Labour has announced plans for every hospital to become an ‘integrated care organisation’ with ‘GPs at the centre’, but GP leaders have warned this could lead to the ‘destruction of practices’.
GP Magazine 14th May asks: Does the DoH want independent contractors? and in the letters on 28th May: Government won’t value independent contractors and on 26th September by Should GPs give up independent contractor status?
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…..
If the public wishes to hear the truth about the NHS they are more likely to hear it from their GP who cannot be punished by his employer since he is self employed, than from a consultant who fears for his livelihood. The whistleblowing and the gagging scandals alone should make the media cry “foul” at this suggestion. A soviet union type healthcare system will result..