Career Focus

Associate general practitioners

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7102.2 (Published 26 July 1997) Cite this as: BMJ 1997;315:S2-7102
  1. Laura Marshall, general practitioner
  1. North Lochs Medical Practice, Gleann Mor, Lochs Isle of Lewis HS2 9JP

    No paperwork, life in a rural idyll, up to 17 weeks off each year, and a reasonable income-too good to be true? Laura Marshall discusses the associate general practitioner scheme


    The associate scheme was one positive development which came out of the controversial changes of the 1990 GP contract. It acknowledged that singlehanded practitioners in isolated areas were having difficulty in finding and affording locum cover for study leave and holidays. It also acknowledged that being on call for 24 hours a day, seven days a week for 52 weeks a year was not a satisfactory situation in the present day NHS. Advertisements for associate general practitioners are ever present in the BMJ and the rewards seem generous. So what is life really like for these associates?

    The associate scheme allows the deployment of an extra doctor between two singlehanded principals, primarily in rural areas of Britain. Most of the posts are in the highlands and islands of Scotland, though there are a frew posts in the inner cities. The scheme thus allows three doctors to work for two thirds of the year each. Though this sounds comfortable, most associates work for practices where on call cover by a general practitioners' cooperative is not possible because of the isolation and distances involved: the associate and the two principals still each have a continuous on call commitment for 34 weeks of the year.

    Flexible time off

    The remaining 17 weeks is taken as study leave and holiday. How this time off is arranged is flexible. Some practices will decide to work in one week blocks, in which up to six weeks of on call are matched by similarly long periods of leave. Others work a system where each doctor has a few days off each week, with increasing flexibility around holiday periods.

    Associate general practitioners are employed by the principals, but their salary is reimbursed by the local health board. The salary itself comes under the registrars section of the Statements of Fees and Allowances (“the red book”). This entitles associates to a car allowance, the postgraduate education allowance, reimbursement of a proportion of medical defence insurance, removal expenses, the distant islands allowance (for those eligible), and up to four annual increments in basic pay. Associates are not eligible for seniority payments or out of hours money. The scheme was originally aimed at doctors who had just completed their vocational training and were keen to experience rural isolated practice before committing themselves to a full time partnership. It was also thought that GPs nearing retirement in a busy partnership might wish to experience a rural practice for their last few working years.

    Advantages and disadvantages of taking an associate post

    Advantages
    • Chance to experience practice before making a long term commitment

    • Less practice management, and an emphasis on clinical skills

    • Flexible arrangements to coincide with child care, partners, and other work

    • Maintenance of superannuation contributions

    • Paid study leave and postgraduate education

    Disadvantages
    • Lower status-associates are paid like registrars and are often perceived as being senior registrars, not qualified GPs

    • Seniority payments-these are payable on the basis of one year for two years worked and then only after the associate has become a principal on a health board's list

    • Out of hours-the rural associate GP is on call for 112 hours a week if full time and yet is not eligible for out of hours money

    • The position is salaried-under schedule E, not schedule D- so there are no self employment tax advantages

    • Housing-an associate working between two practices that are widely separated may require two houses, which can mean frequent moves, though there are additional subsistence payments if this is the case

    Rural practice has its own benefits and challenges. The natural environment is a positive part of this, as is knowledge of a small community and involvement in its activities. The challenge lies in the necessity of seeing and managing everything from first response at a road traffic accident to removing a fish hook from a child's finger. Rural practice is often something that doctors would like to experience-but could not imagine committing themselves to-without a trial run. The associate scheme allows doctors to gain the initial experience which may lead to a career in rural medicine.

    Recruitment

    In practice, the associate scheme does target doctors who have just completed their vocational training and doctors close to retirement. By incorporating job share and part time positions it also provides a flexible career option for a wide sector of GPs. A 1996 study of incumbent associates showed that more than three quarters were over 35 years of age and more than two thirds were women. The majority had been in post for more than two years.

    The associate scheme allows GPs further experience in general practice without the commitment and responsibility of running a practice. It allows doctors to work in remote rural areas and experience a different practice environment to the one in which they trained. It also allows time to decide where they would like to apply for a principal job. And while doing this, associates earn superannuation contributions-a security that locum work does not offer at present.

    Preretirement principals

    At its inception, it was anticipated that the scheme would benefit doctors returning from working abroad and wishing to work for a while in Britain. It also appeals to those doctors who wish to spend more time on clinical issues, hobbies, or exploring a new environment. The disadvantage of this course of action for doctors close to retirement is the loss of senior- ity payments of up to £5000 each year. This may in turn adversely affect pension rights.

    “Generation X” doctors

    Many associates originate from this group-doctors who qualify and then disappear to work and travel abroad. The scheme allows them re-entry into general practice in Britain without having to be instantly aware of all the changes in legislation and business that have occurred in the interim. The generation X doctors can learn these developments through experience as they manage a singlehanded practice, or through talking to their employing GP. As with pre- retirement principals, returning doctors can share their experiences of systems elsewhere, and the new ideas can often be beneficially incorporated into medical practice in Britain.

    About the National Society of Associates

    Our policy document is being presented to the Scottish General Medical Services Committee and has been supported by several local medical committees. We hope that the title of “associate” will be changed to “associate principal with a zero list” (a concept that is already recognised in academic general practice).

    This will ensure seniority payments on a one for one basis and reduce the disadvantage that GP principals close to retirement currently suffer when they join the scheme. It will also improve the out of hours remuneration.

    For further information and advice about associate issues contact the National Society of Associates, c/o Fiona Fraser, Postgraduate Centre,Inverness (tel 01463 704347/704348).

    The scheme allows women doctors access to employment in rural areas where their partner is already employed, and it is an alternative to the retainer scheme. The job is challenging and allows all medical problems to be dealt with. It prevents women doctors being sidelined into the care of children and allows them to use all the skills that they developed in their training. Having a broad clinical workload boosts women's confidence in difficult situations and increases the likelihood that they will be happy to remain in isolated practice. The local communities also benefit in having a choice of doctors to consult.

    Urban associates

    Most associates work in singlehanded and isolated rural practices, but vocationally trained associate schemes have recently been established in inner city areas. One example is the London Initiative Zone primary care development programme. The associate receives a salary, which also covers holiday and study leave, and works in two practices for a year gaining experience of inner city practice.

    Sabbaticals for all

    General medicine has varying challenges and benefits, depending on where it is practised. The associate scheme is the ideal way to encourage diversity and new professional challenges. It could be considered by urban GPs wishing to take a year's sabbatical and work in rural areas; and the reverse direction could also prove attractive. Actually experiencing the jobs that others only read of would improve communication within the profession and allow the development of new perspectives. The scheme has been successful in alleviating the demands of continuous on call singlehanded practice, and it has been as well received by the GP principals who employ the associates as it has by the associates themselves.

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