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Arguments in Favour of an Independent Contractor Model of General Practice

I have written an article on why GPs should consider giving up their independent contractor status and become NHS employees, which was published in Pulse. In this blog post, I will make the opposing argument and will list reasons why we should retain the current independent contractor model of general practice. This will be helpful for those GPs who are against the proposal that we should become NHS employees but who are unable to put together a coherent or logical counter-argument. If anyone has further arguments in favour of the independent contractor model, please let me know and I will add them to the list.

1- The independent contractor model is very efficient. For between 8-10% of NHS spending, general practices deal with up to 90% of patient contacts in the NHS.

2- Because GPs are not NHS employees, they have more freedom to act as patient advocates and to speak up about deficiencies in the NHS.

3- The independent contractor model gives GPs a stake in their practices and encourages them to take a long-term view about the services they provide and to build links with the local community.

4- The independent contractor model encourages continuity of care. Salaried GPs would work shifts and be less interested and capable of providing continuity of care.

5- General practices can operate very flexibly under their current model and respond quickly to changes in national NHS policy, or to local needs and priorities.

6- GPs have freedom as to where they refer their patients. If employed in integrated care organisations that encouraged vertical integration of services, there would be much more limited options available for referrals to specialists.

7- The independent contractor model has encouraged innovation in the delivery of care and the use of information technology. One example of this is the universal use of electronic health records in primary care, in contrast to other settings where paper records often remain the norm.

8- Most GP Principals are very hard working and work well in excess of the hours worked by salaried NHS staff. They also undertake a much wider range of tasks than salaried NHS staff.

9- Replacing the independent contractor model with a salaried GP service is likely to end up costing the NHS more, as salaried NHS GPs would work shorter hours, be entitled to employers' pension contributions, and benefits such as maternity pay, sick leave, holidays, and study leave.

10- GP Principals are less likely to take sick leave than salaried NHS employees.

11- Replacing GP Principals with salaried GPs would make general practice less attractive as a career for medical graduates.

12- Many practices operate out of premises they own. Buying them out of their current premises or moving them to NHS premises would be prohibitively expensive for the NHS.

13- Relocating patients to new NHS premises would be inconvenient for patients, particularly those that may have difficulty in travelling such as the elderly and families with young children.

14- GPs current freedom to practise medicine and run their practices as they feel is most appropriate would be replaced by control by NHS managers thus creating a much more rigid and inflexible model of healthcare delivery.

15- Salaried GPs would be paid substantially less than GP Principals, particularly if employed by commercial organisations rather than the NHS.

16- It's not the independent contractor model that's 'broken' but rather the funding model. We need a fairer method of funding primary care that gives GPs adequate resources to do their job well. See my recent JRSM editorial.

17- A fairer funding model for general practices would also help to ensure that sufficient staff are employed in primary care to meet patients' needs for care, and that patients are treated in community settings whenever possible, thus reducing demands on emergency departments, hospital outpatients, and emergency inpatient care.

You can also read the opposing argument on this blog. See also my JRSM editorial: General practice in the United Kingdom: meeting the challenges of the early 21st century. Another article  by me on the challenges facing NHS GPs in England was published in the London Journal of Primary Care in September 2015.The BMJ also published a 'Head to Head' debate article on this topic in October 2016.


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