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Arguments in Favour of a Salaried GP Service

The independent contractor model has been at the core of general practice in the UK since the NHS was first established and this model has many strengths. For example it has allowed the development of a s strong primary care sector that has allowed the NHS to operate efficiently - NHS general practices have typically used between 8-10% of the total NHS budget and dealt with up to 90% of all patient contacts with the NHS. However, in recent years, general practices have come under increasing pressure through a combination of rising workload, increased complexity of care, and a reduction in the resources allocated to primary care.

Many general practitioners now find themselves struggling to cope with their day to day workloads. This makes it difficult for patients to gain timely access to their general practices and in turn increases pressure on other parts of the NHS, such as Emergency Departments. We are also now seeing a divide developing in the profession between salaried GPs and GP Principals. Would a move to a salaried GP service in which GPs became NHS employees (and not employees of commercial companies) help address these problems? In this blog post, I list some of the potential advantages of a move to a salaried GP service. Please let me know if there are any additional advantages not listed here.

1. Under their current contract, the funding received by a general practice from the NHS is largely a fixed sum based on list size and, unlike the tariff-based payments made to hospitals, it does not increase if a practice’s workload increases. This funding mechanism was devised some time ago and does not take into account recent changes in areas such as primary care consultation rates, patient complexity or the new demands placed on general practitioners for non-clinical and managerial activities.

2. General practitioners currently face unrestricted demands for their services and on their time while having to operate on a fixed budget. Under a salaried model, the primary care service could be funded in a similar way to the tariff-based payments made to hospitals so that extra work was accompanied by additional funding.

3. There is great variation in how individual practice operate and in their staffing levels. A salaried service in which GPs became NHS employees would allow for greater standardisation of operating procedures and staffing levels.

4. As salaried NHS employees, general practitioners would need to be employed on similar terms to consultants if recruitment of high-calibre medical graduates into general practice was to be maintained. Salary levels would also be less variable than they are now.

5. General practitioners would have job plans that would need to give them sufficient time for non-clinical duties and for learning and development, as well as for their clinical duties. They would also be would be protected by the European Working Time Directive from working excessive hours, and be could relinquish some of the tasks they currently undertake. As with consultants, there could be career progression and pay increments based on experience and for taking on additional duties in areas such as management, teaching, training and quality improvement.

6. General practitioners could have the opportunity to work in integrated care organisations that would also employ community staff and specialists. This would encourage the integration of care, shared IT systems and reduce duplication between different sectors of the NHS and between different professional groups.
Integration of out of hours and emergency care could also be improved, with general practitioners working as the first point of contact for most emergency cases and emergency departments reserved for more serious cases.

7. Workforce planning could be improved with general practitioners deployed in sufficient numbers to meet the needs of local populations. Skill-mix could also be examined with transfer of many routine tasks to groups such as nurses, physician assistants and health care assistants.

8. If general practitioners do not start to negotiate now on our employment terms, the alternative is likely to be a proliferation of APMS contracts and employment of GPs by commercial companies on significantly worse terms than those offered to its medical employees by the NHS.

You can also read the opposing argument. See also my JRSM editorial: General practice in the United Kingdom: meeting the challenges of the early 21st century

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