What is the future of GP employment?

What is the future for general practice and, what are the possible employment models for general practitioners? Professor David Colin-Thomé explores

CREDIT: This is an edited version of an article that originally appeared on NHS Networks

The way in which GPs should be employed has been made topical by the Labour Party committing to GPs becoming salaried employees of the NHS. And they are odds on to win the next election.

In all his years in and around general practice, Professor David Colin-Thomé never met a GP who didn’t think they worked in the NHS notwithstanding their independent contractor status. 

He spent 36 years as an independent contractor GP and that status enabled transparently accountable innovation without the dead hand of an external controlling management system. 

Colin-Thomé has often referred to that prevailing and stultifying NHS management culture, yet many and anecdotally especially younger GPs, increasingly prefer a salaried option. And yes, there are adaptive enabling managers interspersed in the NHS.

All payment systems have their potential downsides, but he will only focus on the relevant two:

• Salaried: This can lead to rigidity in how one discharges work responsibilities, more a focus on self rather than the organisation at large and potentially subject to rigid hierarchy
• Self-employment: This can lead to limited accountability, much increased management responsibility and what Labour describes, ‘’how GPs operate financially is a murky, opaque business”. 

So, there we have it, and already polarised positions are being taken up when calm objectivity is required. And of course, the vast majority within the NHS are deeply committed to their work irrespective of the mode of employment.

Colin-Thomé’s hope is that GPs will be offered options about their mode of employment. 

Wes Streeting, Labour’s shadow health secretary said: “I’m minded to phasing out the whole system of GP partners altogether and look at salaried GPs working in modern practices alongside a range of other professionals.” 

Yet he maybe implied an element of phasing in the policy when on BBC TV. Labour people historically advocated salaried GPs but was never official policy. It is intriguing that the salaried option has resurfaced when Labour’s general policy direction is away from the past state control model.

Given the parlous state of our country, the heritage of general practice which many would strongly wish to preserve, is even more important for patients and professionals alike. 

As Prof Kamila Hawthorne, the chair of the Royal College of GPs said: “The partnership model of general practice delivers exceptional benefits for the NHS. It allows GP teams to innovate and tailor care and services to their local patient populations. It is extremely good value for money for the NHS because it relies on the goodwill of GP partners going above and beyond.”

To retain list based general practice is fundamental to Colin-Thomé’s own vision which was delivered in the general practice of which he was a partner. This is to primarily continue to develop and extend primary care provision and by extension reshape aspects of hospital-based provision, and importantly, take a population responsibility for the health of its public. 

Only the autonomy of the independent contractor ensured the implementation of that vision. We only received patchy support from the local NHS.

A lot to lose if cast aside. Yet thanks to a supportive senior manager, that nascent Primary Care Home model he originated, subsequently developed with the National Association of Primary Care (NAPC), received wholesome support from the excellent previous NHS chief executive Simon Stevens. In fact, the precursor to primary care networks.

Labour offering choices within the salaried option is the most propitious way forward. It is right that politicians set policy, but we the health service must take on the ensuing policy development. 

There is a divergence of where general practice is going. There are those who share Colin-Thomé’s more holistic vision of population based general practice, and those who wish a more bio clinical focus to first contact primary care. 

An acceptable divergence which in fact exists already whether GPs are salaried or not. It all depends on the ambition of the vision. If the proposed salaried policy allows such flexibility, there is no issue. 

And the salaried option would totally remove from GPs responsibility for the funding and management of the GP estate, together with governmental direct accountability for GP access. In total a large and welcome funding boost for general practice.

Whatever policy prevails some fundamentals principles must endure. Retain list-based localness as part of a refreshed neighbourhood care (general practice potentially a local anchor organisation), enable clinicians more accountable autonomy (beginning with employment flexibility as part of a developing two-way accountability), and obviate the creeping increasing largeness and distance from its community that the NHS seems to love. 

Without these caveats general practice could become an impersonal outpatient model in a faceless large health centre.

It is time for general practice and its supporters to make their calm voices heard to ensure a flexible future. The flexibilities offered by the 2004 contract had been largely unrealised until general practices in the last few years faced an existential threat. 

There are now a burgeoning number of developments of salaried GPs retaining the merits of population-based practice. Let’s hear more about the attendant management culture.