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The independent contractor model is being left to die

Independent contractor status is a cornerstone of general practice. Alongside the registered list, it has defined the way the profession has worked since the inception of the NHS.

But is becoming salaried the only option?

It offers GPs the freedom to advocate for their patients and speak out about how the health service is working. It is a key reason why the profession is so flexible and able to take on new ideas quickly – long before trusts heard of a ‘paperless NHS’, general practice was scanning in its Lloyd-George files.

And crucially, being independent contractors allows GPs the ability to determine their own future. They own their own premises and employ their own staff; in theory, at least, GPs principals have a level of autonomy as doctors unmatched in the NHS.

But this cornerstone is looking increasingly like a millstone. Many practices are a hair’s breadth away from disaster right now. Just one partner going sick or retiring early can tip a practice into the abyss. Year-on-year cuts in funding have left many with little room for manoeuvre.

For many GP principals this contractual status now feels like an elaborate trap. Their greatest fear is that they will end up carrying the can as their fellow partners bail out one by one. Many lie awake at night, wondering whether the liabilities heaped above their heads will come crashing down.

Speak to younger GPs and a good number wonder why anyone would want to become a partner; all the talk is of ‘portfolio’ careers. ‘I am the only one in my VTS class even considering becoming a partner,’ says a GP trainee at our roundtable this month to sighs of recognition around the table.

And while the profession’s faith in independent contractor status as the best model is undimmed – in a recent BMA survey 82% of GPs supported ‘maintaining the option’ of independent contractor status – it is interesting that just over half of GP partners told a recent Pulse survey they would personally become salaried if offered the right deal.

Today reveal that whole practices are starting to hand their contracts back, with the individual GP partners becoming salaried. In many practices GP partners are looking at resigning en masse so no one becomes the last man (or woman) standing. Others are flogging their premises to private companies.

But is becoming salaried the only option? I am no expert, but surely there are other ways of making the contract more bearable, such as setting limits on workload or introducing payments for activity (rather than the current capitation-based, all-you-can-eat buffet)? Could there be moves to limit principals’ liabilities, as with solicitors?

Super-practices – love them or hate them – do offer an option to retain the independent contract, while giving more GPs the option of a salaried career so they can do what they trained for – practise medicine – and not worry about having to sell their homes if things go wrong.

Scotland is looking at GPs being individually contracted as ‘expert medical generalists’, possibly without the burden of running a practice and employing staff. Could this model be considered elsewhere?

A debate is needed now on how the independent contractor model can be made sustainable. Otherwise this cherished cornerstone of the profession will simply be left to wither and die.

Nigel Praities is editor of Pulse