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In recent years the introduction of PMS and nGMS has allowed a large number of practices to employ salaried or associate GPs. Most registrars now take up a salaried post within a year or two of completing training. The dynamics for all concerned can be complicated, but it is essential to make this new style of general practice work.
There were two initial driving forces for associate posts. The first was the trend among all young working groups in the 1990s to question the model of one job for life. Portfolio careers became common.
The second was the onset of PMS, which allowed practices to employ other GPs without loss of fees such as the basic practice allowance. Up to that point young GPs often became locums in the early part of their career. Associate posts offer better security and a more constant learning environment.
It is important for partners and associates to share a majority of aims. These should include high standards of clinical care, a good working environment, good communication, good working relationships, enjoyment and a desire to achieve good financial rewards.
Most GPs aspire to high clinical care but it is important to renew this ethos on a regular basis. Many practices now make space for regular clinical meetings to include audit, QOF and enhanced service issues. Not only does this reinforce practice standards, it is also a highly efficient way to ensure uniformity and group response to change.
The whole practice team will function better in a good working environment. Wherever possible, associate GPs should be able to work from the same room. Keep rooms well-equipped and decorated and ensure adequate rest facilities. A few practices are also installing air conditioning; how long before this appears in job adverts?
All successful teams communicate well. If you regularly have GPs you hardly see all day, there may well be a problem. While you should ensure you make full use of your IT systems for clinical matters, do also provide the opportunity for reasonable human contact every day. A balance of both informal and formal meetings is essential.
While there will always be essential differences between being a partner and an associate, it is important these are actually seen as a continuum. A newly qualified GP will naturally want to focus on building up clinical experience. An associate post provides this opportunity.
In time, however, some associates will want a partnership role. Current partners must bear this in mind. At the same time, associates must recognise that partners carry extra business responsibilities and risk.
The dangers are that we see ourselves as two groups rather than one and it is here that good working relationships are so vital.
Partners must never be in a position to be charged with exploitation and, equally, associates with lack of commitment. Openness and respect will go a long way to achieve this. There must be clear channels for quickly discussing and resolving problems and misunderstandings.
Designated team members and regular meetings are useful in larger practices.
In order to attract and retain associates, practices must offer an attractive salary. Job adverts are keenly monitored by all GPs so it is never difficult for them to check appropriate pay levels! In practices with more than one associate it is also important to maintain parity.
It is worth mentioning here that GP employers have to pay 'on-costs' when employing an associate. These are employers' NHS pension contributions (14 per cent) and national insurance (up to 11 per cent). This means the job advertised at £70,000pa is costing the GP employer around £87,500pa.
It was only recently that this was the average remuneration for a partner. Some larger practices have several associates so the 'on-costs' are considerable.
Recruitment and retention also depend on flexibility. I started in general practice in 1979. It would have been unthinkable then to ask for a later start to my morning surgery to accommodate school runs. Thankfully, times have changed. Make sure your practice can offer flexible working for all GPs.
All GPs should also be encouraged to learn new skills and improve old ones. It is in the whole team's interest to have as wide a range of skills as possible.
After a year or two of normal surgeries most associates are ready for more variety. Obvious areas are QOF, specialist clinics and enhanced services. Many associates now also have or acquire GPwSI status. Practices with a range of specialist skills are in a much better position.
Generally, the partners in a practice will have more experience. This is an important resource for associates in both day-to-
day clinical issues and personal development. Some practices have in-house
mentoring schemes to formalise this process, which also improves working relationships.
When associates apply for partnerships they usually have little or no experience of non-clinical aspects. A few years ago one of the reasons younger GPs wanted to avoid partnerships was the 'hassle of non-clinical work'. However, some associates are now expressing more interest. We need to foster this interest as it is certain that for many it will further cement the desire for eventual partnership, as it did for so many older GPs.
Tutorials and practical experience could easily be set up as part of an in-house training programme.
It is clear that the main threat to the future of general practice is competition from private organisations. All GP practices are in a unique position to remain the major players provided we can continue to work together.