David Oliver: Making GPs hospital employees won’t solve pressure on hospitals or general practice
BMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o259 (Published 02 February 2022) Cite this as: BMJ 2022;376:o259
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Dear Editors
I agree with Professor Oliver's opinion that the idea of getting GPs to be salaried employees of hospital trusts is misguided and could potentially compromise the independence of GPs with respect to advocacy for patients, as well as concerns about KPI requirements tied in with the trust's performance and goals rather than the patients' needs.
However I am not sure this outlook is shared by the newer generation of GPs for whom the advantages of a salaried position (with the flexibility of part time) is more attractive than the shared profit arrangement of a partnership model. This is reflected by various GPs who are regular contributors to BMJ (ref 1,2) much to the frustration of some (ref 2,3), often from other generations with different expectations/outlook.
In fact there are some who have taken offence at being called "salaried GPs" (ref 4), even if only to differentiate them from those in contractor-GPs. This is despite the fact, as reflected by a regular BMJ columnist, that "partners, salaried GPs, and locums all have their own vested interests" (ref 1) and perspectives; similarly it was alleged that "a lot of salaried GPs who would love to contribute more but because of their contractual status they don’t" (ref 4).
Hence, for those GPs who choose salaried positions over other remuneration arrangement, they may hope to gain that win-win situation in which they may have more control of what they can do for their patients as well as for their colleagues and themselves, but I suspect in the end, many will learn that just like "new lamps for old", they may not like what they have to do (or cannot do) in order to get that salaried position.
And when everyone is having the same contract, the real effect of government whim will be felt, but people wouldn't believe it even if you told them now.
References
1. https://www.bmj.com/content/375/bmj.n2626
2. https://www.bmj.com/content/355/bmj.i5064
3. https://www.bmj.com/content/368/bmj.m515
4. https://www.bmj.com/content/367/bmj.l6229
Competing interests: No competing interests
Partnership or salaried GP - what about the Engaged GP?
Dear Editor,
Sajid Javid's suggestion that hospitals should employ GPs has provoked angst and anger among GPs and others around the potential loss of our autonomy. The source of GP frustration seems to be our assumption that partnership is where GPs will get involved in the running of their practices and in time the wider system. Salaried practice is often sold as "no management commitment" and as a result we may be developing a cohort of GPs who are encouraged to have no influence in how the practice and service around them develops.
This binary distinction misses the point. It sells many salaried GPs short, and can flatter some partners who on occasion do little to get involved in service development. We keep persisting with the historical view that the only way that GP develops is via the partnership model. Yet, as other responses observe, new GPs do not seem to be wanting to engage with that model, and Javid's plans therefore ride on the back of the shift towards salaried GPs in recent years.
Engagement is the holy grail that we who understand the value of General Practice and have seen the partnership model work well in the past are looking for. Engagement is what can make a salaried GP as effective, if not more so than a disengaged partner. Engagement is what makes continuity more likely. Engagement is what Sajid Javid and the government should be looking for. But engagement can't be forced upon GPs, or happen automatically.
Rather than a debate between partnership and salaried, we and government should be asking how we can create engaged health practitioners. For complex reasons the partnership model seems to be struggling in bringing new blood into that ethos. The salaried model is automatically assumed to be lowest common denominator, where you are dictated to as a GP by others. We need to change that narrative, and I think create an environment where salaried GPs can be encouraged and entrusted with the running of practices, but perhaps without the financial risk that often scares younger GPs. The government would gain more support if suggestions of salaried systems came with the acknowledgement and trust that engaged GPs can deliver services in an efficient and patient centred way. Just as has happened for decades.
We all know that fundamentally more GPs are needed. However if these extra GPs are not engaged with their practices, colleagues and services, then GPs will continue to have our usefulness questioned by government, managers and our patients.
So, engagement I think is the aim rather than a binary debate between partnership or salaried. How we achieve that in the changing landscape of work patterns, personal expectations, financial constraints and workforce balance is where our efforts should be concentrated.
Sandy Rough
GP Aberdeenshire
Competing interests: No competing interests