Management Adviser, Trainer and Facilitator
Patricia is an HR specialist in general practice. She was the managing partner of a large practice for more than 10 years, and now provides HR and management advice and training. She is also a trained facilitator and a coach. Together with a GP colleague, Patricia has recently set up a specialist recruitment service to help practices select a GP partner or salaried GP
You may have noticed a big change in general practice over the last few years. "What, just one?" I hear you say. Well, of course, not just one, but possibly the biggest change to fall out of the renegotiated General Medical Services (GMS) contract was that the practice now has discretion about how to provide its medical resources.
Consequently, many practices recruiting a new doctor have the choice of appointing a partner or a salaried GP. According to a survey, less than 30% of advertisements are for GP partners, so it would appear that most practices are opting for the salaried option.1 It is important for the practice to appreciate the advantages and disadvantages of either a partner or a salaried
doctor because there are fundamental differences.
A new partner will help with the clinical workload and the management of the practice. He or she is likely to offer long-term commitment and see it as an opportunity to participate in running the business. An incoming partner will have fresh enthusiasm and new ideas to offer, and will be unlikely to be a clock-watcher or be inflexible. For an incoming GP, a partnership can offer security, stability and an exciting challenge, as well as an opportunity to settle into a career.
However, a partner can be "for life". Even a well-written partnership agreement may not offer much protection if the practice wants to expel a partner for some reason. Of course, partnership deeds often contain a period of mutual assessment but problems may not come to light straight away and the practice can be stuck with a difficult team player or someone with poor clinical or communication skills.
The alternative – and more popular – option is to appoint a salaried doctor. Depending on the profitability of the practice, a salaried doctor's income tends to be significantly less than a partner's profits, making it an attractive option to save costs. In addition, if the partnership is already large, a reduction in team numbers may facilitate better decision-making and help team working.
A salaried GP is also likely to be happy "seeing the patients", allowing the partners to concentrate on managing and developing the practice or perhaps providing other services.
However, practices should be aware of their employment obligations, as salaried GPs have the protection of legislation. In addition, the British Medical Association's (BMA) GPs' Committee (GPC) has issued guidance and a model contract for salaried doctors (see Resource), which every GMS practice is obliged to adhere to. Practices that do not adhere to it run the risk of having their contract withdrawn by their primary care organisation (PCO).
Personal Medical Services (PMS) and Alternative Provider Medical Services (APMS) practices may have more discretion to negotiate a different salaried doctor contract, although this depends on whether the PCO permits this. They are in any case expected to offer an employment contract no less favourable than that recommended by the GPC.
There is a salary range recommended for salaried doctors, with the expectation that the salary is uplifted by a nationally agreed increase each year, with arguably further uplifts to allow progression along the "scale" as experience increases.
As the salary scale is quite expansive (currently around £52,500–£79,000pa), most practices offer an appropriate salary on this scale in line with local market rates. Interestingly, according to a survey, 70% of salaried GPs in PMS practices and 59% of those in GMS practices felt taken advantage of over pay. Many also felt overworked and demoralised.(1)
The model employment contract includes a number of clauses that are often seen as biased towards the employed doctor, including ring-fenced working hours, six weeks' holiday, two extra public holidays, one session a week for continued professional development, sick pay in line with the NHS terms (taking into account previous NHS/GP service), "contractual maternity pay" under NHS terms from day one of employment in the practice, "contractual redundancy pay" based on continuous NHS service and on NHS terms, and Local Medical Committee levy paid by the practice.
The reimbursement of medical defence organisation fees may or may not be included in the contract. A salaried doctor who is a BMA member can ask for their proposed contract of employment to be checked to see how it relates to the model salaried GP contract, and detailed advice and representation can be provided.
Despite these obligations, employing a doctor may not be perceived as having the same risk as appointing a partner. Some practices favour the salaried option with a view to a partnership if things turn out well.
Other practices prefer offering a fixed-term contract – of, say, one year – so that they can terminate the contract if things do not work out. Fixed-term contracts should be used with caution, as employees are protected by all the same rights other workers have. They should also not roll over for longer than four years otherwise they convert to permanent contracts.
Although a fixed-term contract appears a reasonable option, it is also not without risk. The outgoing doctor may be able to claim that a redundancy has occurred at the end of the contract. If this is the case, the doctor could be entitled to redundancy compensation based on total continuous NHS service in accordance with the old Whitley provisions. For example, a salaried GP aged 41 or over with many years' NHS service could have an entitlement of up to 66 weeks' full pay as a redundancy settlement!
Given the marked differences between a GP partner and salaried doctor, there is growing disquiet about the possible growth of a GP underclass. From the practice's point of view, having made the decision to appoint a salaried doctor it is vital that appropriate and fair management arrangements are put in place, otherwise the new doctor is liable to feel isolated and exploited.
The first consideration is ensuring the right person is appointed through a robust and fair recruitment and selection procedure. There is often a temptation to offer the post to someone already known, such as a registrar or a locum, but this may not be the best person for the job.
An average of 40 applications are currently being received for salaried doctor adverts, in some areas much more, making it difficult for practices to differentiate between potential candidates. Interviews should contain assessments of the candidates' clinical and communication skills, as well as asking the right questions. The wrong appointment could have disastrous consequences, such as ending up with someone who is inflexible, a slow consulter or who generates complaints.
The next consideration is to agree transparent working arrangements with a good, mapped-out job plan, a fair salary and other terms. An incoming GP may accept less advantageous arrangements to start with, but this will just lead to resentments later and put a strain on the working relationship.
It is a good idea to include a probationary period in the contract of employment, which will provide a formal opportunity to review how the doctor is performing and fitting into the practice, and give the opportunity to iron out any initial difficulties. However, it is important to understand that a probationary period is meaningless in the eyes of employment law, and employees still have employment and contractual rights, such as following any contractual disciplinary procedure if the practice considers that performance is poor.
Mentoring arrangements are also important, even for an experienced GP, in order to provide a two-way channel of communication. Expectations should be clearly understood and agreed, such as the numbers of patients to be seen each session, extras, visits, adherence to clinical and prescribing protocols, Quality and Outcomes Framework (QOF) targets, record-keeping, referrals, telephone triage, paperwork, etc.
A salaried doctor may have his or her own difficulties at work, such as difficult patients, coping with the workload, attitudes of colleagues, or problems at home. There should be regular opportunities and protected time to discuss and resolve these.
Inhouse performance reviews also need to be undertaken, even though partners do not necessarily feel comfortable with this concept. The BMA provides guidance on this and acknowledges that some areas overlap with the GP appraisal scheme. It is vitally important that the practice is satisfied that the doctor is competent and up-to-date.
The model provided by the BMA (see Resource) provides a format to be completed by the employee and the practice. The employee's section covers: strengths; development needs; goals; working environment and suggestions for role development.
The practice's section covers: achievement of previously set goals; timekeeping; availability; organisational skills; adaptability; teamworking; relationships with patients; use of inhouse services; clinical practice; prescribing; referring; recognising own limits and seeking advice. Training and development needs should also be discussed and agreed, just as you would do for any other member of staff.
Salaried doctors should meet regularly with the rest of the clinical team for educational meetings to discuss clinical developments, the management of specific patients, significant events, complaints, etc. Time should be built into their working arrangements so it is possible to attend these meetings without feeling under undue pressure. Salaried GPs should also be invited to staff meetings and social events to ensure that they really feel part of the practice team.
Involvement and motivation
One of the likely tensions in a practice between a partnership of GPs and the salaried doctor is likely to be the appropriateness of involvement in the running of the practice. Some partners seem to assume that salaried doctors will pull their weight with management issues, such as QOF management, IT development or dealing with staff. They can also assume that the salaried doctor should undertake exactly the same workload as the partners.
This expectation can lead to frustrations from a salaried GP, who may be committed to being a good doctor but may see the salaried position as an opportunity to gain experience and move on to another post or partnership elsewhere. They will also be aware there is often a substantial difference between their take-home pay and that of the partners.
In the current climate, partners may moan about reducing profits, but really this is not an employee's concern, unless of course they feel their own job might be under threat of redundancy or reduced hours. Changing contracts, such as reducing hours, is not something a practice can do without consultation and mutual agreement unless the practice wants to risk breaching the employment contract.
Everyone needs to feel motivated at work, and salaried doctors are no exception. GP partners are often not the best at praising their employees, and many seem to assume that staff know by telepathy how valued they are! Make sure that the partners take every opportunity to express gratitude to all their employees, including their salaried doctor colleagues.
1. Pulse report. The partner-salaried divide.
22 January 2008. Available from: http://www.pulsetoday.co.uk/story.asp?storycode=4116878
BMA – salaried GP contracts