Recent comments on the possible demise of GPs' independent contractor status by outgoing RCGP chairwoman Professor Clare Gerada went down, by her own admission, 'like a bowl of sick'.
Opinions are sharply divided over the benefits or otherwise of the self-employed partner model that has helped to define the British GP over 65 years of the NHS.
Professor Gerada called the model a 'millstone' around the neck of general practice, set up out of 'political and professional expediency'.
The contractual arrangement was a compromise at the foundation of the NHS between the government and GPs who opposed losing their independence and becoming employees of the state health service.
Professor Gerada, who takes up a position overseeing primary care transformation in London with NHS England in November, made her comments while outlining her vision for GP-led, integrated provider organisations, a model she calls 'integrated care co-operatives'.
Speaking to GP, she says doctors in this system would be a mix of salaried and 'not-for-profit shareholders'. Independent contractor status is not incompatible with a move to federations and could even remain in place, she adds, if local areas want to keep it.
However, Professor Gerada believes the case for changing GPs' contractor status is overwhelming. 'We are expected to do more for less, we are expected to fund our own defence, our own training, we are expected to fund our own representation on committees, our own exam, our own examiners, we are expected to participate in inand out-of-hours care for no additional resources.
'I think the only way forward is for GPs to give up their GMS, PMS, to pool it and then to work with our secondary care colleagues to develop proper referral systems, proper care pathways.'
Long-time advocate of a salaried profession Dr Peter Fellows was a GP in Gloucestershire and a GPC member for more than 20 years before he retired earlier this year. He agrees that the cost of partnerships has become prohibitive for young GPs, many of whom would rather take salaried work. It has become 'increasingly threatening' for GPs looking at partnership with the amount they have to stump up.
After years of tight contracts, independent practice is becoming increasingly difficult to sustain, says Dr Fellows, and a salaried service is now 'on the cards'.
'More and more people are coming round to the idea that the only way we will improve the lot of GPs is if we are salaried,' he says.
In the Journal of the Royal Society of Medicine, GP and head of primary care at Imperial College London, Professor Azeem Majeed, also argues that it is time for GPs to become NHS employees.
'Under the current capitation-based funding method, GPs face unrestricted demands for their services and their time, while having to operate on a fixed budget,' he says.
Moving to a salaried service could overcome the divide between principals and salaried GPs, he adds.
That need for a more 'egalitarian' approach is recognised by the chairman of the National Association of Primary Care, Dr Charles Alessi, who says independent contractor status was created at a time when the doctor was 'the beginning and end of everything'.
The need today for relationships with a wider, multidisciplinary and integrated team puts the independent contractor at a disadvantage. Another problem with the self- employed model for Dr Alessi is that it favours smaller practices, when there is a growing 'necessity to have scale'.
On top of financial pressures, there are cultural drivers against independent contractors.
Ross Clark, a partner at law firm Hempsons who specialises in establishing GP provider organisations, argues that there are patientand doctor-led cultural factors.
Patients' access demands and the changing outlook on work-life balance by GPs could both eventually spell the end for the independent, self-employed GP, he says.
Some who regard independent contractor status as having brought great benefits to the profession admit there are problems.
Chairman of the Family Doctor Association Dr Peter Swinyard says while it is not dead yet, it 'may be struggling'. 'It's very hard to think you have a great deal when your income is going down year on year,' he says.
'There will be some who will say, "It's just not worth it anymore, let's just be salaried and be done with it." I think the number of people who feel like that is increasing.'
For Dr Swinyard, the independent contractor provides the 'engine room of innovation' in general practice. Independence means GPs are not tied down by the bureaucracy and administration of the rest of the NHS and are free to innovate and work beyond what the rules and regulations of a centralised system would allow.
'If we weren't independent contractors, we would have to take ideas to a committee, and for someone like me, it would be beyond frustrating,' says Dr Swinyard.
GPC deputy chairman Dr Richard Vautrey agrees that independence is key. GPs' independence and vested financial interest in practices make the service more flexible than the rest of the health service.
'You see the slow pace of change in many hospitals compared with the way GPs are responding to change year after year with the contract and responding within a matter of weeks and months,' he says.
This is how GPs have managed to escape what Dr Alessi calls the 'shackles of central control'.
General practice is the only part of the NHS that is really clinically led, because GPs own and manage their practices, says Birmingham LMC executive secretary Dr Robert Morley. 'We don't get it in hospitals, because they are run by managers and chief executives.'
But Dr Fellows says the idea of independence and entrepreneurialism is a 'load of pap', because in reality, GPs are 'totally tied' by the demands of the NHS system.
Defenders of independent contractor status worry that salaried service could see GPs working to rule, staying home when sick and finishing at 5.30pm, creating capacity problems and affecting standards.
While some GPs may relish the chance to work to such a contract, Dr Swinyard says it should be a matter of professionalism that GPs want to put patients above their working conditions.
Post-Francis, another important consideration, says Dr Vautrey, is that independent contractor status allows GPs freedom to act as patient advocates and makes them accountable to their communities in a way that would not be possible in salaried service, under managers.
Proponents of the status quo fear a change will lead to what Dr Vautrey describes as 'supermarket-style' practices with a small number of managing partners employing large numbers of salaried GPs. 'I think the more you have GPs with a stake in their business, the better,' he says.
While a move towards larger practices, federated when necessary, is inevitable, Dr Vautrey says that can happen alongside independent contractor status.
The future contract landscape is likely to be a mix of local solutions and hybrid models, GPs and other NHS leaders suggest. Dr Alessi predicts a locally determined 'diversity of models', including independent contractors where appropriate.
Detractors of options such as a move to social enterprise, not-for-profit organisations to provide NHS primary care argue that GPs employed by independent providers have all the same disadvantages as being salaried. 'There isn't a halfway house,' says Dr Swinyard.
Perhaps all methods of paying doctors have flaws. King's Fund senior fellow Nigel Edwards says the debate must begin with patients' needs.
The future, he says, is an 'intelligent mix' of models, shaped by local decision and needs: 'There is no magic bullet.'
|Independent contractor status|
- Independence allows entrepreneurialism, flexibility and innovation.
- Stake in business means GPs are connected and accountable to the local community.
- GPs are free to act as patients' advocate.
- More responsive to change through annual contract.
- Compatible with federations/integration.
- Can work alongside salaried and other models.
- Promotes clinical leadership and management.
- Promotes stability and continuity of care.
- Forces change to reflect patient needs.
- Unsustainable under mounting financial and administrative pressures.
- Enforces division between primary and secondary care, does not fit in with effective integration.
- Costs of partnership investment are discouraging young GPs.
- Argument that it allows GPs freedom increasingly dubious in face of rising bureaucracy and targets.
- Some argue independent contractor status is blocking the move to larger practices.
- Model may not reflect modern multidisciplinary team working.