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GPs go forth

Should all GPs become salaried employees of the NHS? Yes

General practice would once again become an attractive career option if GPs gave up independent contractor status, argues Professor Azeem Majeed

The independent contractor model has been at the core of UK general practice since the NHS was established. A strong primary care sector has allowed the NHS to operate efficiently – GP practices have typically used between 8% and 10% of the total NHS budget and dealt with up to 90% of all patient contacts.

However, many GPs now find themselves struggling to cope. This makes it difficult for patients to see GPs. We are also now seeing a divide between salaried GPs and GP partners.

We have seen the RCGP and the BMA lobby for increased support for general practice with little success. To ensure general practice remains an attractive and rewarding career option, and that primary care remains the foundation of the NHS, we now need a serious debate about funding and employment models.

We need to consider more radical options, such as a salaried GP service in which all GPs are employed by the NHS.

A salaried service could allow GPs to be employed on similar terms to NHS consultants, with a salary based on experience and with additional payments for management or clinical leadership. GPs could also then have job plans, as consultants do, with sufficient time for administrative work and teaching.

Another benefit of a salaried service would be better workforce planning for local needs. GPs could be employed by the same organisations as specialists, giving greater opportunities for integrated working with secondary care.

Giving up independent status would be a huge step and one that many would find difficult. GPs benefit from the political clout and freedom to operate as we wish. But if we don’t start to negotiate on our employment terms, the likely alternative is a proliferation of APMS contracts and, increasingly, employment by commercial companies on worse terms than the NHS.

Professor Azeem Majeed is head of the department of primary care at Imperial College London and a GP partner in Clapham, south London

Read more: Should all GPs become salaried employees of the NHS? No

Readers' comments (16)

  • Azeem Majeed

    I have listed arguments in favour of the current independent contractor model of general practice and in favour of a salaried service on my blog.

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  • If being a salaried GP is such an amazing opportunity, why have you been a partner for so long?

    How naïve to think that we would have more influence, rights and decision making skills as an employee.

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  • These words are clearly from an academic rather than a real GP, we - and our representatives - should be publically rejecting this suggestion , as well as the notion of 24 hour care, No other country in the world provides this level of free healthcare and this government is afraid to tell the public that it cannot afford to give people what they want any longer. I believe that there is sufficient finance to provide a needs based healthcare system but we need to be able to say "NO" to the people who chose not to take responsibility for themselves.

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  • It still startles me how are so-called leaders fail to grasp that one of the attractions of pursuing a career in general practice for most young doctors was the independent contractor status, which brings along with it autonomy and the ability to make wholesale changes for the good of our patients rather than being burdoned by the bureaucracy that is embedded within secondary care. Losing our independent contractor status would be a absolute disaster!

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  • This is completely the wrong direction of travel for the profession and I do imagine that there would actually be privatisation of NHS General practice before actually being shifted to a salaried model, however point 8 I do agree with on your blog. what we do need to do is work out why commisioners choose not to award contracts to GP's as opposed to private companies and this needs to be addressed.
    The current direction is not good for anyone.

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  • - anonymous salaried!

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  • Dear Sir,
    I think Claire Gerada is right, but then I have personally campaigned for many years for closer consideration of a salaried contract. My paper "Radical Options For Change" was once circulated to all LMCs and discussed at Conference. We should in my view now press for a new contract as "Consultant in Primary Care Medicine".
    The number of non-principals is constantly growing, as is the number of women in the profession. They are often currently being abused and underpaid as salaried workers.
    The BMA is currently doing remarkably badly at negotiating the Independent Contractor Contract, and will inevitably be walked all over next year. The Government (NHS Employers) was recently refusing to talk to BMA negotiators. It seems that the BMA does not want to take any strong action at all. It is worried about threats to its assets, and doesn't want anyone "rocking the boat". Never forget that GPs form only a small part of the wider BMA, our official trade union. That political weakness is one reason I retired a year early and left GPC. It had become plain to me that we were getting nowhere, and it was very frustrating. I respect Claire Gerada, although I am not myself a Member of The College.
    Too many senior GPs are currently gaining excessively from their position as principals at the expense of non-principals, and are creaming off huge parts of the available practice profits. They also have a wary eye on their personal assets in premises and in dispensing. That is why there is currently such resistance to change. Arguments about shift-work and about loss of continuity in a salaried service are spurious. Our Primary Care Teams have already been largely smashed.
    If we were to seriously push for a salaried service The Government could hardly refuse us, and might just wake up as to how much it would all cost. We might then get a better deal to keep GPs in a fair Independent Contractor Contract. I doubt The Government could afford to pay for a proper salaried service. Except for "The Daily Mail", which is strangely anti-doctor, we all know how good the Government's current deal is for itself. The 2004 contract was well negotiated and was fair for both sides. Splitting the old 24/7 contract had become vital, and something we had campaigned for from Gloucestershire LMC for many years.
    Salaried GPs could not be abused with threats of Dickensian hours, and there are many potential benefits for an employed status, with proper maternity, paternity, and sickness leave.
    The only argument against salaried service that I heard voiced at GPC seemed to be that we would all end up working for "peanuts". Those arguments came from some of the highest earning entrepreneurs, and I don't personally believe they are correct.
    The laws of supply and demand are beginning to bite now with 15% of all GPs having retired early in this area since April, the College currently engineering an additional year of GP training, and massive emigration of young doctors to Australia, New Zealand, and Canada.
    There is now a serious shortage of experienced senior GPs, and also new young doctors prepared to put in long hours.
    If privatisation takes hold it is likely to be on a salaried basis with horrendous terms of service, and loss of NHS advantages. In particular The NHS Pension would be seriously threatened. Salaried Service within the NHS is the answer. The basis of negotiation should be as it is now, i.e. to equalise career earnings of GPs and hospital consultants.

    Dr Peter Fellows

    Former chair Glos LMC and GPC member 1990 to 2013

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  • im surprised at the poor quality of argument from a professor. Looking at his blog one of the main arguments for going salaried is

    'General practitioners currently face unrestricted demands for their services and on their time while having to operate on a fixed budget. Under a salaried model, the primary care service could be funded in a similar way to the tariff-based payments made to hospitals so that extra work was accompanied by additional funding.'

    could be? what a joke - it wont be. there is no new money - does anyone really think the government will open up general practice to a unrestricted tariff where costs will go up massively? the biggest problem our CCG has is a local foundation trust that just does what it likes and charges for it whether its in the best interests of the local health economy or not. more elderly care? better paeds? patients sorted on admiss - All no - more orthopedic surgeons doing more and more athroscopic work at huge cost - YES.

    All a salary would be is 1. a cut in income and 2. a loss of the ability to tell the powers that be they are talking crap - how many times have GPs been right over this - 111 etc etc etc. A friend who is a local consultant got dragged into the medical directors office and was given a talking down and feels his card has been marked for suggesting in a clinical meeting it was stupid that the surgeons and medics had bought different endscopy kit that wasnt compatible with each other - a perfectly reasonably comment.

    The only defence we have at the moment to stop everyone and anyone dumping crap on us is to say thats not in our contract pay us. Once salaried all we will get is - oh do this and this and this and this and why arent you doing this and this and that... no one will care there are only so many hours in a day.

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  • "Too many senior GPs are currently gaining excessively from their position as principals at the expense of non-principals, and are creaming off huge parts of the available practice profits."

    where is the evidence for this?
    in my practice our salaried doctors are on £85K. In addition we pay their defence union and subscriptions, their employers super ann, their sickness (they take more than partners), their maternity (their deal is better than partners) and while we dont have any complaints about them - they have all been with us years and have a good following - they have all cut sessions only 1 works full time. Most want late starts early finishes and none will do an extra session for free when we are short handed. They all do less appointments than the partners and shorter surgeries and less extras. None come in in their own time for mangement meetings, or do anything other than their own work.
    The only one who did we made a partner recently and her comment 6months into being a partner was how much harder it was for almost no increase in her take home (on full parity from day 1). we dont own premesis and have all left £15K of our money in our capital accounts to help the cash flow of the business. one month last year - the NHS was so slow at paying and we suddenly had cashflow issues i took home £28 with several of the partners taking nothing - my wife wasnt pleased. all the salaried docs got their money. Dont get me wrong I like being a partner but Stop telling me i abuse my salaried doctors - they dont want to be partners.

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  • Dr Fellows, Dr Gerada, and Prof Majeed all deserve to be congratulated for having the courage to honestly and openly describe the problems that our profession faces in the immediate future. I agree with Dr Fellows that the BMA and GPC have failed us and it refreshing to see an ‘insider’ telling it as it is, without the bluster and obfuscation which characterise the usual ‘rent-a-quote’ member’s responses.

    The previous contributor tells us, in effect, that his/her salaried colleagues ought to consider themselves fortunate to be on ‘£85K’; however, by failing to disclose his/her own drawings he/she inadvertently underscores the point made by Dr fellows that GP partners have been greedy and, as a consequence must bear some responsibility if general practice in England is no longer seen as an attractive career option for the next generation of GPs (and I speak as an old-timer in his fifties myself).

    I was appalled by the lack of respect and just plain, nasty vindictiveness shown to Dr Gerada when she stuck her head above the parapet last week; more than anything, it made me doubt the professionalism of some ‘colleagues’, as well as their grip on reality.

    We need to stop whingeing and mud-slinging and engage in constructive debate. Drs Gerada, Majid and Fellows are showing real leadership and I congratulate them. More, please, Pulse!

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