Dilemma: Replacing a retiring partner
Your senior partner has decided to retire, whilst your profits are falling. You need to decide whether to replace like for like or try to cover with a salaried GP or nurse practitioner and share out the extra workload. How do you do so?
Consider a change in skill mix
This scenario seems destabilising but may present an opportunity. Could the practice operate differently? Does the outgoing GP carry a large burden difficult to replace or has he wound down allowing things to drift?
A vibrant new partner might lift the practice, attracting new patients, facilitate the provision of new services and find efficiencies previously not considered. Faced with a similar situation my own practice created two new consulting rooms, grew the list by 5%, added an additional part-time salaried GP and raised profits in the first 18 months following the senior partners retirement.
Unfortunately new partners are difficult to find. Many practices struggle to recruit and the majority of newly trained GPs are looking for salaried posts not partnerships.
This dilemma may seem easy to solve with a salaried doctor but it may not be the most palatable outcome. With the cost of superannuation and employer´s national insurance, the gap between a partner´s drawings and a salaried GP´s income may be narrow. A salaried GP will work to a job plan and a BMA standard contract and thus may not carry the same clinical burden as a partner and will probably carry very little of the practice management responsibilities.
Can a change in skill mix help? The use of prescribing minor illness-trained nurses to cover the ‘on the day’ work of a practice at about half the cost of a GP may be the best solution.
Every practice is unique and every solution personal. If this is your dilemma…Good luck.
Dr John Allingham is a GP in Dover and medical secretary of Kent LMC
Overhaul your operating model if you need to
Source: Guy Newman
The retirement of an experienced senior partner in the face of rising workload, falling profits and increased regulation is a scenario that is only too common, and accelerated by recent pensions changes. Such an event should provoke a complete review of practice systems and operations, and question whether a step change may be necessary.
The crucial triangle of operations has at its three vertices: profitability; acceptability of workload; and standards of care. Within the same operating model if one parameter improves another must fall to compensate. Funding cutbacks in general practice have resulted in a recalibration of the operating model to produce reduced workload acceptability (more work) and reduced profitability with no rise in standards of care.
The practice must ask itself the fundamental question: does it want to overhaul its operating model? If not (and they replace like for like) then the future will be an on-going compromise between the existing three corners of the current operations triangle.
A root and branch re-organisation of care and practice structure can reset the balance between workload, reward and care delivery, but may require some radical thinking. Experience suggests the most important thing to establish is agreement in detail between the remaining partners around a common set of goals for transformation, and to be explicit about these before embarking on the project.
Possible routes to change include replacement with a salaried doctor or the appointment of a nurse practitioner, but options such as total triage to increase efficiency, remodelling support staff, outsourcing of some managerial functions, through to federation or complete merger with other like-minded practices should all be seriously considered.
Dr Mark Sanford-Wood is a GP, a GPC member and medical secretary of Devon LMC. He has recently become a portfolio GP with a wide range of interests including a partnership in a practice redesign consultancy.
Size of practice is important
How a retiring partner should be replaced depends on a variety of factors - not least how large the practice is. While an eight-partner practice could easily replace a partner with a combination of salaried GPs and nurse practitioners, the position is not so simple for perhaps a three- of four-partner practice. This is because being a partner brings with it more than just clinical work and sharing that extra load between a small number of partners is not easy.
From a financial perspective the practice should consider the following points:
- Clinical workload: How big is the list per partner? How much skill mix diversification has already taken place? How high a work rate does the retiring partner have?
- Profits: What is the current profit level per full time partner? Is there any financial benefit to recruiting a salaried GP once the employer´s national insurance contributions and superannuation is taken into account?
- Practice capital: If the partners own the surgery then the existing partners will need to buy out the retiring partner if no new partner is recruited. How much working capital does the retiring partner have in the practice? If no new partner comes in then the remaining partners will have to increase their capital accordingly.
- Leased premises: Is there a minimum number of partners required under the lease? How will the remaining partners be released from their obligations on retirement?
Bob Senior is head of medical services at RSM Tenon.