Independent contractor status: a bargain for the NHS
This month marks 25 years since I qualified as a GP. It's hard to believe that for a quarter of a century I have worked continuously in the same practice where I became a partner the day after completing my GP vocational training. It was a completely different world then, with general practice a buoyant discipline and the most popular postgraduate medical specialty. There were no recruitment or retention problems; 80 GPs applied for the partnership position I attained. I joined with 'three years to parity' - the norm then - whereby the privilege of partnership overshadowed a graded increase in pay in the early years.
It was also customary to join a practice for life, such that I took out a mortgage for a property in the local area before commencing my partnership. I also secured a loan to buy into and fund the development of the practice premises. With high double-figure interest rates at the time, the rent reimbursement was far lower than our mortgage outgoings. As partners, we invested in our surgery at a loss, coupled with negative equity that lasted for 12 years. This is in stark contrast with the returns expected by the private financiers of GP estate today. None of this was an obstacle, though, since, like other contemporary GPs, I was driven by the long-term commitment of ownership, a sense of vocation, the empowerment of autonomy and the reward of giving continuity of care to patients and families I have now seen for over a generation.
On reflection, no commercial organisation would have touched the practice I joined. It would have made no business sense to put in the time, energy, or financial resources for what clearly was not a quick 'profitable' venture. This is why the independent contractor partnership model has been an absolute bargain for the NHS, run as it is by GPs who are directly responsible for caring for their patients and who provide uncosted long-term loyalty and dedication to local communities. Their commitment has also fuelled innovation and a spirit of professional entrepreneurialism. Compare this with England's short-term commercial APMS (alternative provider medical services) model, whereby non-clinicians often run general practices via remote control and a balance sheet, primarily driven by maximising profits within a limited timeframe.
Short-term contracts damage continuity
In light of this, it is extremely concerning that Pulse magazine recently reported that NHS England's London area team has a blanket policy of only offering APMS contracts for the procurement of all new or replacement GP contracts. This will destroy the fabric, ethos and success of general practice, creating instability and change every few years, and is at odds with the government's own 'named GP' agenda. It will also put off those doctors looking for a long-term commitment and exacerbate the recruitment crisis. Then there is the expense of short-term contracts requiring short-term profit, not least the costs of tendering and managing local contracts. We already have evidence that many APMS providers have been unable to deliver on contract values or have left at the end of their tenure. In other cases, contracts have been decommissioned due to poor value for money - and let's not forget that many APMS contracts are better funded than their GMS (general medical services) or PMS (personal medical services) equivalents.
NHS England London has justified its policy on the basis of competition law in England, arguing that all contracts need to be opened up to private providers. However, BMA legal advice is that even current procurement regulations allow for flexibility and require consideration of several factors before a decision can be made about whether to open up competition and what contract to offer. There is therefore no obligation to solely offer APMS contracts to the exclusion of GMS or PMS. In light of this, I have written a letter of rebuttal to NHS England London.
I fully support GPs receiving fair recognition and financial reward for their hard work, and I also emphatically believe that GMS long-term contracts provide proven best value for money for the taxpayer and comprehensive dependable quality for patients. NHS England's priority should be to provide stability and support for the independent contractor status model and GP partnership.
Ultimately, the root problem that must be addressed is competition legislation in England, brought in under the previous Labour administration and cemented by the Health and Social Care Act. This is why the BMA is rightly calling for a repeal of the act, so we can rid the NHS in England of the wasteful and damaging ideology of enforced competition.
The future is flexible
I fully recognise we are in different times from when I qualified as a GP, with many in the current and future workforce wanting greater flexibility, shorter tenures and diversity of contractual options. The BMA GPs committee very much supports these differing aspirations. Therefore, it is important that the independent contractor model evolves to offer opportunities for all GPs - from those wishing to work as partners, in salaried positions or as freelance locums, to those with portfolio careers incorporating management or clinical specialist roles. Fundamentally, all GPs should be able to work in the rewarding environment of clinician-led, patient-centred care that has underpinned the service most surgeries have been offering their patients for decades.
Share your views on the future
The GPC has also started examining GPs' aspirations and concerns for the future. As part of this process, we are holding a free workshop for trainees, newly qualified and sessional GPs. The event, hosted by Leeds local medical committee on 23 September, will cover:
Come and share your views at Weetwood Hall Conference Centre and Hotel, Leeds, from 6.45pm. Food will be provided and travel expenses reimbursed. To attend, email email@example.com.
Finally, if you'd like to share your thoughts on the future of general practice, or any other area of concern, join the debate in our dedicated online community The Practice.
Chair, BMA GPs committee
GPC in the media
This fortnight's biggest story was the announcement of new inspection sanctions from the CQC (Care Quality Commission). The BMA's response was widely reported on the BBC and in the Daily Telegraph, Guardian, Yorkshire Post and Daily Mail. I was also interviewed on BBC Radio 4's Today programme, BBC Radio 5Live, Sky News, the ITV lunchtime news and the BBC News Channel.
In addition to this, GPC deputy chair Richard Vautrey was interviewed on ITV's Good Morning Britain and LBC Radio, GPC member Rob Barnett appeared on BBC Radio 5Live, and there were further mentions on every BBC regional radio station, including interviews on BBC Radio London, Merseyside, Tees, West Midlands and Derbyshire.
Dr Vautrey also appeared in a documentary for ITV's Tonight programme, which looked at the pressures facing general practice. Elsewhere, the South London Press reported on another of our GP premises case studies, Dr Vautrey discussed recruitment levels among GPs with BBC Radio London, and I appeared on BBC Radio 4's Inside Health documentary 'Conflicted Medicine: Specialists and GPs'.
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