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Azeem Majeed: General practitioners should give up their independent contractor status and become NHS employees

2 May, 14 | by BMJ

Azeem_majeedGeneral practitioners (GPs) have worked as independent contractors since the NHS was first established in 1948. However, we now need to review whether this model of general practice is what the NHS needs in the 21st century, and consider an alternative model in which general practitioners become NHS employees.

In many ways, GPs are already de facto ‘employees’ of the NHS. Much of the independence that GPs once had has been taken away by the government over the last decade. GPs’ workload and funding is now largely determined by the contract that their practices have with the NHS.

GPs are currently under pressure because of rising workloads, an increased complexity of the care that they need to deliver, and a reduction in the resources allocated to primary care. Many general practitioners now find themselves struggling to cope with their day to day workload. 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.

How can we address these problems and make general practice a more rewarding career for doctors? If we are to ensure that general practice remains an attractive career option, and that primary care remains the foundation of the NHS, we need to consider the introduction of a salaried GP service in which GPs are employed by the NHS.

A major benefit of a salaried service would be better workforce planning. GPs could be placed where they were needed, and employed in sufficient numbers to meet the local needs for primary care, including providing access to patients with acute problems and managing the complex care of elderly patients. They could be employed by the same NHS organisations as specialists; thus giving greater opportunities for integrated working and bridging the gap between primary and secondary care.

GPs would also be relieved of the burdens of running a practice. For example, responsibility for dealing with substandard premises would fall on the NHS, not on GPs. A salaried service would also allow junior doctors to understand the work and salary they might expect as GPs, and reduce the uncertainties that currently exist for them when choosing their long term career.

Under a salaried service, GPs could be employed on similar terms to NHS consultants, with a salary based on experience and with additional payments for taking on duties in areas such as management, clinical leadership, teaching, and training. GPs could then have job plans, just as consultants do, with sufficient time for management, quality improvement, and teaching duties—as well as for their clinical activities. As employees, GPs would also have the same employment rights as other NHS staff, such as maternity, paternity, and sick leave and access to occupational health services.

Giving up their independent contractor status is a big step and one that many GPs will find difficult to do. It may be that this is not something that is introduced nationally, but as an option in parts of the country (such as London) where workload is high, GP premises are often inadequate, and the recruitment of GPs is difficult. A mandatory standard NHS contract for salaried GPs working in such areas would be a far better solution for primary care than the alternative: GPs who are employed by commercial companies, and on significantly worse terms than the NHS’s medical employees.

Conflict of Interest: I am a GP principal at the practice of Dr Curran & Partners in Clapham, London. This article is based on a talk I gave at the Pulse Live conference on 29 April 2014.

Azeem Majeed is a professor of primary care and head of the Department of Primary Care and Public Health at Imperial College London. He is also a GP principal at the practice of Dr Curran & Partners in Clapham, London. He can be followed on Twitter (@Azeem_Majeed).

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  • Roisin Costello

    Azeem , I am an Irish GP . I can see how GPs might get so demoralized and so overworked that the easiest option in exhaustion becomes opting for status as NHS employee .
    The problem is I cant see how this will reduce waiting lists or ultimately improve the doctor /patient lot .

    In Ireland , the equivalent body , the HSE have a deplorable record
    regarding waiting lists in hospitals, trolleys in accident and emergency and loss of outlying smaller hospitals following planned ‘ reconfiguration ‘ such that many larger hospitals are now drowning in overload of patients and unable to concentrate of more specialized aspects of care .
    We spend 3 percent of health care budget here on primary care as opposed to 11 per cent in the UK .

    The GP body here have a huge fear that handing over general practice to the HSE will destroy the one part of the health service hitherto working ( so far , and lately under cracking pressure ) .
    It does not reassure me to hear that becoming an NHS employee is seen as a solution for UK Gps . I know for a fact it would be the end of proper general practice in Ireland
    Ultimately ? : Bureaucratization.

  • Prof. Azeem Majeed

    There are arguments for & against the current independent contractor model of general practice in the UK. Based on the reaction of the 400 or so GPs who were present at the conference at which this proposal was debated, the great majority of GPs remain in favour of staying as independent contractors – at least for now.
    http://www.pulsetoday.co.uk/news/finance-and-practice-life-news/gps-overwhelmingly-against-move-to-a-salaried-profession/20006562.article#.U2hsbfldVuI

  • Prof. Azeem Majeed

    Thanks for your comments Roisin. I have been a GP Principal for many years and can see that the independent contractor model of general practice we have in the UK has many strengths.

    See http://medical-centre.blogspot.co.uk/2013/10/arguments-in-favour-of-independent.html

    However, this model is going to become increasingly unviable because of pressures on primary care funding (the BMA reports that NHS spending on primary care has fallen from 19% to 8% in recent years), increased expenses (e.g. higher renal charges, costs of CQC registration), greater complexity of clinical care, pressure to improve access and opening times, and new areas of work such as commissioning.

    Unless the UK government commits to supporting primary care, the current model of general practice will become increasingly unviable. A salaried option is not ideal but if does happen, both GPs,& patients would be better off with GPs as salaried employees of the NHS rather than as employees of commercial companies.

  • sanjay das

    This works so well for secondary doesn’t!? NHS has the highest sick rates and the lowest employee satisfaction. are hospitals coping with the workload or are they struggling, have inadequate premises or bankrupt in rip off PFI premises.

    This concept was the long ambition of the health civil service for decades, as it would remove power from Gps and reduce pay. They wanted a cap of 70k a year. However it never happened due to huge cost of employment benefits and the cost of managing and maintaining estates.

    Primary care is the cheapest most efficient part the NHS, maybe being independent contractors is part of the reason for this?
    I think the best solution is Gps running and owning the private companies in a co op, or federation. In the end of the day all patient care is going to come from Gps, it.’s Better managers and the such work for the GPs not the other way round.

  • Prof. Azeem Majeed

    I agree that the independent contractor model of UK general practice is very efficient – see http://medical-centre.blogspot.co.uk/2013/10/arguments-in-favour-of-independent.html

    However, NHS England refuses to fund this model at the level needed to meet the requirements of modern general practice. This is leading to rising workload and reduced funding for primary care in England.

    Other models – such as GP federations – may be suitable alternatives but they also need to be resourced adequately if the NHS is to meet the needs for primary care services.

  • Denis Pereira Gray

    ADVANTAGES OF THE INDEPENDENT
    CONTRACTOR STATUS

    Many, like Professor Majeed [1], have questioned GPs’ independent contractor status (ICS). Majeed is right about the severe workload pressures in general practice. Salaried service would not alter and might exacerbate them. The pressures follow serious under-resourcing i.e. a 76% increase in recruitment of hospital consultants since 2000 against only 21% for GPs[2] plus the decimation of district nurse training.

    The ICS should be retained, as it is the best contract for patients providing more choice and chance to change doctor. Salaried bureaucracies rarely allow patients/clients to choose or change professionals, e.g. hospital consultants or social workers.[3] Salaried status encourages staff to look up to bosses, not outward towards patients.

    Most community professionals are independent contractors including accountants, architects, dentists, and surveyors and the self-employed are fast growing in society. The flexibility of the ICS fosters responsibility and innovation, badly needed in the NHS. GP computing developed, GP- led, far faster than in big hospitals with
    their many salaried staff. Independent contractors outside the NHS identified high death rates in the Mid-Staffordshire Hospital Trust.[4]

    Salaried staff in law are, as stated by the Court of Appeal, “servants” in a “master-servant relationship.”[5] Hospital consultants, as salaried employees usually have gagging clauses in their contracts. Independent contractors cannot be easily gagged.

    Those enthusing about being salaried, being “placed,” and given “job plans” by managers, should read “When managers rule.”[6] Patients and doctors need more flexibility, clinical involvement, and clinical innovation and the independent contractor status fosters these.

    Yours
    faithfully

    Denis Pereira Gray

    Eleanor White

    Alex Harding

    Philip Evans

    St Leonard’s
    Practice, Exeter EX1 1SB

    Declaration DPG, AH, and PHE are independent contractors

    References

    1. Majeed A. General practitioners should give up their independent contractor status BMJ; 2014:348:39

    2 O’Dowd A
    Ratio of GPs to hospital consultants needs to shift says new NHS chief BMJ; 2014;
    348;g3037

    3. Pereira Gray D General practitioners and the independent contractor status J Roy Coll
    Gen Pract; 1977; 27:746-746

    4. Francis R. Report of the Inquiry into the Mid
    Staffordshire Foundation Trust: Public
    Inquiry, 2013; London, DoH

    5. Court of Appeal. The Times Law Report; 1977, 5 November

    6. Jarman B. When managers rule. Editorial BMJ:2012;345:doi10.11.36/bmj.e8239 19 December
    Accessed 17May 2014.

  • Prof. Azeem Majeed

    Like Sir Denis and his colleagues, I am aware that the current independent model of general practice has many strengths. http://medical-centre.blogspot.co.uk/2013/10/arguments-in-favour-of-independent.html

    However, the current model has led to a situation in which the proportion of the NHS budget spent on primary care is declining and general practice in many parts of the UK is sinking under the dual pressures of rising workload and falling NHS funding.

    Whatever model of primary care is adopted, we need to ensure it is adequately funded and staffed by suitably trained & committed professionals.

  • Rod Storring

    Continuing where I was,the GP as was wouldn’t have tolerated the loss of control over his/her patients as seems to be the case now.With this has gone the responsibility for each patient as well as the earlier efficiency,and not surprisingly now the request for another £3billion to keep the GP head above water!

  • Rod Storring

    The monetary beneficiaries of the new contract were the GP partners and very understandably this has inevitably led to a reduction in GP partners numbers.Who wants to share this money by appointing a new partner when there are enough GP trained doctors around who will do the work?
    The independence of General Practice in the UK was dependant on the GP/partner system as was and this needs to be restored.
    The youngsters,the part-timers and all the GP trained doctors should by statute(Jeremy Hunt please note) be allowed to become GP partners.
    The profession and its union the BMA has sold out its patients and its professional well being and should stop blaming the government for the current state of affairs.
    “I never see the same GP twice”is the common UK patient experience.This indicates to me the de facto disappearance of the family doctor.
    The GP/partner as was wouldn’t have tolerated the loss of control of/responsibility for his/her patients as now seems the case
    A salaried Primary care service is not the answer.Ask your secondary care colleagues.

  • Tina Ambury

    There is a fundamental flaw in your logic Azeem and it’s in the statement “GPs could be placed where they are needed,…”
    I have been a Salaried GP most of my career, something that I _chose_ to do. I work in a deprived area and have chosen to do so.
    Therein is your problem. Choice.
    When an employer chose to place me somewhere I did not want to be I resigned and looked for the type of practice I wanted to be part of.
    A good employer recognises this and works with the employees to the benefit of all concerned. . Unfortunately, the future you envision does not seem to.

  • Rod Storring

    I am unable to edit what I had said below but I would like to add that rather than compounding the mess already made by the profession of a primary health service that was the envy around the world by formalising the salaried route it is taking,it needs to take more notice of the patients as individuals and it ought to try to re-establish the professional job satisfaction that used to be so much commoner for GPs than now seems to be the case.
    The inefficiency that results from “I never see the same GP twice”,the patient being told,”you are only allowed one symptom”whilst the GP is busy on the computer earning QOF money asking questions irrelevant to the patient’s current problem together with all the other inefficiencies,which incidentally everyone is aware of and which have been allowed,again by the profession,into the system,has resulted in the GP work-overload which undoubtedly exists.
    Pouring another £3 billion into this mix as the government is being asked to do by the GPs will only make things worse,and the only beneficiaries will be

  • Rod Storring

    ….and the main beneficiaries will be the GP worthies who have the ear of the government and those who are also busy building up their empires on the back of all that extra money which the politicians will no doubt find given the proximity of the next election.

  • Prof. Azeem Majeed

    Thanks Sanjay. In my most recent blog, I discuss the merits of GP Federations. See http://blogs.bmj.com/bmj/2014/06/09/azeem-majeed-are-federations-the-way-forward-for-general-practices-in-england/

  • Prof. Azeem Majeed

    Thanks for your comment Tina. To clarify my statement ‘GPs could be placed where they are needed’, the distribution of GPs across England could be more closely linked to the need for primary care services. Clearly, no GP can be forced to work in a particular region but the current regional variation in the number GPs could be improved.

  • Prof. Azeem Majeed

    You raise some important points Rod. However, I do agree with the RCGP and BMA that primary care needs a larger proportion of the NHS budget. We would need mechanisms to ensure that this funding went into improving primary care services.

  • Rod Storring

    I am afraid that the RCGP and BMA represent many vested
    interests,the latter mostly to do with the remuneration of its union members.
    I am more interested in the professional job satisfaction of the GP given that this necessarily is closely linked to the interest of the patient.
    In that context I would be interested in your enumerating the important points that you feel that I have raised

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