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The days when partnerships automatically replaced a leaving partner with another partner are over, so view your next vacancy as an opportunity for a unique solution, says Dr John Couch
The days when a partnership automatically replaces a leaving or retiring partner with another partner are over. This is often through necessity, but increasingly it is a chosen option. On average a six-partner practice will face this choice every three or four years, so most of us are affected sooner or later.
A quick scan of GP jobs vacant sections reveals that most adverts still cast a wide net and ask for applications from prospective partners or salaried GPs. There are, however, an increasing number of salaried GP-only advertisements. Some practices are simply replacing a salaried GP, but others are making a clear decision to manage on fewer partners.
Until recently advertisements had to cast a wide net to ensure a decent selection of applicants in a market that has been meagre for many years. Now that it is getting easier to recruit in many areas, some practices have the real luxury of considering several options.
Now that NHS payments to both nGMS and PMS practices are mainly partnership dependent rather than partner dependent, the number of replacement choices has increased. They are:
·Like-for-like partner replacement
·Practice nurse and/or nurse practitioner
·Remaining partner(s) increasing time commitment.
These are not exclusive, and any combinations can be considered. In some cases necessity governs the choice. If you cannot recruit any GPs at all, the last two options become inevitable!
Making a business decision
Assuming you have all the above options available, look at the decision from a business point of view first. Areas that should be considered are:
·Maintaining/improving clinical standards
For property-owning practices there is a natural fear, especially in smaller groups, of reducing the number of partners owning the premises. With the average buy-in loan at around £150,000 this is understandable. If you have already borrowed this amount, do you really want to increase your loan?
The thought can be daunting. However, provided rent reimbursement figures are favourable, this can be an opportunity for remaining partners. In the current low-interest climate, rent reimbursement in many cases covers or even exceeds loan repayments.
The key is to have a carefully-worded practice agreement to ensure leaving partners get their money with sale of the property as the bottom line if remaining partners do not wish to take further equity.
In the current climate, many private companies are happy to buy GP surgeries with the prospect of 7-8 per cent rental return as well as capital growth.
This may be an opportunity to increase profits and drawings. For instance, if a nine-session partner on a £120,000 profit share leaves, you could replace them with 13 sessions of salaried GP time for the same amount, thus freeing up partner time to increase private, QOF and enhanced service income.
Alternatively simply recruit nine sessions of salaried time and remaining partner profits will increase anyway. This also has a positive spin-off on superannuation. If individual partners' NHS profits increase, then so will final NHS pension.
You should also examine your practice's current clinical hours and efficiency.
And a change of personnel is an opportunity to make changes in clinical practice, perhaps setting up more chronic disease clinics or starting a formal triage system.
Practice nurses and nurse practitioners can take on some of the tasks currently designated to GPs, for instance routine chronic disease clinics. The ability of nurses to prescribe helps this process enormously.
The cost of a nurse practitioner is half that of a salaried GP. The economics here are compelling.
Most partners take on some non-clinical work. This will leave a gap in your business if you do not replace them with another partner. You need to decide how this can be filled.
Can your practice manger and administration team help? Do you need to recruit more staff? Does another partner have the spare capacity to fill in?
Most practices have opted out of out-of-hours. GPs only do this work through choice and on their terms. This has been one of the best aspects of the new contract and has reduced stress levels for many.
There may now be spare capacity among part-time partners. You may decide to replace at least some of the missing time with partner hours. This is certainly a good moment to float the idea of increasing hours with your existing partners.
Skill mix profiles
Accepting that the calibre of any replacement is critical, it is also helpful to look at the profiles of the groups outlined in the box, left. This can help in deciding the correct combination for your practice, assuming all choices are available.
As I have stressed, we have entered an era where many practices do have the luxury of choice when a partner leaves. Each practice is unique and the same will apply to the best solution. Consider your next vacancy as an opportunity.
Replacement choices: pros and cons
·Likely to be committed to concept of partnership
·May purchase property share
·Likely to take on non-clinical work if required
·Likely to stay longer than a salaried GP
·Most expensive option in terms of remaining partners' profit share
·Same training as partner applicants
·Total salary package less than profit share of equivalent partner
·Likely to want part-time post
·Falls under employment law
·Likely to move within five years
·Less likely to take on non-clinical work
Practice nurse/Nurse practitioner
·Total salary package, including on-costs, approximately half the cost of equivalent salaried GP
·Can prescribe if trained but limited formulary
·Good at protocol/template-based chronic disease management
·Can triage with appropriate training
·Can train for specialist role
·Not easy to recruit in many areas
Existing partner expanding time
·Will not need induction or time to settle in
·Already known to other partners
·No windfall increase in profits
John Couch is a GP in Ashford, Middlesex