Is salaried practice the future?
Since 2004 general practice have seen an 800% increase in the number of salaried GPs, with reports of poor contracts, terms and conditions of service with little autonomy and career progression amongst the younger generation. Shadow health minister Andy Burnham has also recently predicted a move towards increased salaried work. Dr Beth McCarron Nash, a member of the BMA training sub-committee, and Dr Amy Small, a member of the UKGPC, discuss why general practice is so unpopular, and whether the partnership model is on its way out.
What’s the value in protecting the partnership model - wouldn’t it be better for GPs to all become salaried GPs?
Dr Beth McCarron-Nash (BMN):
The small cottage industry partnership will not survive in its current form and the workforce must adapt. Young doctors have trained in a shift-based system, become accustomed to moving about and working in larger teams, and have differing aspirations from a career as a GP.
Dr Amy Small (AS):
I have to agree. Changes not only to pay and conditions, but pension hikes and workload are going to drive older GPs out. And there are far too many talented young doctors moving abroad to get a better quality of personal and professional life. If we are not careful we will find there is no-one left behind in general practice. If we want to maintain some autonomy, we need to mentor and encourage GPs who view their work as their vocation. I will often grumble and moan about my job and workload but would never really consider doing anything else.
Why is general practice so unpopular with medical students at the moment?
BMN: I’m sure the reasons for this are complex and multifactorial: constant anti-GP media stories, reports of falling GP morale , falling income, increasing complexity and ever spiralling workload are having their effect on our future colleagues’ career choices.
Trainees are also now facing longer training to become a GP, meaning increased debt. Few partnership opportunities and comparably less job security means many junior doctors feel a career in hospital medicine is a better bet.
There is also considerably less exposure in medical school to general practice, and this needs addressing if we wish to promote our specialty .Many people chose general practice as they value the autonomy, flexibility and ability to be a partner in a business as well as working as a generalist. But most young doctors do not seem to want the risk, cost of salary and increased workload associated with partnership.
AS: On a rather basic level general practice isn’t ‘sexy’ like some hospital medicine. You don’t get to say you took part in an operation to remove a man’s stomach/leg/arm, or bring someone back from the dead, and do all the things you see on telly in shows like ER or Casualty.
Medical students and junior doctors are not immune to the GP ‘bashing’ that goes on in the media but I feel that there is a certain amount of bashing that goes on within secondary care as well. Some junior doctors feel it’s a competition to see how many GP referrals they can ‘bat away’. This is usually due to lack of understanding about what goes on in primary care so I agree it’s fundamental that all junior doctors rotate through general practice to understand how the whole system works together.
As a salaried doctor I felt frustrated at the perception that I was ‘second best’. For me, the goal was always to achieve partnership. But as a partner, I find the workload overwhelming. I have cut down my number of sessions recently – I now earn a less than I did as a salaried doctor and with a lot more responsibility.
When I first qualified I wanted a six-session partnership within about 10 miles of my home where I got to leave at 6pm every day. I don’t think this kind of job really exists any more. A GP’s ‘normal’ working day is not conducive to getting out of the door in time to pick up the kids from child care or school either.
What are some of the ways in which partnership can survive if the cottage industry model fails?
BMN: Protecting our independent contractor status, and protecting list-based general practice is absolutely crucial if we are to have any sort of professional autonomy. We must empower ourselves by merging or federating and we must also become much more business-savvy to survive.
AS: My non-partner colleagues (all in their thirties and forties) all say they would consider partnership in the future, but none of them want it now. So, the question is, if we have a cohort of GPs who may retire early, and a cohort who aren’t ready to be partners yet, how do we fill the gap? Firstly we need to get out of thinking that a 50-60 hour week as a full time GP is normal. We cannot keep working at this pace.
Another way forward is to encourage practices to recruit more part-time partners. You may get lack of continuity, but things can be done to overcome this problem with buddy systems, for instance. We need to get better in-depth looks at how practices do things differently. The beauty of being a partner is that you can run your practice the way it suits your particular catchment area.
We need ways of getting practices together to look at how appointment systems, IT systems and triaging are used differently. We need to look closely at how we use nurse practitioners in our skill mix. I think we need do less work on QOF under the new contract, and I suspect many GPs will agree. In summary, we need to be far more open about how we run our surgeries, and share around our knowledge. Federation is key.
Dr Beth McCarron-Nash is a GP in Cornwall (soon to be a partner in Devon) and was recently the GPC negotiator responsible for education, training and workforce. Dr Amy Small is a GP partner in Edinburgh and a member of the UKGPC.