Is independent contractor status doomed?
Dr David Coleman and Dr Tony Gu debate
There is nothing wrong with the independent contractor model, in itself. It is inherently efficient, incentivising subcontractors to operate in the most cost effective way to increase their profits. It allows for a degree of freedom for the way subcontractors can operate their business, allowing for local adaptation and to changing environments. Unfortunately, the strengths of the model are also its inherent weaknesses. The crux of the matter is that the independent contractor model is reliant on external factors to make it effective and in the current climate does not have the right contractual framework, the political resolve, nor the macroeconomic factors to make it viable.
The NHS monopoly employer status forces practices to sign up to a single capitation based GMS contract. This means subcontractors cannot charge market rates for their services and have to absorb any future rises in demand through the ‘all you can eat’ system. Even worse, the contract forms a shackle for GPs to absorb more work that is felt to be politically expedient, such as unplanned admissions or extended hours.
Proportional funding for primary care for the contract from this April is approximately 7.2% of the NHS budget, an all time low. More importantly, running these businesses are increasingly expensive. The unsavoury truth is that between the immutable factors of ageing demographics, rising demand for increasingly more complex services, and not enough money to go around, the NHS will be in a form of austerity for many years to come. There is no political will to change this either, with the Government focussed on Brexit and its economic ramifications.
The only conclusion I can draw is that there will be no political stomach or economic freedom for a massive uplift deal like the 2003/4 GMS contract, which I feel is the only thing that can save the IC model. Partner income will therefore continue to decline whilst workload rises. With the addition of an interrelated workforce crisis, there is now genuine concern that independent contractor GPs are running the risk of being the ‘last man standing’, a situation which can be a financial catastrophe. The subcontractor takes all the risk of the business, which allows NHS England and the Department of Health to abrogate all responsibility should things go wrong. Compare this to failing hospital trusts being bailed out, for example. It all adds immeasurable stress on an already stressful environment and it is no surprise that many new GPs do not wish to take up partnership.
I am in no doubt that GPs can run practices better than NHS managers. However, there is now so much bureaucracy and risk associated with partnerships, coupled with dwindling income, that the average partner may only be making slightly more than their salaried employees. Many are realising they are taking on far too much risk for very little extra reward. The freedom that independent contractor status previously gave GPs in running their own business is also eroding away. A quick look through a CQC checklist will tell you how little genuine freedom there is – does a university practice really need dementia protocols?
Independent contractors are good for patient continuity and its efficiency is good for the NHS. However the current NHS landscape means it is just not good for the GPs. I am not happy coming to this conclusion, and I wish it were different. But this is the current reality. Just ask the record number of practices asking to hand their contract back.
Dr Tony Gu is a locum GP in Manchester
Since its inception in 1948, the NHS has been built on a foundation of strong general practice delivered through an independent contractor model. Practices organised like small businesses have long been praised for their efficiency, flexibility and ability to innovate, and this remains even in the current climate.
No-one can deny that GPs are under tremendous pressure. Regardless of contractual status, we are all struggling to manage an increasingly complex and utterly relentless workload. Being a partner undoubtedly adds another dimension of worries, but it also brings its own unique professional rewards.
Despite the ongoing erosion of our independence and constant contractual tinkering, general practice is still largely led by its clinicians. We know our practice populations better than anyone and we have the freedom to make decisions about how we run our services in a way that is best for patients. For example, in my practice we have developed a bespoke triage service that allows patients to choose whether to wait for a preferred doctor or be seen sooner by someone else, which improves access while still prioritising patient choice and continuity of care; patient satisfaction is high and our working lives have improved too. But would such a specific local innovation have been as easy to implement if we were salaried employees, pitching it to a large management team? I sincerely doubt it.
Independent contractor status allows GPs to act as independent patient advocates, able to challenge CCGs, NHS England, hospital trusts and other providers where appropriate. This is an absolute necessity in an age of multiple providers, and wouldn’t be possible if we were employed by one of these bodies.
As independent contractors who are clinicians with a strong overview of the practice’s needs, we are able to adapt our staffing accordingly. For example, we have recently recruited a community matron and emergency care practitioner to lead on care planning and help improve continuity of care for our housebound patients. Having the final say about who we recruit allows us to maintain a cohesive team with a shared ethos.
The current trend for working at scale clearly appeals to many, but so-called super practices or federations can still tap into the benefits of independent contractor status. As well as offering economy of scale and opportunities for career progression, large clinician-led organisations could reduce partners’ individual liabilities and significantly reduce the risk of being the last partner standing.
During the last decade general practice has been undervalued and underfunded. This is the root of our current woes and there is no simple solution, least of all wholesale and costly structural change. While there are common themes, the challenges facing a practice in London may be quite different to those facing colleagues in rural Cumbria or indeed suburban South Yorkshire. Independent contractor status allows GPs the flexibility to find solutions specific to their area and ensure general practice survives.
Dr David Coleman is a GP in Conisbrough, South Yorkshire