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Business as usual? Building a Better General Practice

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Our Building a Better General Practice campaign has been a fascinating exercise. We have had a range of voices from across the spectrum of general practice. Some are well-known names and others aren’t – but they have all thought deeply about the essence of general practice.

Last week’s panel meeting was perhaps the most interesting as we spoke about how GPs should be contracted – in a nutshell, the salaried or partnership debate

You might feel this has been done to death, but there was real nuance in this debate. The central point became – if you were designing general practice from scratch, would you want it to be arranged as autonomous small businesses?

The consensus of the panel was that the partnership model worked in the past, before we had a mixed workforce (salaried and partners) and micromanagement from ministers and NHS managers. But now, we have the worst of all worlds – partners tied to a contract that is so prescriptive as to make them almost salaried, but having to take on all the bureaucracy associated with running a normal business.

So when we made our survey live, I was expecting our readers to reject the idea of general practice comprising small businesses. But I was wrong. There was a complete split on the question of whether the current partnership model is obsolete – an average score of 2.5 out of 5. But when it came to the more general statements of general practice as being comprised of autonomous businesses, there was more agreement – 4.02 for the question ‘is it possible to work in autonomous businesses and provide adequate clinical care?’

Perhaps most surprisingly, then analysing based on age, the younger generations were in fact a little more in favour of a partnership-style model than the older ones.

So what can we take from this? GPs are not in favour of moving to a similar model as hospitals, run by the NHS and managers, even if headed by a medical director. Yet there has to be a change – again, overwhelmingly, GPs say that running a business shouldn’t take any time away from clinical care.

It is not easy. But squaring this circle is essential if we are going to get general practice out of the crisis it is in. And, unfortunately, I have little faith in ministers supporting GPs in this. So it remains up to the profession to put forward a positive case in terms of how general practice should be run. So please continue contributing to our surveys, and sending your thoughts to as you have been doing. Because GPs really do know best when it comes to general practice.  

Jaimie Kaffash is editor of Pulse. Follow him on Twitter @jkaffash or email him at


John Graham Munro 4 August, 2021 3:29 pm

Reminding G.Ps they did a course in Medicine not Business Studies would help

Vinci Ho 4 August, 2021 7:49 pm

It is always dilemma , like many issues in life :
(1) Jaime , I really hope your campaign , Building a better General Practice , can turn out to be meaningful . In a way , it reminds me of Biden advocating in world politics , Build Back Better World(B3W), which could be potentially easy said than done .
(2) There is apparently an animosity between general practice and the government right now. It is corollary considering how GPs felt being exploited during last 18 months in the midst of the pandemic. My philosophy is that the side with far more power will always have to compromise more.
The reality is GPs had saved the reputation of a government(and its academics) who were too over-confident(perhaps arrogant)to read the dangers coming in the beginning of this historic event . Those into politics will probably know this could be an essential narrative carried onto negotiation tables.
(3) I am not surprised that young colleagues are more keen on GP partnership ,which is reminiscent of what I learnt from them last couple of years The old model of GP partnership has undoubtedly met its ‘expiry date‘ but does not necessarily equate to ‘obsolete and delete’ .
Salaried and locum positions are always good in buying times against a backdrop of multiple uncertainties which also characterise the world we live in right now . Being self-employed running a small to moderate business is often attractive in a longer term ,provided that objectives conditions are satisfied. The autonomy is in the line of liberty and flexibility ideal for the young generations. In a world where illiberal democracy and autocracy are deliberately trying to replace the western universal values , this conflict is perhaps the zeitgeist of this early era of 21st century .
(4) But then it begs the question , ‘ are GPs really free to do their proper job?’ The answer is a resounding NO because the system repeatedly fails to understand the true meaning and identity of general practice in NHS .
Doctors are trained primarily to deal with patients’ medical , mental as well as social problems. They were not trained to deal with politics , economics and statistics. Obviously , in a health system funded by taxpayer money , the argument is always whether services are so called ‘value for money ‘ ( or the old terminology cost-effectiveness) . But do people really understand what this politically correct label mean ? Probably not for those sitting higher up in the system playing comfortably with their computer mouse in their well protected office rooms .
Those striving everyday at the frontline, however , do . In context of primary care , grassroots GPs(not politicians and technocrats) are the representatives to reflect to the system what are practical and feasible to deliver better care to our patients. Our knowledges of our own patients are the building blocks of continuity of care which is the key to true quality care . And that is the fundamental argument why at least the old GP model was already value for money . Politicians either refused or made no attempt to understand this .
(5)Then it came targets , templates , read codes and ,most disruptive , workload shifted out of hospital etc .General practitioners are forced to become diagnosticians (to benefit secondary care) as well as tick-box machines. One can argue the former can be achieved by developing more specialist expertise among some GPs(those with extended roles ) but the latter is just abhorrent to most GPs and their practice managers.
So what about asking a designated personnel to take on all these time-consuming , serving Big-Brother micromanagement tasks ? Here comes the one wearing the suit ,aka the manager (or the meanager; sorry can’t help it😈) who is not a clinician and only loyal to the decrees imposed by whoever further up the system.
Then the ideology of PCN led by clinical director landed on our doorstep . To me , it is an ‘experiment’ pushed forward as other alternatives were well exhausted .
(6) Sadly , once again , the original objective to help GPs reducing workload was betrayed. The system exploited PCNs as political expedient to provide ‘solutions’ for various deep-sitting problems probably requiring a wholesale of political , economic and social interventions instead .
The clinical director, more like a low grade chief executive , tries to dodge these bullets of bureaucracy for practice colleagues , is on his/her own when it comes down to accountability. Many are GP partners still committed to clinical sessions in own practices. The arithmetic simply does not add up . Practices are supposed to work together to ‘improve’ outcomes. Instead , colleagues are stretched beyond limits to breaking points while demands continue to rise with no control .COVID-19 and the vaccination programmes just demonstrated how damaging is this poor interpretation of PCN ideology by the system. GPs continue to leave the profession prematurely.

So what would I want to say to these young colleagues? It is important to consider all your options appropriate to your circumstances before taking on a partnership. Once you have chosen to be a partner , be prepared to be up against the system which is always throwing nonsensical demands on you .
Know your medicine but also know your politics and economics well .
Do not isolate yourself and get out to develop connections.
Most importantly, ‘arm’ yourself to be ready for a push-back . Politics is always interested in GPs .
Believe what you are doing everyday . I cannot agree more when Adam Peaty said everything was only built around what you believed , after team GB won a historic, gold Olympic swimming medal (among a total of eight medals ) in 4×100 mixed medley in a new world record .
Somehow, my Spidey sense just told me that GP partnership is not to disappear just yet but you guys (young GP partners ) need to find endurance and resilience somewhere, somehow using your wit …..
Good luck 😎

Decorum Est 5 August, 2021 12:07 am

Vinci Ho you’re right. But that’s a particularly long rambling account. Just ask. Do next generation of GPs want the ‘shit’ conditions of contemporary GP practice?

Vinci Ho 5 August, 2021 6:16 am

There is a Chinese saying ,’ On the Yangtze River , the waves from the back are pushing the front continuously.’
I would not want to imagine, predict or judge what the youngsters will choose . As a 56 years old man , my mission is to only listen and help as much as I can .
After witnessing what has been happening to young people in Hong Kong last two years , my heart bleeds……

Dave Haddock 5 August, 2021 11:23 am

The NHS is killing GP. Escaping the NHS would be my priority if starting again.

A non 5 August, 2021 1:15 pm

What strikes me is there is almost no difference in responses across age groups – you seem to be really eager to find age related differences when in reality the figures really don’t show any..and where claimed, the differences are small – are they actually statistically significant? There’s always danger in looking for evidence of stuff we have already decided on. This is a tendency which is widespread across many issues. It doesn’t lead any closer to truth, it just reinforces people’s biases and is one of the great problems of our age.

John Graham Munro 5 August, 2021 3:16 pm

Our family doctor used to charge sixpence per visit—then put it in an old tobacco tin——100 years on— and we now have G.Ps whose consulting rooms resemble ”counting houses”

David Jarvis 6 August, 2021 1:57 pm

Vinci Ho an older Dr thinking about the future for the next generation of Drs and how we best ensure their future is a good one. We all may need their help as patients one day. And John Graham Munro who seems a rather embittered old Dr who feels his was a superior time and hates any changes whilst offering little positive or constructive. Hmmm.

My take is Govt hate small GP partnerships for 2 reasons. One is they are hard to fully control and continue to act hopefully for the best of their patients. Two is a bit like the internet as well as being hard to control their diffuse nature with no one single off switch makes them rather robust and difficult to kill off or replace. They do seem to be trying but My income has risen over the last 5 years steadily despite them. Strange.

A non 11 August, 2021 7:15 pm

Im personally in favour of retaining a partner model, with GPs as independent practitioners but with real autonomy over how they organise their work. The centralised micro management needs to go. However ongoing problem needs to be difficult the partner/ salaried power imbalance. Currently we have a situation where partners continue to sign stupid contracts which are almost impossible to fulfil in the knowledge they can delegate great swathes of the most ball breaking stuff to an army of salaried minions. If they didn’t have that option and all Drs were equal they might think a little harder before signing up. As it is a growing minority of controlling GPs sign up to idiocy comfortable in the knowledge they can get some other sucker to do they stuff they don’t want to. There is a major imbalance within the profession which is distorting decision making – if we had more realistic contacts maybe more people would choose partnerships and not end up treading water as salaried slaves or portfolio escapees.