One of the new Primary Care Act pilot sites, Community Health Sheffield trust in partnership with a Sheffield inner city GP practice, is developing a 'salaried practice'. This raises several issues, including developing the GP salary scale, GPs' fears about their relationship with the trust, and concerns about management and accountability.
As the Primary Care Act pilots go live from 1 April, salaried GP posts will become operational across the country, with salaries and terms and conditions all negotiated locally. Should salaried GPs be part of an incentive scheme which retains the flavour of the 'small business' and 'independent contractor status' or should we move directly to the salary scale and terms and conditions of salaried hospital medical staff? These are just some of the questions being asked by community trusts setting up salaried schemes.
Our advertisement for a salaried GP post for a Sheffield inner city practice offering a salary of pounds30,000-pounds35,000 attracted four applicants, with 15 people requesting applicant information. We contacted the 11 people who did not send in an application to find out why. Two part-time GPs were appointed to the post.
As contract sums are based on historical earnings within the practice, GP salaries will have to reflect previous earnings if the project is to remain within budget. A critical point in our salary negotiation was how long newly appointed GPs took to reach parity with the two senior GPs who were already in the practice and transferring onto the scheme.
Consultant salaries gave four incremental points, and this was mirrored in the salary scale offered at the practice. However, parity in general practice is more complex. Salaried GPs were historically 'assistants' and viewed as less important than the partners. Understanding cultural differences within our negotiations was vital.
Transfer from GP principal to salaried status under the Primary Care Act entails removing GPs from the medical list. GPs need reassurance that their salaried years will count towards eligibility for long service payments in future. Not being on the medical list also has implications for GPs seeking additional work outside their salaried contract. An additional problem encountered in Sheffield was the refusal of the local GP out-of- hours co-operative to contract with the trust because it would affect its mutual trading status. The co-operative will only admit GPs who are on the medical list. Up to a fifth of younger GPs could be interested in a salaried service.1 How do we evaluate the benefits of salaried employment?
For the GPs, and particularly those embarking on a career in general practice, accepting a fixed and guaranteed income is preferable to uncertainty. There are also benefits of reduced management and administration, enabling GPs to concentrate on clinical skills. This is particularly valued by newly qualified GPs, for whom taking on clinical and managerial responsibilities together can seem onerous.
The flexibility of a salaried post is valued. A GP in a partnership is expected to stay in practice for many years; frequent moving around is not viewed favourably. But this may actually be encouraged in the salaried arena to enable GPs to gain wider experience. Opportunities to participate in research and clinical audit are a definite attraction to many GPs, and working as part of a community trust gives access to support, facilities and networks previously unavailable.
Fears about the community trust as a bureaucratic organisation, with the ability to take away GP autonomy and restrict freedom, abound. Such fears will only be allayed as relationships develop. Another way of ensuring that salaried GPs are not viewed as 'second-class' is to make sure that they maintain the same level of autonomy as 'contractor' GPs.2 Loss of professional autonomy and the ability to act as the patient's advocate are fears expressed by those opposed to the scheme.
There are also fears that the 'gate-keeping' role of GPs will be affected by community trust employment. In reality, GPs will shape services from the inside and with the control and influence to modify services to suit local needs.
How will we know if the salaried scheme is successful? Ease of recruitment and retention is a critical factor in inner city practices. Fears that a salaried GP will behave differently from his independent contractor colleagues and will be lacking the financial motives to work hard have yet to be proved. For most inner city GPs, overwhelmed by their workload and an inability to retain staff in difficult areas, any option that enables services to run more smoothly has to be welcomed.
1 Medeconomics 1996; 17(11): 21.
2 Primary Care Act: personal medical services pilots. Medical Word Winter 1997-98.