General 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).