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Independents' Day

The independent contractor model is being left to die

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Independent contractor status is a cornerstone of general practice. Alongside the registered list, it has defined the way the profession has worked since the inception of the NHS.

But is becoming salaried the only option?

It offers GPs the freedom to advocate for their patients and speak out about how the health service is working. It is a key reason why the profession is so flexible and able to take on new ideas quickly – long before trusts heard of a ‘paperless NHS’, general practice was scanning in its Lloyd-George files.

And crucially, being independent contractors allows GPs the ability to determine their own future. They own their own premises and employ their own staff; in theory, at least, GPs principals have a level of autonomy as doctors unmatched in the NHS.

But this cornerstone is looking increasingly like a millstone. Many practices are a hair’s breadth away from disaster right now. Just one partner going sick or retiring early can tip a practice into the abyss. Year-on-year cuts in funding have left many with little room for manoeuvre.

For many GP principals this contractual status now feels like an elaborate trap. Their greatest fear is that they will end up carrying the can as their fellow partners bail out one by one. Many lie awake at night, wondering whether the liabilities heaped above their heads will come crashing down.

Speak to younger GPs and a good number wonder why anyone would want to become a partner; all the talk is of ‘portfolio’ careers. ‘I am the only one in my VTS class even considering becoming a partner,’ says a GP trainee at our roundtable this month to sighs of recognition around the table.

And while the profession’s faith in independent contractor status as the best model is undimmed – in a recent BMA survey 82% of GPs supported ‘maintaining the option’ of independent contractor status – it is interesting that just over half of GP partners told a recent Pulse survey they would personally become salaried if offered the right deal.

Today reveal that whole practices are starting to hand their contracts back, with the individual GP partners becoming salaried. In many practices GP partners are looking at resigning en masse so no one becomes the last man (or woman) standing. Others are flogging their premises to private companies.

But is becoming salaried the only option? I am no expert, but surely there are other ways of making the contract more bearable, such as setting limits on workload or introducing payments for activity (rather than the current capitation-based, all-you-can-eat buffet)? Could there be moves to limit principals’ liabilities, as with solicitors?

Super-practices – love them or hate them – do offer an option to retain the independent contract, while giving more GPs the option of a salaried career so they can do what they trained for – practise medicine – and not worry about having to sell their homes if things go wrong.

Scotland is looking at GPs being individually contracted as ‘expert medical generalists’, possibly without the burden of running a practice and employing staff. Could this model be considered elsewhere?

A debate is needed now on how the independent contractor model can be made sustainable. Otherwise this cherished cornerstone of the profession will simply be left to wither and die.

Nigel Praities is editor of Pulse 

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Readers' comments (17)

  • Reality check and a thought provoking article, Nigel!
    There are now 7,962 GP practices in England – one in 20 has disappeared since 2010. The rate of loss of local surgeries has speeded up – 79 closed and 55 opened in 2010 but in 2013, 126 closed and only 13 opened.

    By the time of next election in five years, the general practice model of the last 67 years will see revolutionary changes, we might begin to see GPs working as part of a broader non-acute sector, in larger teams, in different settings, and for new employers. A new tier of physician associates is planned, along with more nurses and pharmacists. These skilled non-medical professionals could be allowed to take on bulk of work traditionally only associated with GPs. All of this would be unrecognisable to our GP from 1948. Private sector providers want to de-professionalise and down-skill the practice of medicine in this country, so as to make staff more interchangeable, easier to fire, more biddable, and above all, cheaper.
    Time to unite and fight!

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  • Interesting article & response from Dr Chand. What worries me about the physicians associates, nurses, nurse practitioners & pharmacists is the responsibility. Who will be the fall guy if a complaint comes in - will it be the individual or the employing partner who is in the firing line?

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  • One option instead of burning out and changing to salaried - is to do less.

    Instead of seeing 18 patients (usually more) see 12 - and use the extra hour for admin.

    I think we as Gps feel guilty and keep trying to do more. We have worked harder and harder but now is the time to say enough - offer less appointments.

    Urgent cases can go to the new well funded WICs or AE

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  • Ivan Benett

    Come on, be kind, put it out of its misery. It's over a hundred years old. It was never perfect and has not kept up with the times. Most young GPs don't want it. Most partners moan about it. Let it go. RIP

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  • Agree, but I am worried its replacement will be worse.

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  • Dear Ivan,

    Although I have now joined your salaried ranks to preserve my sanity, you do not speak for me.

    I'm afraid Nigel's assessment is accurate and I, for one, mourn the end of the ICS. It is, without doubt, the most cost effective and satisfying way to deliver primary care but it has been run into the ground and that is why many are turning their back on it.

    What does it need? It's easy really. Adequate funding within the global sum or a fee per activity, crown indemnity, abolition of CQC and end to the micro-management, in place of treating us like professionals.

    Just watch the carnage of sky rocketing investigations, referrals and admissions when we have less continuity and other HCPs performing our role. Only then will the rest of the country mourn the end of ICS.

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  • Folks, much as I hate to agree with Ivan, you can't fight the treasury. They want it dead. Best thing we can do is let it go. It is already dead. If HMG don't want ICS, you can't keep a state-funded ICS alive. They can simply suck all the air out and let it suffocate.

    The only other option is a privatised ICS, but the market will soon consolidate this into the supermarket model - just look at Specsavers, Pets At Home etc.

    Either the market will deprofessionalise it, reduce our art to McDonaldised replicable activity, performed by the cheapest possible staff, or the DH will at the Treasury's behest.

    If what you want is "proper medicine", form a private firm and offer quality, not quantity. At present we are in the 'pile it high, sell it cheap' NHS. If you want to give 'luxury' healthcare (ie see the organ grinder, not their monkey), you must find a way to offer it somewhere else, and figure out who your customers are.

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  • Vinci Ho

    The momentum of this swing is certainly more towards 'All Salaried' right this moment as the Chinese said ,' the drift of the situation is a lot stronger than any individual human being .' But is this really the end position ?
    While I totally agree our older partners bailing out from their position impossible , the interesting question is are we talking about precisely the same sentiment in our younger colleagues ? The phenomenon is undeniable in terms how many youngsters would want to be salaried right now but is that their answer in 10 or even 20 years time? Of course , there are other choices like academic, portfolio(whatever its definition) GPs or perhaps chief executive in a private health organisation ??I dare not make any prediction. The lesson in Brexit where young people felt being coerced to go along with the choice made by the older ones is still resounding .
    Question is whether there will still be 'choices'? I suppose once a choice is gone , the situation cannot be reversed.
    NHS GP partnership model has been cost-effective because it kept the administrative cost low(some of you may not agree) and as I said , it allowed us to see the good and bad of a health model , left or right in the political spectrum. Coming from an origin(Hong Kong) where 90% of general practice is based on self funding , I also could see pitfalls in the system with respect to social justice .Perhaps , the UK model has been pushed too much to the left as politicians are harvesting political brownie points from its ethos all the time .
    Whether we like it or not , the model will need to be 'upgraded'(but may not necessarily be all super sized/mega practices) if it is not to be scrapped altogether. Two things stuck in my mind:
    (1) The government needs to clearly define the limit of how much NHS can deliver, hence ,afford (re-workload and workforce)with transparency of arguments. 'Luxurious' demands should come with a fee and you probably know what I am going to say ;charging a fee for weekend routine GP appointment is my example . Of course , we never believe in honesty in politicians and nothing stops them from carrying on milking the cow which will simply fold up NHS no matter we all go salaried or not.
    (2) Whether we like it or not(thanks to Tories again!),it is so obvious where personal health budget will go . Rather than relying on patients going rampage spending in all sorts or having no clue , a 'middle man' will have to come in to ensure validity and at the role has been dumped on CCG. Otherwise , we can all see private (insurance) companies coming in to play.To me , the difference between the two is the invaluable quality of continuity providing necessary information to make judgements( which is one of the key virtues of NHS general practice)despite many go for fast food ,conveyor belt primary care. I may be wrong , an upgraded model of GP partnership can be indicated but of course , there is also the permanent haunting of 'conflict of interest' from the wonderful section 75 of Health and Social Care Act . The government must make a decision how to spend and its experiences with private companies so far are poor .
    While the leadership(s) of this government is clearly in tatters , it is an opportunity to think and debate clearly what we are fighting for while keeping the defence line still tight against the common enemy.
    Choice is all yours, young Padawans and I always respect your choice(s).
    For myself , as I said in the past , the day I stop believing what I am doing or saying , I will walk . Life is short after all......

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  • Salaried model is simply too expensive - the employer has to pay too much for contingency whereas partners can take a chance that they won't need sick cover etc, so I really hope that the independent model (whether as at present or through super-practices) is still there in 5 or 10 years

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  • If you value something, you invest in it and cherish it.
    Our penance has been a reduction in funding from 11% to 7% of NHS share and an orchestrated serial dismantling in the papers of General Practice.
    If an elected Govt. wishes to dismantle GPs by simply reducing funding, it is their prerogative. the ultimate aim is acheaper service. I am not sure that is going to happen

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