As a GP partner, I was extremely disappointed that the RCGP called partnership unfit for purpose in evidence to the House of Lords for their recently-published report, ‘The Long-term Sustainability of the NHS and Adult Social Care’.
The current chair, Dr Helen Stokes-Lampard, told the Lords: ‘We all have to be realistic about what the future holds, and, whilst personally I love the partnership-led model of general practice, I know it is not likely to be fit for the long-term future’.
All parts of the GP workforce should be concerned about a fully-salaried model
Her comment was used to support the report’s conclusion: ‘The traditional small business model of general practice is no longer fit for purpose and is inhibiting change. NHS England, with the help of the Department of Health and the profession, should conduct a review to examine alternative models and their contractual implications. The review should assess the merits of engaging more GPs through direct employment which would reflect arrangements elsewhere in the NHS.’
The thought of NHS England conducting a review into anything more complicated than a sandwich order should chill the blood of any sane GP, even before the additional threat that the GP workforce’s employment should ‘reflect arrangements elsewhere in the NHS’. Given the recent junior doctor contract imposition, the downward trend over the past decade in terms and conditions, and the attack on locum doctors both in and out of hospital, partners, salaried doctors, and locums all have cause to fear the repercussions of this report.
What the ‘alternative models’ to GP partnership might be is hinted at by the other contributors to the report. Professor Clare Gerada, the last-but-one chair of RCGP, told the committee: ‘In more or less the last week of my chairmanship I said I thought the independent contractor status was not fit for purpose. I felt we needed to unpick it, and GPs needed to still be in charge of their organisations, but that could be done in a different way. The different way is … to have an overarching management structure with salaried doctors within it.’
That management structure, of course, is exactly what Dr Gerada’s Hurley Group uses. Inviting partners in an organisation in direct competition with GP partners to give evidence on the current model for primary care provision is rather like holding an enquiry into turkeys’ survivability over Christmas and asking Bernard Matthews to comment, but to be fair Professor Gerada did repeatedly declare her conflict of interest. It is for the House of Lords to explain why they ignored it in reaching their conclusions.
There is not a jot of evidence to support the idea that running primary care under a salaried model benefits patients or the profession. The current GMS contract means that salaried doctors working for GP partnerships are guaranteed the BMA’s model contract terms and conditions, a protection they would not be afforded working for larger organisations. The extent of these organisations involvement in out-of-hours, and how that is factored into salaried doctors’ contracts, are also concerns.
There are legitimate debates to be had about why general practice is currently unpopular as a specialty, why partnership is unpopular with newly-qualified GPs, and how best to address these problems. The RCGP has made no attempt to have that debate with its membership, and instead is calling the thousands of partnerships around the country ‘not likely to be fit for the long-term future’ while promoting an entirely untried and untested new model of care to policymakers. The blog they rushed out after the report was released was a platitude-laden attempt to appease current GP partners which no-one outside the college will read. The message the public will take from the House of Lords report is newspapers like the Times running stories headlined ‘outdated GP system harming patients’.
The fundamental issues affecting primary care at the moment are a lack of time, money, and people, as Professor Gerada, at least, agrees. A contract cooked up centrally and imposed unilaterally will not provide these, nor the ‘local solutions to local problems’ which evidence to the House of Lords called for.
By contrast, I would argue one of the strengths of the partnership model is that we are a little like herding cats – while it’s difficult to get even all the practices in a locality agreeing on anything, that diversity is a strength. The current GP partnership model provides multiple small, agile companies, rooted in their own locations, and primarily interested in the healthcare of the population they look after. That is a template for innovation – it just needs to be properly funded.
Professor Helen Stokes-Lampard, RCGP chair responded:
The College has never said that partnership is ‘unfit for purpose’. We fully support the partnership model and believe that it is the bedrock of high quality family health care in the UK. It has been a trailblazer for innovation in general practice over decades, providing excellent care and services that our patients rely on, while also delivering excellent value for money to the wider NHS.
As an enthusiastic GP partner for 15 years, I see this first-hand at my own practice in Lichfield. One of the great strengths of general practice is that it adapts to the changing needs of our patients. In the current climate there is no one-size-fits-all approach and GP practices must be able to choose the best way of working, in our own interests and that of our local populations.
In my lengthy evidence to the House of Lords Committee on a wide range of issues affecting general practice, I made clear the benefits of the partnership model – but also the importance of flexibility in the way we work in our local communities.
As the landscape shifts, we will all need to consider other models of care provision, where appropriate, that are sustainable in the face of rising demand and an ageing population. But as these models develop, we must also ensure that GP partnerships are able to adapt and remain sustainable.
If the partnership model is to remain a strong feature of primary care in the UK then it needs to be supported. The College will be responding to the House of Lords report and discussing the issue at RCGP Council in due course.