A salaried profession
I am well aware that the foremost GP bloggers, The Jobbing Doctor and Dr Crippen, are not salaried doctors. They are GP principals, partners in their businesses and I would venture to predict that both JD and JC will not be terribly thrilled at the prospect of a fully salaried profession. So, are they dinosaurs that deserve to go the way of the, er, dinosaurs?
There has always been something of a hierarchy with GPs. My hairdresser thinks that the real proper doctors are partners, then come salaried doctors then come locums at the bottom. I smile politely; she is the one with the scissors. This is not a particularly helpful viewpoint as each group brings appropriate qualities to the workforce. The issue seems to be that these differences are getting magnified and distorted.
Scotland is thinking about a salaried profession. There is a clear concern about a so-called two tier profession. My own post in January (GPs that wind me up – No 8) touched on this issue.
8. Practices that employ salaried GPs and nurse practitioners when what they really need is another partner.
This is primary care on the cheap and is often primarily motivated by the profit share for the existing partners. This pill is often sugared to ease the conscience (for the more sensitive souls) with mealy-mouthed excuses about skill mix. This letter agrees.
We could be more honest as a profession – few patients realise that GP surgeries are run as businesses for the profit of the partners. Maybe that’s why GP principals are kicking up a fuss?
If GP principals pursue this policy then the endpoint will be a fully salaried GP profession. Of course, it probably won’t be in the current GPs’ working life so why should they care?
GP principals have, for all the protestations, been shrinking their numbers. The proportion of salaried GPs has risen from 12% in 2005 to 33% in 2007. The RCGP’s Dr Clare Gerada:
Young GPs who feel ‘the ladder being pulled up’ as they are denied partnerships may defect to the private sector. The report points to ‘evidence that some private employers offer better terms and conditions’ than traditional general practices.
Now this may be for the simple reason that the practices fear for their survival in difficult times if they do not protect their interests. However, a common line is the ‘not me guv’nor’ defence. It reminds me of dog-walkers. It’s never their dog that has crapped on the pavement. It is always someone else’s dog.
Do I think that GP practices should be killed off as (semi) independent entities? There are serious problems with a salaried workforce – there is a lot of stability built into a system where GPs are financially and emotionally invested in the community. This stability then leads to the holy grail of good continuity of care. This is an incredibly precious commodity that is difficult to quantify; it’s not tangible and it will resist QOF quality markers. However, we all know when we have experienced it. If you have ever had a problem that needed more than 2-3 visits to the GP you will quickly come to appreciate it.
The Future
The more I consider the future the more I am happy with my three rules of general practice that I posted last September. In fact, I am considering elevating these to the loftier status of Laws. Maybe they could be eponymously named? It would make a fine alliteration.
Law 1. Every person in the UK is entitled to care from a named GP.
And they have to have reasonable access to that GP. As I said then: one patient, one genuinely responsible GP.
Law 2. The ‘named GP’ should have a maximum number of patients on their list.
This protects against larger polyclinic rubbish as well as the current situation where principals are forced into squeezing their own little workforces.
Law 3. The ‘named GP’ must retain a measure of control over how that clinical care is delivered.
Does the current system deliver on these Laws? Well, largely yes, but it is running into problems because it is squeezing Law 2 for economical reasons (government driven) and Law 3 with top-down targets and directives (government driven).
Would a fully salaried workforce do any better? I am not convinced that a salaried profession can deliver on any of these essentials. There is a danger of losing your named GP and there may be more mobility of GPs within the workforce with little control over numbers of patients. I find it highly improbable that a salaried workforce will gain control over the delivery of clinical care and it is more likely that more and more care will be pushed toward ‘cheaper’ alternatives. And before anyone hollers, I do not think that is because patients will become massively empowered instead. It is far more likely that there will be distant management from private companies delivering minimal care of government specified targets.
The current model of GP partnerships needs some tweaking. I’m happy to be salaried (A Positive Choice) and I don’t feel any sour grapes about partnership. For all its faults I suspect it is a good mechanism for delivering personal primary care.
Rather than bowing to the external pressures with a fully salaried GP workforce maybe what we really need now is a Save the Dinosaur campaign.
Hi Northern Doc,
Brilliant post and certainly very very relevant to me at the moment.
I qualified as a GP in 1999 and started locuming in three different but neighbouring PCTs. This was with a view to becoming known in the area and hopefully applying for partnerships.
The PMS contract came and salaried doctors were the trend. I was approached by one of the surgeries and offered a salaried post and accepted. It was a good job in a good surgery. Partnership posts were less frequently advertised.
I left this practice in 2007 after accepting a “salaried post with a view to a partnership” – something which I would not recommend to anybody in hindsight. After resigning from this job after 14 months I went back to locuming and eventually found myself working a maternity locum in the original surgery where I worked as a salaried GP.
The response I received from the patients was phenomenal! Several tens of people have warmly welcomed me back and have been genuinely pleased to see me again. Continuity matters.
The partners are a husband and wife team in a 2-branch (both dispensing) surgery – they are not interested in other partners but instead employ 2 salaried doctors and a nurse practitioner. It would be fair to say that they do not find themselves challenged in the same way that a dynamic group a 5 partners would be.
I have had several interviews over the years (8 applications, 6 interviews) and not got the job.
But I am pleased to report I start a partnership in a few weeks and am thoroughly looking forward to the challenge.
In fact, I’m thinking of sticking Lawson’s 3 Rules of General Practice to my consulting room door.
Hi Armchair Daddy – thanks for the comment and many congratulations on landing a partnership. It has certainly been a tough couple of years for those GPs that aspire to partnership.
I have to admit I am deeply cynical about the ‘view to a partnership’ wheeze. While I can understand partners’ reticence when it comes to making the big jump and commitment of taking on another partner I think it can be used unscrupulously. I suspect this policy has resulted in a considerable amount of rancour between some GPs.
Good luck with the new job – but until government policy starts valuing continuity above ease of access then I think it will be tough times ahead.
Hello Northern Doctor.
Congratulations on an excellent post. Last September we had a senior partner retire, and despite having a polyclinic being dumped in our patch we decided to replace her with a full-time partner. This was a financial risk to us, especially as we could lose patients.
I feel this is important as I want the practice to be thriving and successful when I go in 4 years time.
There are other partnerships, but just not that many advertised. I was examining with a chap from another practice last tuesday who has just been changed from salaried to a partner, and we are considering changing our practice around so we increase the numbers of partners.
I quite like your laws as well.
JD
Thanks JD.
I think there is a reasonable possibility the salaried/partner situation will bottom out fairly soon – there are a lot of practices out there who recognise the value of having enough principals. I don’t think the changing demographic is necessarily going to lead inexorably to an all-salaried workforce.
Presumably (although I have no personal experience of this) all the other tasks involved in running a practice become a real burden if there are insufficient partners. Short-term measures to cut commitments/costs may be superceded by those pressures and I hope it swings back again.
As JD says, your laws are attractive. Me likes.
Too, the explicit partner/salaried doctor duality is shifting and like you I don’t feel it’ll play out to a totally salaried workforce.
Of course, a salaried work firce would be hellishly attractive to managers, since medics are then tools to use in elements of the business as directed, and are more easily replaced and managed. Fits with models of polyclinic and doctors at Tescos etc very nicely. If the medics run and have vested interests (financial, professional, personal) in the business, the GP is a far more powerful force.
I’d much rather have partners rather than salaried GPs, principally because there’s then the option for the GP to do things their way (more of the time) rather than didactic control (eg from a polyclinic’s business manager, all of the time), and I’m of the view that GPs know how to do General Practice best. Partners mean GPs are more in control. A wholly salaried work force compromises that, unhelpfully.
Although I meet with GPs regularly, it’s years since I’ve been jobbing in GP land myself, so I’m out of touch with practice organisation and would happily believe a non-partnership model could deliver, if a persuasive argument by coal face GPs were presented to me.