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At the heart of general practice since 1960

Salaried GPs are not cheap option

The new contract has unquestionably put an extra strain on staff. How have practices coped with this, and also the staff cost implications of the new contract? Dr Jim Sherifi has his own views.

The new contract has unquestionably made more work for staff. It firmly established primary care as a service provider in the true commercial sense, ie payment for service. As such, nGMS heralded a big shift in working practice and consequently practice organisation, away from the previous 'doctor-centric' philosophy.

In effect, it was no longer practicable for doctors to personally do all that they previously had done, thus heralding acceleration towards a team-based form of health care delivery.

In parallel with that has been an increasing acceptance by patients to see other members of the practice team to meet their health needs.

However, at this time ­ and some would argue that it is an anachronism based purely on a historical hierarchy ­ the doctors within a practice are still expected to provide strategic and operational leadership for the team as a whole.

Preliminary figures for the attainment of points under QOF for the year 2004/5 suggest the vast majority of practices exceeded 900 out of the potential 1,050 points on offer.

Undoubtedly they have done so through a multitude of means. Those that have done so with minimal anxiety and effort have used the skills available in the practice team through forward planning, training and above all delegation and trust.

The sensitive and pragmatic empowerment of team members has not only led to greater individual job satisfaction but also to a greater sense of involvement, belonging and value.

All these, in turn, have led to a more harmonious, congenial and subsequently, efficient, working environment resulting in maximising the income for the practice.

Traditional v. new

It is not only doctors who have needed to adapt. Every member of the practice team has also had to re-examine their traditional role and how it could be affected in the future for the efficient delivery of QOF.

Within our own practice it was immediately apparent that there was a degree of cynicism about the philosophy leading to nGMS and scepticism on the relevance of its delivery. This varied between the groups and the feelings had to be put aside in accepting the de facto implementation of the contract.

The staff were asked, not told, to help with the implementation of nGMS and further details on how they could do so were dealt with in smaller meetings. Natural leaders came to the fore in these meetings and these were informally co-opted to liaise between the doctors and rest of the staff.

In our practice, the first year of QOF activity highlighted the fact that some targets were easier to achieve than others. The foundation for success has been the need for accurate and standardised record keeping. This was reviewed in regular meetings either in small groups or in the practice as a whole.

During such meetings, overall progress was discussed, areas where targets were falling behind were identified, the causes noted and things put right. Extra resources were allocated to those areas that needed them but only in relation to the cost/benefit to the practice in points.

In that respect, the cost of employing additional staff might outweigh the potential income gained from hitting QOF targets. The way that QOF has been broken up into distinct areas (clinical and organisational) lends itself logically to the setting up of individual teams to manage bite-size chunks of the recording and delivery.

Staff needed to be rewarded for the extra input and responsibility involved in the delivery of QOF targets.

Rather than an increase in basic pay across the board, they were motivated, both intellectually and financially, through a system of appraisal and bonuses, based on attitude to, and amount of, extra work involved. Some areas of work were more demanding and time-consuming than others.

Summary

nGMS has introduced a need for novel working practices, based on team work and individual responsibility. Target-driven remuneration must be extended to cover all members of the practice to maintain staff morale, efficiency and pay.

Jim Sherifi is a GP in Sudbury, Suffolk

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