Should all GPs become NHS employees?
BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5064 (Published 05 October 2016) Cite this as: BMJ 2016;355:i5064All rapid responses
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I thank Sir Denis Pereira Gray for his thoughtful comments. Sir Denis has been a long-standing and very prominent advocate for primary care. I acknowledge that there are many benefits for GPs being self-employed and I have listed some of these in a previous article.[1] For example, GPs do have more freedom to speak out about health services than salaried employees of the NHS. It is also true that many professional groups – such as accountants, architects and surveyors - work in partnerships as self-employed practitioners. One key difference between these groups and GPs is however that a typical general practice obtains nearly all its income from one funder: the NHS. This gives the NHS considerable power over GPs and the ability to unilaterally modify contracts, confident in the knowledge that GPs have to either accept the terms the NHS is offering or give up their contracts.
The current reality in the NHS is that an increasing number of GPs are finding it difficult to work as GP partners.[2] Their clinical and administrative workload is increasing, they are having to take on greater clinical risk, and the NHS is placing an increasing regulatory burden on them. Unless these problems are addressed, there will inevitably be a decline in the number of GPs who want to be partners in a medical practice. Hence, it seems inevitable that we will see a continuing increase in the number of GPs who are salaried employees. I would prefer these GPs to have a standard national contract rather than the very variable employment terms offered by the commercial providers of primary care.
References
1. Majeed A. Arguments in Favour of an Independent Contractor Model of General Practice. http://medical-centre.blogspot.co.uk/2013/10/arguments-in-favour-of-inde...
2. Majeed A. Primary care: a fading jewel in the NHS crown. London Journal of Primary Care 2013;7:89-91. http://www.tandfonline.com/doi/full/10.1080/17571472.2015.1082343
Competing interests: I am a GP Principal in an NHS general practice that employs salaried doctors.
I thank Michael Tremblay for his response. He proposes a model in which doctors would outsource themselves to work in ‘chambers’ and then offer their services back to the NHS. One problem with this approach is that the typical general practice would have only one funder: the NHS. As a 'monopoly purchaser' the NHS would then be free to offer whatever terms it wished. Doctors who did not want to accept these terms would not have other customers they could turn to and this would therefore make this model very different from other professional groups who work in chambers who generally have a range of individuals and organisations that want to buy their services.
Competing interests: I am a GP Principal in an NHS general practice that employs salaried doctors.
I thank Dr Alfred Lake for his thoughtful comments. I agree with Dr Lake that one of the key arguments for GPs being NHS employees – rather than self-employed, or employed by general practices or commercial companies – is that this employment model might then allow greater integration of primary and secondary care. GPs and specialists would in this model be employed by the same employer, thus allowing for closer working between GPs and specialists. I also agree with Dr Lake that we need to address the issues that are leading so many doctors to leave the NHS, and encourage policies that promote the retention of staff from key professional groups such as GPs.
Competing interests: I am a GP Principal in an NHS general practice that employs salaried doctors.
I thank Dr Paula Wright for her thoughtful comments. I agree with her that the variation in employment contracts for salaried GPs does create problems and often results in a worse employment contract than that offered by the NHS to its own employees. Mandating a standard national contract for salaried GPs in England would be as step forwards and help reduce the variation in their terms of employment. I also agree with Dr Wright that working for larger employers (sometimes described as a ‘general practice at scale’) could create better career structures for salaried GPs with the option then of taking on roles in areas such as management, research, teaching or quality improvement.
Competing interests: I am a GP Principal in an NHS general practice that employs salaried doctors.
Sir Denis talks of several advantagesof independent contractor status. But the first of the seven advantages listed by him is NOT an advantage or a disadvantage. It is merely a statement of what happens in certain other means of earning a living.
He mentions the gagging clauses in consultant contracts. May I remind the readers that the original Nye Bevan set-up permitted the hospital doctors and dentists to say anything, to write anything, without let or hindrance. This Whitley Council clause was removed about thirty years ago, with the blessings of the BMA.
Why the BMA agreed to permit the employers to gag doctors and dentists remains obscure.
Competing interests: No competing interests
Several important advantages of the independent contractor status have not yet been described in your columns. [1], [2], [3]
1. This is the normal contract for leading community-based professionals including accountants, architects, barristers, dentists, solicitors, and surveyors, including the biggest national firms.
2. Independent contractors usually work in partnerships, much the best background for working in partnership with patients.
3. Independent contractors usually allow clients/patients more choice of professional than hospitals with salaried hierarchies.
4. The Court of Appeal has ruled [4] that salaried staff (including doctors) are in a servant-master relationship with managers.
5. Consultants in the hospital service have gagging clauses in their contracts: general-practitioner partners do not.
6. The Independent contractor status is substantially more flexible, fosters responsibility, and allows professionals much more say about colleagues, staff, and working environment.
7. Female doctors in general practice on average have their first baby three years earlier than women doctors in hospital doing anaesthetics, medicine, or surgery. [5] This three-year difference, in favour of general practice, is especially important to women in their early thirties
References
1. Godlee F How should doctors be employed? BMJ 2016;355; i5394
2. Majeed A Head to JHead: Yes BMJ 2016; 355: i5064
3. Buckman L Head to JHead: No BMJ 2016; 355: i5064
4. Pereira Gray D The independent contractor status J Roy Coll Gen Pract 1977; 27:750-56
5. Goldacre MJ Davidson JM Lambert TW Doctors' age at domestic partnership and parenthood: cohort studies. J R Soc Med. 2012 Sep;105(9):390-9. doi: 10.1258/jrsm.2012.120016. Table 5.
Competing interests: Sir Denis Pereira Gray has previously been salaried part-time as a Professor of General Practice whilst simultaneously being a part-time Managing Partner in General Practice.
This proposal seems to be an excellent example of solving the wrong problem really well.
Rather than GPs losing independent contractor status, consultants (and perhaps many others for that matter) could move from being salaried to offering their services independently, perhaps much in the way lawyers do (chambers), or through clinical arrangements that 'outsource' clinical services that can be sensibly ring-fenced. What the NHS needs, and all healthcare systems desire, is flexibility in face of changing demand.
So, what am I talking about?
It is called the Hollywood model [1], so-called because it is how films are made. It is also used by other sectors of the economy, particularly where innovation is highly valued (such as in research -- think the pharma industry's R&D arrangements with small biotechs), or where considerable organisational flexibility is needed to respond to a rapidly evolving work landscape (hmmm, sounds like healthcare), but this what people mean by the on-demand economy (or Uberisation if you like).
I suggest that the NHS might benefit from moving away from employment as the solution, toward novel arrangements for the delivery of care. For instance, why is the hospital a monopoly supplier of clinical specialists, when direct patient access is really what want, e.g. oncology. [2] Unbundling hospital services into the community is a desired goal, so why are we talking about solutions that produce greater aggregation of working arrangements.
Would this undermine the NHS desire for service integration? Well, it might focus minds on service flow, rather than fussing about organisational structures. Keep in mind that integration of services can be achieved with multiple actors; the assumption that putting everyone in the same organisation constitutes integration flies in the face of organisational dynamics that as organisations get larger, they become largerly transactional and inwardly focused rather than toward the customer/client/patient.
Future care, even in the next 5 years, will be quite unlike what it is today. This extends across the whole spectrum: we need to look at the work to be done first, then decide what skills and knowledge is needed and finally who has that knowledge and how many, therefore, of them are needed.
Sincen the ways clinical work is done is changing, and the NHS needs seriously to address how it engages with the talent pool; my suggestion is toward greater flexibility in working arrangements for getting that work done.
And that is the right problem.
1. Davidson A. What Hollywood Can Teach Us About the Future of Work. The New York Times [Internet]. 2015 May 5 [cited 2016 Oct 11]; Available from: http://www.nytimes.com/2015/05/10/magazine/what-hollywood-can-teach-us-a...
2. Department of Health. Direct Access to Diagnostic Tests for Cancer. 2012.
Competing interests: No competing interests
Though the promulgated perception is that we have a 'National Health Service', in reality we have a health service provided for the nation to an unacceptably varying standard across the land. The major reason for that is our continuing struggle with the compromises, many medical, agreed at the inception of the NHS which should have been properly addressed soon after.
A major problem (one of the elephants in the room,) which Prof Majeed describes as an anomaly, is that how general practice works remains essentially as when the NHS was formed in 1948 in that it is based on the independent practitioner model which militates against the necessary integration (within primary and with secondary care) together with the delivery of a mandated standard of care (the range in quality of service provision in primary care is much wider than secondary). The problem remains, because, as identified by Dr Buckman, GP contractors presently have the freedom to run their practices as they wish with the resultant adverse consequences there for all to see.
As another responder notes, there are many countries where general practitioners, family practitioners and primary care physicians are self-employed. But our model is very unusual, in fact unique.
The Collings Report from 1950 (1) should be required reading and the properly integrated health centre approach more recently promoted by (now) Lord Darzi the way to go. Yet even in 2013 the BMA General Practice Committee report (General Practice – providing solutions for the future) showed they were clearly stuck in the past.
Housing an area’s general practices together in one location (which some dub a 'polyclinic') with other health professionals, investigative services, minor injury unit, clinics for secondary care staff and so on (be they all by then salaried or not) would result in a network of modern purpose built facilities providing access at least 8-8 of which the local community could be proud.
Making all GPs NHS employees needs serious consideration but we must, anyway, do something soon as the problem is worsening with so many experienced GPs (even under the present arrangements) opting out early.
1. Collings JS. General practice in England today—a reconnaissance. Lancet 1950;1:555-79.
Competing interests: No competing interests
The 2010 BMA survey of sessional GPs found the salaried GP experience has been highly variable with many Salaried GPs reporting frustration about not being employed on the model BMA contract 50% (i), perceived isolation (ii), lack of increments both for seniority and for DDRB uplift. Support from colleagues was the most important factor to consider when deciding whether to accept a post and morale was highest amongst GPs employed under the model contract.
Some salaried GPs want a purely clinical role and are given QoF responsibilities with no protected time; some salaried GPs want a wider role in the practice and feel marginalised as they cannot develop their interests as leaders, educators, commissioners (iii). There is a perceived discrepancy in pay for sometimes equivalent amounts of work which was felt acutely immediately after the pay rises which came with the 2004 contract and QoF.
A significant growth in Salaried GP posts came on the back of locally negotiated PMS contracts, aiming to addressing recruitment problems in more deprived areas. There is some doubt that PMS salaried options addressed recruitment problems (iv). Salaried posts did allow freedom from Out of hours work (for 1/5) and from practice management (v) , were associated with a higher proportion of time spent on direct patient care and OOH work, and were also associated with similar levels of job satisfaction to partnership (vi) . Satisfaction with remuneration was higher even though average pay (£43K/FTW) was below target net remuneration (£52k). There was also higher satisfaction with recognition for good work.
Overall stress levels were lower for salaried GPs, but there were higher stress levels associated with professional isolation, and insufficient resources from the practice (vi). There is evidence that salaried GP work (when compared with capitation based earning) does not adversely affect quality of care, productivity or GP behaviour (vii). Interestingly mobility remains significantly higher for salaried GPs than for principals (26% a year versus 3% in 2004/2005 and 19% versus 10% in 1996/1997) (iv) which is a further reason to ensure that the model salaried contract retains the concept of continuity of NHS service.
To make salaried posts successful there is a need to distinguish between salaried roles according to the degree of managerial responsibility, through job planning and job descriptions (viii) . This may address mismatched expectations. Salaried GPs without a fixed base (employed locums) will have an increasing role and may suit GPs who mainly want control, security and flexibility over timing of annual leave. Practice at scale offers the opportunity to ensure terms of sickness, maternity and redundancy reflect the model contract without excessive financial risk, whilst allowing the development of robust education and support networks, with managerial effort concentrated in those that relish such roles.
i BMA survey of Sessional GPs 2010. Confidential report.
ii Morrow G, Kergon C and Wright P (May 2010) Support for Sessional GPs Report to the Royal Medical Benevolent Fund.
iii http://www.rcgp.org.uk/policy/centre-for-commissioning/~/media/Files/Rev...
iv Ding A, Hann M, Sibbald B. 2008. Profile of English Salaried GPs: labour mobility and practice performance. BJGP p20-25.
v Williams J, Petchey R, Gosden T, et al. A profile of PMS salaried GP contracts and their impact on recruitment. Fam Pract 2001; 18(3): 283–287.
vi Gosden J,Williams J, Petchey R, et al. Salaried contract in UK general practice: a study of job satisfaction and stress. J Health Serv Res Policy 2002; 7(1): 26–33.
vii Gosden J,Williams J, Petchey R, et al. Salaried contract in UK general practice: a study of job satisfaction and stress. J Health Serv Res Policy 2002; 7(1): 26–33.
viii Job planning: Guidance for GPs. GPC Sessional Committee 2014
Competing interests: No competing interests
Re: Should all GPs become NHS employees?
If I may respond to Dr Azeem Majeed. Yes, there is the notion of chambers, which has been around as an approach for some time and in itself may be a possible solution. Clinical expertise in other countries enjoy considerable flexibility in organising the structure of the work they do. My own experience in a hospital, albeit some time ago (McMaster) showed how considerable internal flexibility contributed to new ways of working.
My suggestion had less to do with the money than with altering the design and structure of the work done by doctors and clinical colleagues. I fear that we tend to use the money as an excuse not to make changes, but individuals having greater control of their work flow would have greater personal satisfaction which would translate into more, not less, innovations in patient care and service delivery.
I accept to some extent the monopoly purchasing of the NHS as such, but in reality, healthcare working conditions are local and doctors can always move to another location or hospital that offers improved working conditions. Transparent purchasing practices can be used to encourage novel working arrangements. Such transparency would have the effect of restraining authoritarian purchasing by monopolists so there is no abuse of that purchasing power. While the UK is leaving the EU, it is worth noting the NHS has a dominant position under EU and UK competition law and as such is legally prohibited from abusing that dominant position, something that would happen if it attempted to use that position abusively. There are numerous examples though where government monopoly power is driving whole sectors into a rabbit hole: we can think of local authorities and social care, nursing homes, etc. These show the reason why price setters who can legally setting a ceiling tariff, should not also be purchasers.
I am all for creating the workforce of the future and submit this will only come with efforts to unbundle, and loosely couple the workforce, not lock individuals into tightly integrated care with organisations and professionals having very limited scope for flexibility. I am happy to share my blog post which addresses this in much more detail: http://policyinsider.com/unbundling-the-future-of-health-and-social-care...
Competing interests: No competing interests