2030.
  • Design care around groups of people with similar needs rather than around groups of professionals with similar skills.
  • All people of working age should be offered the option of digital consultations with in-person appointments available via easy access facilities at 24-hours’ notice, with access at the weekend and in the evenings.
  • All people with one or more long-term conditions should have a single care coordinator, a co-produced care plan and longer routine appointments with the GP by 2022.
  • People with serious enduring mental illness should have routine physical health care available at their homes by embedding GPs in community mental health teams.
  • Every neighbourhood in England (25,000 to 100,000 [people]) should have access to a purpose-built multi-specialty integrated care facility with embedded diagnostics by 2030.

Source: Better health and care for all - a 10-point plan for the 2020s

Readers' comments (56)

  • It REALLY REALLY annoys me when those who are "in " with those in power do so much to disrespect the rest of the work force as to distance themselves away from us mere mortals to save their own pay packet but siding with what their friends wish to hear !This is not support to grassroot GPs

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  • Isnt this bloke a busted flush,why let him tinker more.

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  • Left to our own doctors, like all humans, form their own groups through mutual interests. We are tribal and always will be. This is where central control, which has been getting far worse, goes wrong. Doctors should be helped to form their own groups. This will create job satisfaction, stop emigration, early retirement and improve recruitment. Forced integration never works and ultimately eventually falls apart like the Balkans did when Tito died.

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  • I'm with Peter and Paul
    I WOULD know one end of a Colonoscope from the other, but I do fear the Dear Lord lacks that reciprocity!
    Not being NEGATIVE, honestly, but all of this is far too little, far far too late :(

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  • Well I promise that I would do around 50% of the work that I do now if I were salaried. I would leave on time, take all of my lunch breaks and cop off home even if the paperwork wasn't finished.

    And how is HMG going to manage the thorny issue of property - are they going to buy up all of the GP practices? Or insist everyone comes to a central hub...?

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  • This your theoretical Utopian academic recommendations will not work in practice . I am not sure if you are a GP and if you are not I implore you to take 1 week out of your Lord's Chamber to go and sit in with a full time practising Gp partner to appreciate more his or her workload and practice commitments .
    Otherwise, I urge you to focus more on your 'LORDSHIP'

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  • If I have satisfactory remuneration
    Sick pay
    Holiday cover
    Crown Immunity/Indemnity
    Paid Study Leave
    Funded Study Leave
    Loss or reponsibilty for employing staff (ensuring current staff will be emloyed)

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  • Peter I think you have nailed this one.
    If general practice was to design a tertiary care bowel facility what would it look like?
    hmm that is the next GP registrar study away day sorted!
    well. I think that I would no longer have employed surgeons. I think that the surgeons would need to move towards working as a chambers. Hospitals could then literally buy in the surgeons as needed. We could also really outsource diagnostics from different trusts and then have hyperacute IT links that would send information forwards and backwards. We would then establish MDT processes based in the practice with the patient and the GP having a seat at the table deciding on the best treatment response. there would then be follow up within the chamber.

    Surgical teams and chambers would operate on a regional basis as opposed to being part of a single hospital group in order to provide sufficient operative procedures, per individual surgeons.

    Hospitals would need to be modifiable spaces like we are in general practice.

    That would be where I start in my review of what I think a tertiary care service would look like.

    - anonymous salaried!

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  • A few thoughts: -
    Nigel is a good guy but is a devotee of WAS - expect his report to be heavily influenced by this.
    WAS actually works against the continuity of care we had in the GP partner model; patients seen by a succession of "different doctors", rather than a smaller number of partners and among them one who knows the patient best.
    Ara Darzi is a good guy too. And he may be right that the impersonal WAS style 100k patient practice is all we can afford in 2018 - but let's be honest about that.
    As patients, we have to prepare to be met with an eConsult-style interface and if we do have contact with a GP it'll be remotely (some prefer that). When & if you do get a F2F consultation, it'll rarely be with the same clinician twice in your lifetime.
    As per PC's analogy, once we've all sold our clapped out cars and jumped on the collective bus, there's no going back.

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  • anonymous salaried! - Well stated.
    And key to the efficiency that you would expect from the chambers model would be that surgeons would use standardised operating techniques and equipment. Good luck with that one. Walk into any hospital today and you'll see the same operation done in the same theatre by different surgeons with different equipment, operating packs, staff roles etc, etc.

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