The special LMCs conference will be getting straight to the nub of one vital issue facing general practice: would moving away from an independent contractor model to an alternate model, such as a employed service, be better for the workforce?
It is unsurprising this has been asked as we are now becoming almost used to damaging shortages, especially acute in the north of England and the Midlands. Last year 600 trainee spaces were unfilled and a major survey of GPs found that a third were considering retiring, primarily as they were burnt out from working in an underfunded, over-worked environment.
The government continually promises that the cavalry is about to come over the hill, but so far all that has arrived is piecemeal and small scale. The current GP 10-point workforce plan has helped improve retention schemes and promote the value of general practice. However, even its strongest enthusiasts (including me) would shy away from saying it has solved the real crisis gripping our profession.
So is an overhaul of our employment status the way forward?
Salaried GP service
Under an employed model, GPs can have allocated time to deal with the non-clinical/patient facing aspects of the job, such as quality improvement, regulation, teaching and management. Moreover, it can be argued plausibly that much of the independence that GPs once had has eroded away in the last decade.
The profession is regulated and micromanaged to an unprecedented level. The levels of regulation and bureaucracy have placed GPs, as independent contractors, as the focus of criticism for failings in the wider NHS.
Another problem faced by GPs as independent contractors is the burden of running practice premises. Despite the funding announced by NHS England to improve premises, 75% of the successful bids have experienced delays in their project as the BMA recently pointed out in findings reported by GPonline.
By relinquishing the responsibility as independent contractor for dealing with substandard premises, GPs will be able to free up time and focus on aspects of care that only GPs can deliver.
However, there are significant catches. General practice is the only part of the NHS that is (almost) entirely clinically led, because GPs own and manage their practices. One of the biggest strengths of the model is the freedom to innovate. The fact that GP practices respond to change every year with the annual contract is a testament to this.
GP practices are also able to change and adapt to reflect patient needs in a much more fluid manner compared to secondary care where change can seem pedestrian. Most practices are run by GPs working with a small team of admin staff and management. Does general practice want to get tied down to the same level of bureaucracy and administration of the rest of the NHS by becoming entirely employed?
GP practices are also owned and run by ‘local’ GPs in most instances. This promotes stability and continuity of care. The fact that GPs have a stake in the practice, which is in effect a local enterprise, means GPs are connected and accountable to the local community. This unique relationship will mean that GPs are free to act as patients' advocate.
Despite being independent contractors, GP partners can work alongside salaried and freelance/locum GPs. Again, doctors working for doctors at such a large scale is unique to general practice. This means that the ‘employer’ can relate to what the ‘employee’ has to deal with at a much more minute level compared to the rest of the NHS.
Clearly there is no perfect answer to this scenario. As a GP partner, I personally feel the current model has more than enough life in it and we should fight to preserve it, but I am not blind to the strains being caused by problems outside of its design.
Motions at the LMC conference reflect the workforce problems facing the profession. Newly qualified GPs are shunning the independent contractor model and the experienced/senior GPs are fed up with what general practice is being turned into. And in the middle you are left with a large generation of GPs who are probably too young to retire, and too old to retrain or migrate. We talked about the perfect storm last year - are we now looking at the end of general practice in 2016 if the government does not back its rhetoric with resources?
Photo: JH Lancy