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At the heart of general practice since 1960

The partner-salaried divide

Pulse asks why salaried GPs are so unhappy, and talks to partners who say cash shortages are forcing their hands

Pulse asks why salaried GPs are so unhappy, and talks to partners who say cash shortages are forcing their hands

The voices tend to be anonymous, but the words are no less powerful for that.

‘It's creating a two-tier system in general practice where partners are the upper tier, and it's almost as if you're not being treated as a fellow colleague,' says one salaried GP who works in the Midlands. ‘You start to feel, are they hanging on because it's purely greed, or is there anything else going on?'

Is this GP displaying signs of paranoia, or is there really something sinister going on in the heart of general practice? Salaried GPs certainly seem to think so. Two thirds now believe they are being exploited by partners, according to Pulse's survey. It is a claim rejected 70% of partners, but one which appears to be opening up a damaging divide through the centre of the profession.

The figures are certainly stark. Only 27% of job ads analysed by Pulse – and dating from September 2007 - were for partners. The figure is down slightly from 29% in September 2006, and reveals the extent of the shifting of the sands of general practice. In 2006, 5,400 GPs worked as salaried or assistant GPs according to the Information Centre, a figure which had doubled since 2004 and is believed to be still rising fast.

The GPC admits in a Pulse debate this week that the shift may partly be an ‘unintended consequence' of the GP contract, which does not specifically incentivise practices for replacing partners. And a quick analysis of pay figures for recent years suggests another reason for the dramatic rise in the salaried workforce - employing a salaried GP is simply a cheaper option than replacing a partner and the gap is widening. Between 2005 and 2006, GP partners' pay rose by 10%, while the pay of salaried GPs went up only by 3%.

Dr Michael Uprichard, chairman of the National Association of Sessional GPs, believes they have become the ‘less expensive and more easily controlled' options for partners, with the cost of employing locums rising.

It is ‘unacceptable', he says, for partners not to offer inflationary pay - urging employed GPs to be more assertive in defending their position. ‘They are entitled and indeed owe it to themselves to negotiate an equitable contract,' he says.

But Pulse's survey reveals that many salaried GPs appear not to be doing so. As many as 37% have not been offered the BMA contract – more than half of those working in PMS practices, and over one in five of those in GMS practices, where the contract is supposed to be automatic.

Many salaried GPs feel the consequence of exploitation, with 70% of those in PMS practices, and 59% in GMS practices, feeling taken advantage of over pay. Many also feel overworked and demoralised.

Dr Ruth Chapman, a locum and GP trainer, says the grievances of salaried GPs are about much more than just money. ‘The main implications will be about the decreased morale, and moving away from the traditional general practice model, with less emphasis on family doctors and continuity of care. It's a big issue, and will lead to more demoralised doctors in general practice.'

Almost half of partners in the Pulse survey admit concern that the divide is destabilising general practice. But partners strongly reject accusations that it is their ‘greed' that is to blame. Many point instead to the huge financial uncertainty currently facing general practice, brought about by two successive pay freezes and the Government's relentless agenda of primary care reform.

Dr Fay Wilson, secretary of Londonwide LMCs and chair of the 2008 LMC conference, where the issue is bound to be a major source of debate, says the profession is currently witnessing the ‘growth of a GP underclass'. She rejects accusations of greed, and says the problem is down to ‘anxiety about whether partners can actually afford another partner.'

‘We'll see partner workload going up and opportunities going down, because of the continuing insecurities about finances,' Dr Wilson warns.

Dr Vicky Weeks, chair of sessional GPs sub-committee, also blames the Government for the ‘tremendous tensions throughout the whole of general practice'. She stresses that morale is low among partners as well as salaried GP.

But there are increasing concerns that the growing split within general practice plays entirely into the hands of the Government, which is content to divide and rule.

One partner in Yorkshire says: ‘It makes the workforce more mobile and less committed, which is not intended as a criticism, simply an observation. Obviously the Government sees it as a lever to disrupt traditional General Practice.'

Whether it is greed or Government policy, the Department of Heath is hardly likely to do anything about the salaried/partner divide, so can the profession act effectively from within?

The GPC signalled its intention to do something about it months ago.

At the last LMCs conference, Dr Hamish Meldrum - then GPC chair, now BMA leader - set out the potential crisis in no uncertain terms, calling on delegates to ‘nurture our young GPs, encourage our young GPs, stimulate our young GPs, value our young GPs, offer partnerships to our young GPs'.

Dr Meldrum suggested that if partners failed to act, there could be dire consequences, adding: ‘Don't let the short-term financial pressures lead you to make decisions that will lead to the long-term detriment of general practice and bring about a self-fulfilling prophesy that will place the control of general practice into the hands of fewer and fewer people.'

The BMA had been thought to be planning a major initiative to try to help tackle the issue, nothing has materialised yet materialised.

Dr Buckman, current GPC chair, says the plans have been sidelined by the bitter contract feuding with the Government. ‘Encouraging doctors to take on partners is most definitely part of our policy,' he says. ‘It was a hot issue until a very big hot issue turned up, but I don't think it's become less of an issue. Will we do something? Obviously it's something we're going to talk about.'

But Dr Buckman admits that the situation may get worse as ‘GPs won't want to take on partners because of fear of something that they can't afford.

‘My answer to that concern is, you're always better having a partner than an employee, and I would encourage people to make their working colleagues partners.'

Dr Buckman fears that the victors of the dispute could be APMS private providers who he claims could pick up disgruntled salaried GPs as ‘cannon fodder'.

The Pulse survey finds that 60% of salaried GPs would consider working for a private company under APMS, with over a third indicating that they were more likely to consider this option than a year ago.

Dr Sabby Kant, a GP partner in Hillingdon, claims the two-tier environment will see more and more salaried doctors flocking to the private sector to find work. ‘There's currently such a bottle neck for salaried doctors, with roughly 40 applications to one post,' he says. ‘At the moment, principals are laughing all the way to the bank but it could be our own un-doing. Darzi wants 25 doctors in one polyclinic. You'll get 25 salaried doctors coming in there with their hands up, queuing up to provide services for the private companies.'

An exodus of GPs to private APMS companies would also surely play into Government hands. The GPC knows if it is to take the Government head on, it needs a united profession behind it. The question is, is there anything more it can do than simply paper over the cracks?

Are salaried GPs being exploited?

Yes

Dr Suraj Sharma, a salaried GP in Liverpool and former city councillor, was previously a GMS partner for 25 years and says he believes that GMS practices who take on salaried doctors are doing so ‘only to make money'.


He says: ‘I can understand why they are saying that. I'm a senior GP, and prefer to go salaried, but I think new doctors are exploited with pay in GMS practices. Most are not getting the deal that they are entitled to. Earnings are related to quality points, but salaried doctors are not getting any reward for that.


It is exploitation. The partners don't want to take on more partners, they have very good incentive to take salaried doctors, and increase their earning related to quality points.
He added: ‘Not giving an inflationary pay rise is really reckless on their part.'


No

Dr Peter Smith, a GP partner in Weston super Mare, blames the Government for destabilising general practice, but feels that salaried GPs will have to accept a pay freeze until the situation is resolved.


He says: ‘For administrative staff, we will need to honour our commitments. Partners and salaried GPs will have to accept a pay freeze until the situation is resolved. A salaried doctor may feel that they are entitled to the same treatment as administrative staff but they already enjoy a higher salary and many benefits from their professional status.


He adds: ‘We found that less and less newly trained GPs were willing to take on the additional responsibilities of running practices. If anything, I feel that their current salaries are a little on the high side, given that they have significantly less involvement in the day to day running of the business.'

Dr Ruth Chapman: Salaried GPs' grievances are more than just about money Dr Ruth Chapman

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