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..Should we switch back?

Salaried GPs could increasingly be attracted to partnerships in future, says Dr John Couch

The last few years have been a turbulent time for general practice. But there is a comforting French phrase, 'plus ça change, plus c'est le meme chose', that can help to give perspective.

Older GPs like me have been watching successive waves of GP registrars for some sign that partnerships have not gone permanently out of fashion. Few of us relish the prospect of a completely salaried service either for ourselves or for the profession as a whole. There are some indications that we may be able to avoid this.

Popularity of salaried/locum options

Most of the reasons for the popularity of locum and salaried posts in recent years are clear. There has been a massive shift in the profile of the average GP to over 75 per cent female and largely part-time. This has coloured many of the factors below.

Until recently, partnerships were responsible for out-of-hours cover, even if this was sub-contracted to co-ops or deputising services. There was always the possibility of that responsibility reappearing (in areas suddenly vacated by Healthcall this became a reality!). Paperwork and long consulting sessions were also negative factors that could be overcome by a carefully negotiated salaried contract with a PMS practice.

With around 50 per cent of practices owning property, this was seen as a heavy anchor on a generation generally aspiring to a portfolio career. A salaried post allowed three months' notice and then freedom to move on. Business aspects also fell out of favour with young GPs wanting to focus on clinical work rather than administration and finance.

Finally, there was an economic reason. With the exception of the last 12 months, the difference in net income between salaried and partnership posts has not been significant. It has been difficult to argue against the logic of: 'I can earn almost as much, with no out-of-hours, less paperwork, no non-clinical responsibilities and no financial investment as a locum/salaried GP, so why apply for partnership?'

What has changed?

But now there have been some significant changes to make many younger GPs question this view. The first is of course the new GMS contract. This has allowed practices to opt out of OOH cover formally. It has also given GMS practices the option already available to PMS, of employing salaried GPs.

Having faced considerable shortages of partner applicants for many years, not surprisingly large numbers of practices now advertise for a salaried replacement. Primarily this is simply a way of filling posts, although in many cases it also allows partners to increase profits too.

The feeling is that extra paperwork, non-clinical activities and financial risk have to be taken on by someone. It seems only fair that if GPs chose a salaried option to avoid these, there should be a greater financial reward for those who chose to take this work on. Accounts for 2004/5 show partner income has at last started to rise to a more appropriate level. This will not be lost on non-partners.

Many partnerships no longer insist that a partner should purchase property. In fact, as the buy-to-let culture has grown, the financial benefits have become even clearer to existing partners who are more willing to take on higher levels of property equity. Those GPs who do become partners also find that practice agreements are more likely to make clear allowance for exiting partners' capital.

In many cases practices taking on more salaried GPs have actually been able to create protected time for partners. This has allowed defined space to cover QOF, enhanced services, non-clinical work, study and catch-up time. Time is still well filled, but stress levels have fallen.

There is another very interesting point. Over the last few years a cohort of GPs who have been in salaried or locum posts for a while has built up. Many are finding that they are ready to take on more challenge. In reality some are becoming bored and do not feel stretched. They can see what life is now like for partners and some actually feel they are ready to make this the next stage of their career.

Outside forces

The new contract also opened the door for third-party providers of primary care. Recent publicity has indicated that the Government may ring-fence around 10 per cent of the primary care budget for private companies to build new GP premises and run primary care services from them. If this were limited to under-doctored areas we might feel more comfortable but, given the scale of financing, it seems clear that this is likely to introduce direct competition against partnerships in many areas.

The spectre of shiny, new, well-equipped buildings, staff with corporate smiles and tightly-managed, target-rewarded GPs competing against decaying partnership premises with demoralised staff and GPs is looming. This more than anything should make all GPs realise that the threats are from without not within.

What are partnerships doing?

Practices have had to adapt to market forces over several years and have become used to partnership shortages and working with fewer partners and more salaried GPs. Therefore few advertisements are currently placed solely for a partner. Around 50 per cent are for salaried only and the rest keep all options open by offering both salaried or partnerships.

Some practices are now offering 'salaried with a view to partnership'. This can be an excellent way for both parties to assess each other over an agreed period before a partnership is agreed. Some salaried GPs are also interested in gaining experience of non-clinical work. This trend is very encouraging and seems to offer the most hope of repelling the gathering corporations. It is vital that practices consider such posts rather than continuing to shrink partner numbers. It is also vital that salaried/locum GPs consider making the extra commitment required.

When I applied for partnership many year ago it was normal to be offered a 'three years to parity' post. I did not have to take on non-clinical work for this time as it was recognised that I needed to sharpen my clinical skills and get to know my patients. I was certainly ready for more once this time was completed. It is tempting to draw analogies with the many salaried GPs who have now reached this same point. Plus ça change....!

John Couch is a GP in Ashford, Middlesex

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