Intended for healthcare professionals

Careers

Salaried GPs versus partners

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2413 (Published 12 May 2010) Cite this as: BMJ 2010;340:c2413
  1. Ingrid Torjesen, freelance journalist
  1. 1London
  1. ingrid_torjesen{at}hotmail.com

Abstract

Ingrid Torjesen looks at the changing general practice landscape and asks whether the shift to a salaried model is necessary or desirable

A decade ago general practitioners (GPs) in training would expect to become partners within a year or so of completing their vocational training. Changes to how general practices are contracted to provide services have encouraged many practices to recruit salaried GPs rather than take on new partners.

In 2008, the National Audit Office revealed that a fifth of GPs were salaried, and the BMA believes the proportion has risen slightly since then.1

Today’s newly trained GPs have the same aspirations, but frustratingly have found partnership vacancies to be in short supply as practices attempt to maximise profits for existing partners. The income of a partner increased by 58% in the first three years after the introduction of the general medical services contract, but pay for salaried GPs rose just 3% in the first two of those years.

Conflict of interests

Richard Fieldhouse, chief executive of the National Association of Sessional GPs and committee member at BMA General Practitioners Committee, says salaried GPs have been “hoodwinked” because the bodies representing them at national and local level—the BMA’s General Practitioners Committee (GPC) and local medical committees (LMC)—are predominantly made up of GP partners. “At the moment you have no choice if you are a salaried GP; you have to be represented by your boss,” he says. “That just doesn’t work.”

Salaried GPs do not necessarily need a separate union to represent them, Dr Fieldhouse says. “I think the BMA could do the job, and ultimately they are probably in the best position.” He emphasises, however, that if the representation is within the BMA, it is important that it is independent from GP employers. “The starting level seems to be ‘how can the BMA represent salaried GPs, within the GPC?’ It automatically restricts it to within the GPC.”

This would only be possible if the GPC is totally objective and creates an infrastructure that will allow as good as independent representation within its confines, he concedes. “It’s like a parent. Some parents will let their kids do absolutely anything, but will obviously create a protective nurturing context around them. And there are some parents who are oppressive. It is getting that balance right.”

Currently, salaried GPs are represented through two GPC subcommittees—sessional GPs and representation. The GPC has acknowledged, however, that representation could be improved nationally and locally. The sessional GPs subcommittee is due to report its recommendations to the GPC before the LMC conference in June.

Beth McCarron-Nash, GPC negotiator, admits the subcommittee was formed in response to salaried GPs’ concerns that the GPs representing them had a conflict of interests. “We are doing a root and branch look at that, including representation at LMC level and national level to make sure we get the representative structures right so that everyone feels that they are getting a fair say,” she says. “Some LMCs are fantastic at representing sessional GPs, and others unfortunately don’t have the structures currently there for sessional GPs to get involved.”

The chairman of the GPC, Laurence Buckman, says, “LMCs know that they are meant to have sessional doctors on their committees and that they are meant to co-opt them if they don’t get elected by natural means. Most LMCs do that, but there are a few that don’t. We can encourage them, but we cannot force an LMC to do something that it doesn’t want to do.”

Bridget Osborne, chair of the Royal College of General Practitioners Wales, has been a salaried GP for 14 years in Conway. Before that she was a half time partner, but found the on-call commitment very difficult. “My husband was a consultant ear, nose, and throat surgeon, and it was just impossible when I was out on call in the morning and he had to get to work,” she explains. After breaking a hand in an accident, she re-evaluated her work life and resigned from the partnership. She worked in community paediatrics and took up her present salaried post after her third child was born. “At the time that I started, the real benefit was that there was no on call. The other main benefit was that there was no responsibility for running the partnership.” Dr Osborne runs two other businesses—a farm and her husband’s private practice. “I thought, I can’t cope with a third,” she says.

Disadvantages of a salaried post

The downside of a salaried post is that a salaried GP will earn less than a partner, will be focused on clinical care, and will have no involvement in the development of the practice (box). This is not an issue for Dr Osborne as she does not want the administrative burden of a practice because of her other commitments. Given that she is quite senior and has been at the practice longer than any of the partners, she is relatively well paid and the partners will often seek her views. However, for a younger GP who is starting out on his or her career and who has taken a salaried role out of necessity rather than choice, the lack of involvement in practice management can be very frustrating.

Pros and cons of salaried posts and partnerships

Salaried posts
  • Fixed salary

  • Contracted duties and hours

  • Focus on clinical care of patients

  • Work under direction of employing GP partners

  • Limited opportunities to learn new skills outside of clinical care

  • Highly compatible with side career or family responsibilities

  • Suit a person who might want to move jobs frequently and quickly

  • Suit a person wanting a more passive role in the practice

Partnerships
  • Potential to earn more, with share of the practice profits

  • Take on risk and responsibilities of business

  • Variety of responsibilities in addition to care of patients

  • Opportunity to be involved in development of practice

  • Opportunity to learn about practice business from other partners

  • Less compatible with side career or family responsibilities

  • Responsibilities make moving to a new post more difficult

  • Suit a person wanting to forge a career in general practice

“As a junior partner of course you are part of the decision making team, so you are learning from the other partners, but if you are salaried you are not learning from the partners how to run a business,” Dr Osborne says.

“If you were going to develop your general practice career, you would not have experience in management and human resources skills and all the things you need to run a practice and actively manage the staff.”

A small study by the National Primary Care Research and Development Centre has shown that young salaried GPs do feel “disenfranchised” with their lot, and it warned that by employing increasing numbers of salaried GPs “principals may be undermining the very ethos of general practice.”2

The researchers interviewed 22 principals and seven salaried doctors at 22 practices, so they were able to compare and contrast the experiences of partners and salaried GPs within the same general practice environment.

Helen Lester, professor of primary care at the National Primary Care Research and Development Centre at the University of Manchester, who led the research, says: “We found that salaried doctors on the whole wanted to do more and they felt quite frustrated that their requests to be more involved with the business side of the partnership were on the whole not listened to.”

One salaried GP said, “They are not recruiting new partners, so they are feathering their own nests essentially . . . I think they are abusing the younger generation of doctors.” Another said, “I didn’t particularly want a salaried job . . . I’d prefer to be more involved with the practice side of it . . . when it comes to making a decision, ultimately it is the partner’s decision, and there are some meetings that I am not allowed to go to.”

Professor Lester says in some cases principals were aware of this frustration. “Principals have a decision to make when somebody retires. They can employ somebody at probably £30 000 less than a principal will earn and take that little bit extra themselves, or they can think about the future generations of leaders in primary care. The people who are now coming out of training schemes need to become partners to learn the business. Yes it means that the principals will have to share the profits around a little more, but they will also get some time back to do other things.”

She points out that it is “false economy” for practices not to take on partners. “In 10 years time, who will be running primary care, in terms of the day to day running, unless we teach people what it is about and give them opportunities to cut their teeth?”

Professor Lester is now a part time salaried GP, but was a partner at a practice for 14 years, where she was taken on as “a locum with a view.” This was helpful, she says, as it enabled her to learn about the practice and for the practice to size up her work. “There was no sense of exploitation because I knew jolly well that come October I would become a principal.”

The view of the Royal College of General Practitioners is that the partnership model is the best way forward for general practice and that GPs should be working in partnerships unless they have a good reason not to, such as onerous family commitments or a side career in another business, in medicopolitics, or in academia. It believes that the availability of sufficient partnerships for GPs who want them is vital for the development of young GPs and the practices where they work, as well as for the profession itself.

Short term gain

By offering salaried posts, practices may be gaining financially in the short term, but Dr Osborne warns that they are missing out on the enthusiasm and involvement of a young partner with lots of ideas. “If you are not offering a partnership you are losing out on that potential for developing your practice.”

Debs White is a trainee on the Tees Valley vocational training scheme and a member of the BMA’s Junior Doctors Committee. One of the reasons she chose general practice is because she wants to be a partner, so that she can be her own boss, run her own business, and make decisions about how she does her work. “I’ve seen in hospital posts the frustrations that consultants can have on a daily basis about the systems they work in and their inability to implement new systems. That is certainly a big part of my motivation for wanting to be a partner.”

Dr White believes that partnerships are the gold standard for the delivery of general practice because partners have a much greater personal investment in the long term care of the patient, in the way the business works, and in the way the practice as an organisation looks after patients. “People who have invested in the business and the organisation to deliver health care to patients are the best people to take general practice forward.”

Dr McCarron-Nash, who was previously a partner but is now a salaried GP, says there is a perception that partnerships are either not available in some areas or that there are less than there should be. “As a result there is a group of young doctors who feel disenfranchised because they were told they were going to get x and they have got y.”

Dr Buckman says the GPC has spent the last four years trying to encourage practices to take on new partners rather than salaried GPs. “I understand why they don’t feel they want to, but I think they are wrong,” he says.

He adds, however, that judging by adverts in BMJ Careers, the number of partnerships has “risen quite steeply in recent months” and there is “now an appreciable number of proper partnerships.

“That doesn’t solve the problem for thousands of people who want to be partners but aren’t. It may solve it in time, but it is not going to solve it quickly and I understand why [some GPs] feel very frustrated.”

The GPC would like to see incentives put in place to encourage practices to take on partners, particularly in deprived areas and areas where there is not enough doctors, but concedes that this is unlikely with the current squeeze on public spending.

Dr McCarron-Nash says ideally this would be “a golden partnership scheme,” where the practice would get an incentive to invest in taking on a partner providing that doctor agreed to stay in the locality for a significant period of time—say, , five years.

Dr Buckman admits: “I don’t think the government or the Treasury are going to go for that.” But he outlines another alternative, which would be to alter the way that the global sum is calculated to give salaried GPs a baseline amount of money that isn’t linked to the funding formula. He proposes money for running the practice that is not related to the number and type of patients on the list. “I think that is possible, but I wouldn’t be overoptimistic,” he says.

Reducing the earnings gap

Although profits from providing general medical services soared in the first three years of the new contract, they have now tailed off and begun to fall. Meanwhile, salaried GPs have continued to be awarded modest pay rises, reducing the earnings gap between the two groups.

Dr McCarron-Nash hopes that this will make practices more inclined to take on new partners, because the cost of paying a salaried doctor is now closer to the cost of a profit sharing partner.

Dr White has also seen more advertisements in BMJ Careers recently, and this has made her feel much less worried about finding a partnership than when she embarked on her GP training a couple of years ago. “You just want to see that there are options there, not as many as maybe you would like, but there certainly are options there in terms of partnerships at the moment.”

References