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Gold, incentives and meh

'Shaming' GPs? No, we aim to support them

Getting your staff mix right and finding the money to pay for it is a vital skill ­ Dr Peter Stott shows how to do it

One of the benefits

of being a PMS rather than a GMS practice is that for some years PMS practices have had the financial freedom to employ a greater range of staff. Under the old GMS contract, practice income was dependent upon the number of partners. Under PMS, it always was dependent upon the services offered.

So PMS practices could reduce the number of doctors and employ more ancillaries. Now nGMS has brought GMS practices in line. But PMS practices were given a head start and many are several years ahead of GMS in developing their skill mix.

Developing your skill mix

The major new skill in the primary care mix has been nurses. For the population of 10,000 patients in our practice we now have two health care assistants, two RGNs and two nurse practitioners. They are all job-sharers with a total working week of nearly three whole-time equivalents.

Developing their role has been our biggest priority over the last three years, and a certain amount of forward planning and budgeting has gone

into it. In the process, we downsized from being a 5.25 WTE GP practice to a 4.75 WTE GP practice.

Some of the money saved on the doctor's salaries was used to pay for the extra nurses.

Salary change

Salaries and partners' drawings are the biggest expenditure in any practice ­ upwards of 90 per cent of all costs.

A review of salaries over the last five years shows that total salaries remained reasonably constant for doctors, reception staff and managers.

But nurse salaries have increased by between 30 and 50 per cent, year on year. Since year 2000, the total spent

on nurse salaries has increased by a factor of three.

Freeing up money

So how have we gone about it? For a start, we could not have contemplated this were it not for the cost-saving opportunity afforded by the retirement of our ex-senior partner and his replacement with a part-time partner. This freed up about £40,000.

Retirement opportunities are one way forward; but now nGMS has produced new GMS income which can be used to develop the skill mix. But, however you look at it, there is inevitably a need to identify new money.

Resourcing change

£40,000 is quickly spent ­ in our case expanding the total nursing workforce by 1.5 WTEs and upgrading two RGN nurse posts to those of nurse practitioners. Now our nurse salaries run at about:

Nurse practitioners: £39,000

RGN practice nurses: £24,000

Health care assistants: £14,082

Total £77,082

Greater reliance on salaried nurses rather than GP partners has other financial implications. One of the biggest is the need to provide effective cover when nurses are sick or on holiday.

Others include training, pensions, provision of medical protection cover, subscriptions to the Royal College of Nursing and new equipment. Then there is the new NHS pay scale to consider ­ Agenda for Change ­ and it's somewhat of an unknown at this point.

And there is the business of increased pensions contributions. So we have recently begun to think about how we might be more organised in our financial planning and whether we could prepare an indicative budget for the nursing team. This would be operated by our senior nurse practitioner who is designated as our 'nurse manager'.

Nurse manager's role

The nurse manager would be expected to cover the year with staff and provide the practice with nursing skills and equipment, all from an indicative budget allocation. We all agreed this would have the benefit of making the nurses more aware of the financial imperatives while allowing them to be more in control.

Any new money from the quality initiative could be fairly disbursed; and if there was money over, we agreed this could be used creatively!

Budget setting

Budgets can be set in two ways ­ historically or in terms of future work to be provided. Allowance needs to be made for new commitments as well as efficiency savings. So for the terms of this exercise, we decided to act like the rest of the NHS and to take historical budgets as a start, building on them in terms of the new services to be offered and new monies as they became available.

At the moment, our indicative nursing budget is based upon year 2003/4 which comprised a number of elements:

Staff salaries: £76,000

Nurse practitioner

medical insurance £600

Journals, etc £100

Equipment and dressings: £3,000


dressings not yet identified

Training: £500

Nursing locum cover: £4,000

Total £84,200

A number of things are immediately apparent. Regular salaries are by far the most important item ­ 90 per cent of expenditure. Locum costs are the most easily avoided ­ except where long-term sickness absence intervenes. And our minor quibbles about costs of equipment are exactly that ­ minor quibbles.

We may need some insurance for extended sickness absence, and minor savings could be made in terms of equipment, but this does not amount to much overall.

In reality

We have debated whether this budgeting exercise is worthwhile given that staff salaries are really the only major variable. Is it fair to expect employed staff to take on this level of responsibility given that their salaries are fixed? This was just an academic exercise, but our overall view would be that the quality initiative has brought new monies into the practice.

Some 40 per cent of this will be reinvested in the practice. The remaining 60 per cent could be allocated to an improved salary structure which would motivate and retain staff.

We need to have some system of identifying the contribution individuals have made, of allocating resources fairly and of making the process transparent.

We have performed the same budgeting exercise for the doctors and for the reception staff. As a result we know that between them the doctors (and their locums) earn 65 per cent of total salaries; the nurses earn 10 per cent; and reception/managers earn 25 per cent.

We are discussing how we can take this forward; how we can decide the contribution each can make to the quality initiative; and finally how we should resource the necessary changes.

Everyone is expecting great things from the quality initiative and one of the most important spin-offs will be the ability to motivate and reward our ancillary staff with a fair share of the increased practice income.

The result

So as a result of this exercise, now the new money has appeared, each department, doctors, receptionists and nurses can each make an 'indicative' bid.

Each department is more motivated to recognise the contribution they can make; we can see more clearly where new resources are needed; and wherever possible salaries can be increased to retain and motivate staff.

Peter Stott is a GP in Tadworth, Surrey

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