Is a two-tier profession inevitable?

Jonn Elledge reports on how incentives to take on partners could repair the split in the profession.

At a recent registrars' conference, the next generation of GPs were relieved to hear that a plan is afoot to find them work. 'You can either retrain as solicitors,' GPC chairman Dr Laurence Buckman said, 'or you can emigrate. Failing that, we might have to do something for you.'

The pressure to do just that has been growing for some time. Young doctors have long complained about the lack of opportunities on offer. Anecdotally, salaried roles now outnumber partnerships three to one, and as many as 100 doctors are applying for some jobs.

Split in the profession
GP's survey this week shows that this issue is now threatening to split the profession. Nearly 70 per cent of salaried doctors want the BMA to campaign for more partnerships, compared with just 40 per cent of GP principals.

The feeling among many young GPs, says GPC trainees subcommittee member Dr Katie Bramall, is that they have been told: 'We trained you for 10 years, we don't need you now - tough.'

Now the BMA is at last moving to tackle the problem. At the recent annual representative meeting (ARM) in Liverpool, the profession passed a motion calling on the GPC to negotiate new contractual incentives to encourage practices to make room for more partners.

The dearth of partnerships has come about because the new practice-based GMS contract made it cheaper to replace retiring partners with salaried doctors. Link funding to partnerships, so the theory goes, and you solve the problem at a stroke.

Asked how such incentives might work, Dr Buckman points out that they already exist. The expanding practice allowance (EPA) is supposed to provide up-front funding to practices that want more staff. This should provide the capital investment they need to grow their list and, ultimately, their profits.

The only slight drawback to the EPA is that it doesn't actually exist. 'I'd take on an extra doctor tomorrow, if the money was available,' says Dr Buckman. 'But every time we say "let's make it operational" the government says it already is.'

The problem is that the allowance isn't included in the core contract, but is an initiative led by primary care organisations (PCOs). Where PCOs are happy with the capacity their practices already offer, they feel little need to pay for them to expand.

The apparent failure of the EPA highlights the biggest block to actually making incentives happen. They will not work if they eat into the profits of existing partners; that means they have to involve new funding.

But the DoH has shown little appetite for pouring more money into general practice. Some prominent GPs speculate that ministers are actively seeking an all-salaried profession, to make it easier to negotiate; if that's true, it is unlikely to want to spend money increasing partnership opportunities.

'You'll never get incentives if you haven't got the government on side,' argues Dr Michelle Drage, who proposed the incentives motion to the ARM. 'You have to do a salesman job and find a reason they would want to do it.'

By way of example, she suggests attaching the new cash to initiatives promoting federalisation - essentially, resurrecting the Red Book's group practice allowance.

'It's highly unlikely the government is going to throw money at partnerships. But it might work if we sell it as taking on more colleagues to build a bigger and better NHS.'

GPC negotiator Dr Beth McCarron-Nash makes a similar case, arguing that there 'might be mileage in beginning negotiations around under-doctored areas'. If something like the EPA were to be targeted on areas served poorly by current arrangements, the government might suddenly become interested in funding it.

A radical solution
There is a more radical solution to the partnership problem, however.

Earlier this year BMA chairman Dr Hamish Meldrum told the health select committee that the practice-based GMS contract he helped draw up had had some unintended side-effects, and could 'have the effect of reducing the number of doctors in primary care'. The contract should be rethought, he hinted.

If the entire contract is up for grabs, then GPs could see a return to the days when they were paid per partner. That would certainly meet with the approval of many of those who answered GP's survey.

But whether the negotiators - or the profession - have the stomach for another new contract remains to be seen.

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