GP partnerships versus salaried roles: what to consider when choosing a career pathBMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5001 (Published 07 August 2019) Cite this as: BMJ 2019;366:l5001
General practice was once all about being in a partnership. In the early days of the NHS, carving out a career as a GP involved investing in a commitment to owning a practice and often a share of the premises.
More GPs are now entering the profession on a salaried basis or choosing to leave partnerships to take up salaried positions. Figures from NHS Digital show that the number of salaried GPs rose from 10 283 in September 2015 to 12 508 in December 2019.1 Since then the numbers have risen further, to 12 710 in March 2019, although the figures are not directly comparable, as the way these workforce data are calculated has changed.
Security and autonomy
One advantage of choosing a GP partnership over a career as a salaried GP is job security. Richard Fieldhouse, chair of the National Association of Sessional GPs (NASGP), says that the security associated with partnership is about not only income but “knowing you’re putting your stamp on the local community,” in how patients are cared for and treated. “It’s like being a captain steering a ship in a particular direction: you can have control and a vision of care as a GP partner,” he says.
Being your own boss, whatever pressure your practice is under, is another benefit of being a GP partner, says Peter Holden, a GP principal in Derbyshire. “The government does try to micromanage. You only have to answer to yourself and your partners.”
Having a certain amount of autonomy brings other advantages, says Mohammed Jiva, a GP partner based in Middleton. “You can construct the hours you work that week,” he says, adding that this autonomy also allows you to decide the way services are delivered within a practice and to influence the wider healthcare system.
One of the biggest difficulties associated with being a GP partner, and one of the major barriers to becoming one, is ownership of practice premises. Richard Vautrey, chair of the BMA’s General Practitioners Committee in England and a GP partner in Leeds, says that GPs are moving away from property ownership because of issues with recruitment and retention.
“One of their fears is being the ‘last person standing’ in a partnership,” he says. “If partners leave and are not being replaced because of recruitment difficulties, the risk to remaining partners becomes more burdensome and they are left worrying about the liability they are carrying.”
Vautrey says that GPs considering going into a partnership need to have their “eyes wide open” to the risks and financial implications, and they can seek professional advice from the BMA. GP partners are the people with ultimate responsibility for the practice, he says: “You have the responsibility of managing all the patients that present on a particular day. As workload increases, partners are the ones dealing with those pressures—the buck stops there.”
That responsibility extends not just to delivering services but also to staff, their pay, sick pay, training, and organising locum cover. Holden says, “As a principal, you’re not just a doctor that looks after patients: you’re an employer, manager, you’re a financier, and an educator—and all of these things have to be paid for.
“Remember, you’re self employed. There’s no sick pay, no maternity or paternity leave, or the benefits of a study leave fund. That comes from your take home pay. And it’s your house on the line if things go wrong.”
In contrast, he says, the experience of being a salaried GP is the same as for any other employee: “You know what your hours of work will be, you have sick pay, you should have study leave allowance, and considerable professional freedom. It’s about being a GP without the hassles of practice management.”
Holden adds that the shortage of GPs nationally means that salaried GPs now have more security of tenure than in the past, as practices “are desperate to keep them.”
For people starting work as GPs, one attraction of a salaried path may be the chance to sidestep the financial responsibilities and outgoings associated with being a partner, particularly considering the level of student debt they face.
Holden says, “That is the case at the moment. That is why younger GPs are going for salaried jobs, not partnerships, and undoubtedly they will have a better work-life balance.”
He says that there is “no question” that GPs are disillusioned and leaving partnerships. “Most GP partners have not seen a pay rise in 10 years: most have taken a substantial pay cut. It’s a more hostile environment—professionally, legally, and commercially,” he believes.
Fieldhouse, in his role as NASGP chair, hears many stories of disillusionment with partnership practice life. He explains, “I’ve had GPs say to me: ‘Richard, I was a partner, I couldn’t sleep at night, I was depressed with my life and career, and I hated being a GP. Then I stopped being a GP partner, and I realised I was happy, and that it wasn’t that I hated being a GP.’” He says that many of these GPs had decided to become salaried practitioners or locums.
For 28 years Julian Parkes worked as a GP partner in Wolverhampton. Then the practice subcontracted its General Medical Services (GMS) contract to the Royal Wolverhampton NHS Trust. He is now a salaried GP and, like all of the other practice staff, his terms and conditions have been transferred over, including his salary. He says that an advantage of being salaried is, “hopefully, a defined workload for a defined pay—and, if you are asked to do extra work, that should come with extra pay.”
Parkes believes that the changes in general practice need to be recognised more widely. “We’ve got to work out a better system of primary care that takes into account workload and [accepts] that some GPs don’t want to be partners,” he says. “It’s either recognising this or pushing on with an old, outdated, 1948 model of general practice that I don’t think now works and is not fit for 2018.”
For Fieldhouse, the major benefit of a salaried life is the potential flexibility.
“It’s relatively easy to change jobs, although this will depend on location,” he says, “so if you’re living in the city there’s an abundance of practices needing salaried GPs, but you tend not to have much choice if you’re living in a rural area where there may be just the one general practice.”
Salaried GPs also have the freedom to develop special interests without having to sort out hiring a new receptionist or worrying about migrating to a new IT system. And Vautrey suggests that, for GPs starting their career, having a salaried status can be a stepping stone to becoming a GP partner in the future by “helping them to gain more confidence and acquire more skills in a more supportive environment.”
Holden says that a salaried position is also a valuable means of allowing GPs to “step down from their responsibilities in a partnership [if they] are at the middle or towards the end of their career but want to continue to work in community practice.”
Having a salaried GP status can give a sense of career control. Equally, it can result in feeling a loss of power and a lack of esteem. Holden says, “You don’t have the prestige of being a partner. You also have to fit in with practice procedures and routines over which you may have no control.”
As a salaried GP, says Vautrey, “You don’t necessarily have the same involvement in decision making within an organisation, or the same financial benefits, and you may feel a bit more disconnected from it in a way you wouldn’t if you were sitting round the table as a partner.”
Despite a demand for salaried GPs there may not be any guarantee that a post will be long term. A practice may, for instance, decide to replace a salaried GP role with an advanced nurse practitioner post.
Whether the shift towards salaried positions will continue, says Vautrey, depends on “proper investment in general practice.” He hopes that this will result from the government’s review2 to reinvigorate the partnership model.
“Whether you’re a salaried GP or a partner is less important than ensuring the future of doctors who want to become GPs and to give them flexible options,” he says. “That’s because one of the strengths of general practice is having flexible arrangements at different times of your career.”