Salaried, partnership or something else? Building a Better General Practice

We have had the third meeting of the panel to discuss building a better general practice. This week, we explored how GPs should be contracted to provide healthcare services. The survey is now closed

Main conclusions from the previous survey

• GPs would like to work 32 hours a week on average, if they were happy with the state of general practice

• GPs are supportive of providing any service that could safely and adequately be provided within general practice

• Easy access to secondary care support as well as to clear, concise information on local guidelines, pathways and services during patient consultations is absolutely essential, and with this, GPs would be are happy to provide complex care for undifferentiated illness beyond basic training

• Protocol driven care (ie, routine chronic disease management) should be provided by other members of the multidisciplinary team, and not GPs

Summary of third panel discussion

Salaried model or partnership

The group immediately said that this is not as simple as a dichotomy between a ‘partnership model’ and a ‘salaried model’.

In 1948, general practice was a pure partnership model, which many agreed worked. Yet, especially in recent years, it is a hybrid model and in some ways two tier.

And it is difficult to distil what is meant by a partnership model – and how it differs from what would be a salaried model. General practice is not a normal business. GPs usually only hold a single contract, which they don’t negotiate directly – there are very few, if any, other businesses like this. If GPs were salaried to the state, what would the difference be? The current nature of general practice means that partnerships are feeling more like a salaried role, with the levels of micro management and mandatory training, etc – it has many of the drawbacks of a salaried role without any of the benefits.

A big difference in the partnership model now to when it started is that it used to be all partners – the hybrid model is relatively new, but it does diminish some of the positives of the partnership model, including introducing an aspect of hierarchy to proceedings. The system has ‘evolved into this sort of bizarre self-employed, uncomfortable hybrid versus salaried’. The only point which distinguishes the partnership model is that the buck stops with the partner.

In terms of a salaried model, we need to distinguish between being salaried to the state – similar to how secondary care works – and being salaried to a more traditional business, as is what happening with the large American company Operose taking over a number of APMS practices.

There are options in between too. A chambers model exists for placing locums with practices, where GPs are self-employed but pay a proportion of their salary to the chambers, who provide admin support, giving practices a single point of call. If starting from scratch, this could be applied to patients and GPs too, with GPs being self-employed and choosing their own hours and workload, with patients registered to locums.

Benefits of a business-based model

The partnership model encourages innovation – for example, IT in general practice is miles ahead of secondary care. It also encourages GPs’ position as an advocate for patients.

It also ensures that the GP has an investment in being an advocate for the patient.

Under this model, the GP has the sense of ownership and responsibility and is dependent on providing a quality service (eg for fear of list size dropping otherwise and therefore income being affected).

It is also a powerful stimulus to ensure all the work gets done and done well.

It also tends to root the practice in the local community, with the perception they are ‘our GP’, which results in an increased sense of ownership by the patients and community. It also potentially leads to less abuse of the system compared to a faceless corporate delivery type service, with little continuity of personnel or care.

Within the current model, there is generally more satisfied staff than in the corporate settings, while sickness absence rates pre-pandemic are also significantly lower in general practice compared to the rest of the NHS.

Benefits of moving away from partnerships

Survey respondents expressed a desire to work an average 32-hour week, but this might not be consistent with a partnership model. With the need to run the practice as well as provide clinical work, this is probably impossible in that time. You can potentially do this with job-shares, etc, but this will require more GPs – which, under this exercise, is not doable (as this is not something that can be achieved in the short term) .

GPs principally want to provide clinical care, but a partnership model involves time being spent on ‘employing staff, sorting out property, worrying about accounts, jumping through hoops to maintain income, repeatedly applying for ridiculous small pots of money just to fund the job’.

We are saying to new recruits, ‘You can either run a business, have an uncertain income, be responsible for your employing a staff, have unlimited liabilities in various forms, and do the job you’ve trained for or do the job you’ve trained for with a sensible contract’.

There is a new mindset for younger generations that you don’t stay in the same place you’re whole career, and this is true in all professions.

Equally, opportunities for entrepreneurship for medical graduates might not be necessary. There are a number of professions that don’t lend themselves to entrepreneurship (ie, teaching, medical specialists, academia, etc) and there are ways that GPs could channel their entrepreneurial spirit if they so wished.

Other models

The survey showed that GPs felt small practices should continue to exist, but should work in larger organisations if they can. There are a number of LMCs who are seeing PCNs as a poisoned chalice – but the principle of them might be sound.

There is a suggestion that there is nothing to stop primary and secondary care being co-located – so long as GPs are not seen as being house officers or the like for secondary care.

Our panel in full

Dr Nonso Anekwe, First Five GP in London

Dr Rehaan Ansari, ST3 GP in Lincoln, GP partner in APMS practice

Dr Katie Bramall-Stainer, chair, UK LMCs Conference

Karin Bruce, practice director, Jubilee Healthcare

Dr Richard Fieldhouse, chair, National Association of Sessional GPs

Dr Poppy Freeman, founder, Covid-19 Primary Care Resource website

Professor Clare Gerada, former chair of the RCGP

Dr Keith Hopcroft, Pulse clinical adviser

Dr John Hughes, chair, GP Survival

Dr Devina Maru, founder, Health Pioneers charity

Dr Sharon Raymond, director, Covid Crisis Rescue Foundation

Dr Kamal Sidhu, chair, British Association of Physicians of Indian Origin GP Forum