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Should general practice become a wholly salaried profession?

The inequity between partners and salaried GPs is corrosive for general practice, argues Dr Daniel Franks. But Dr Yealand Kalfayan says salaried GPs have no long-term investment in practices nor incentive to work beyond the minimum necessary standard.

The inequity between partners and salaried GPs is corrosive for general practice, argues Dr Daniel Franks. But Dr Yealand Kalfayan says salaried GPs have no long-term investment in practices nor incentive to work beyond the minimum necessary standard.

I've been a partner in a 4,000-patient semi-rural practice for five years. The partnership model seems to have served general practice well until now, but I'm concerned that it is now causing serious divisions in our profession. I believe one solution is a nationwide salaried GP service, but it would need to be implemented on our terms.

GPs may be fighting to maintain independent contractor status, but they are far from independent. We all moronically tick boxes and jump through hoops to generate our income. We are artificially set up as businesses, yet the contracts we hold prevent us from truly running as businesses. And in any case, operating as a business is actually distracting us from getting on with what it is we are trained to do - looking after our patients.

Because we run as businesses, when income streams freeze, costs have to be reduced to maintain profits. The problem is that partners, despite being warned of the folly of doing so, are saving money by hiring salaried GPs to plug the gaps when partners leave. This is disenfranchising a large proportion of the GP workforce and if you read the online forums you'll know many salaried GPs plainly see this as exploitation. If GPs are not treated equitably, then the partnership model has failed.

The GPC and RCGP have highlighted this problem and are looking at ways of tackling it. I believe the salaried option should be included as one of the potential solutions, yet the recent Scottish LMCs conference voted overwhelmingly against even discussing it.

The benefits of being salaried with a contract in line with that of NHS consultants would be considerable:

  • There would be equity between GPs. No longer would I earn £20,000 less than - or more than - my neighbouring GP colleague because of outdated and unfair funding formulas. The partnership model does not match workload or quality of service with pay and it never will.
  • We would become protected by employment law.
  • We would be entitled to properly funded paternity and maternity leave.
  • We would be entitled to sick pay. GPs have some of the lowest absence rates in the NHS and there is a fear that absence would increase if GPs were salaried. If it did, would this be because sick GPs are now working when they shouldn't be? Probably, which is clearly not good for patients.
  • Crown indemnity would be extended to GPs - it is unreasonable that GPs have to pay for cover when hospital doctors do not.
  • We would be eligible for the NHS final salary pension scheme. Why should consultants benefit from a 6% contribution to the scheme when GPs have to pay in more than 20% and only have a career average scheme?
  • We would gain access to study leave and a study budget, which would keep us up to date and benefit our patients.

There would undoubtedly be some vocal losers, but this is a price worth paying for equality throughout our profession.

A frequently used argument against adopting a salaried service is that it promotes laziness. Were you lazy as a salaried hospital junior? Or as a GP registrar? I doubt it. How hard GPs work and how conscientious they are depends on their professionalism - whether salaried or a partner. It is the inequity between GPs that will promote the feared jobsworth culture in future - not whether we are salaried doctors or partners. This has to be addressed, and fast.

Dr Daniel Franks is a GP partner in Stanley, Perthshire, and vice-chair of Tayside LMC

A decade ago general practice had a recruitment problem. Medicine in the UK faced an uncertain future. Despite the new administration having had 18 years in opposition to plan what it would do with the health service, it dithered for its whole first term. The indecisiveness and incessant anti-doctor media spin produced an atmosphere of confusion and apprehension. Newly trained GPs were unwilling to plunge into the choppy waters of partnership. As a model, partnerships appeared out of date.

A sudden flood of salaried options increased choice and defused the recruitment crisis. There had only ever been a trickle of non-partnership posts in general practice, but the option to work with minimum extra commitments became available to substantial numbers of younger GPs.

In the first years this seemed idyllic. Indeed it was GPs in partnerships who felt disadvantaged. The income differentials were not large. The salaried doctor scooted off home punctually at 6pm while the partners were left in the practice doing the administration and paperwork.

But soon practices realised that although employment of a single salaried doctor did not generate much extra income for the remaining partners, there were bigger gains as partners retired and were replaced by more salaried doctors. As the proportion of salaried posts has risen it has created an increasing financial pressure against the appointment of new partners.

There are now practices in which a small cabal of two or three partners is employing numerous salaried doctors. The once unified, co-operative, mutually supportive world of general practice is disintegrating. Responsible, personalised, long-term care is threatened.

Salaried doctors complain of exploitive working conditions and feel they will never attain the security of a partnership. The best trainee doctors will be put off general practice by the lack of long-term stability. Those forced to accept salaried positions will lose the understanding of how good-quality primary care can be organised. This knowledge and expertise will dwindle until the profession is deskilled and at the mercy of unscrupulous government.

Can salaried doctors be expected to invest time and effort in a practice in which they have no long-term future? What salaried doctor is going to go the extra mile under these conditions? Their incentive is to practise to the minimum necessary standard, to keep to time, to fill in the forms and to clock up QOF points. We are producing a generation of doctors who feel exploited, who do not want responsibility and will ultimately lack the experience to fight for high-quality primary care.

What is at stake is how we are seen by the public and our hospital colleagues. The value we bring to medical care is based on our local knowledge. This is accumulated over years and cannot be bought off the shelf. Continuity not only makes day-to-day work more logical and efficient, but also provides a consistency that supports long-term planning.

Knowing how the separate parts of a complex medical community interact is essential to fighting for sensible change and development. Continuity and a personal investment in a practice enables us to learn from experience. We cannot negotiate with those whose attention span is limited to the next election unless we have a deeper understanding than they do of how practices really function.

The solution is not complicated. The number of salaried doctors employed by a practice simply needs a limit. A ratio of one salaried doctor to every two partners might be appropriate. It is to be hoped this debate will gather momentum and will stir our professional leadership into action.

Although dissatisfied younger GPs are ultimately bad for patient care, politicians who wish to cut the bill for general practice may be quite happy to ignore their plight. A divided profession is easier to manipulate. We have to act now to limit the increase in salaried doctors.

Dr Yealand Kalfayan is a GP partner in Bristol

Yes No Do salaried contracts promote a box-ticking approach?

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