Less bureaucracy, easier hours and a fixed salary may sound tempting, but will GPs want to give up their independent contractor status? Alison Moore reports

Imagine a world where you finished your training in your mid to late 20s and went into your first job. You then stayed there, in the same place, doing substantially the same tasks, until you retired. Changing jobs was frowned upon, and moving more than once could be career suicide.

Most health service managers, used to a fluid job market and frequent moves, would find this bizarre. But since the NHS was founded this has been the dominant model for GPs.

Now this model is being questioned. Many GPs still value their independent contractor status - the vast majority are still GP principals - but others want to see alternatives.

Over the past decade there have been moves to offer GPs more options, including a number of schemes which allow them to be salaried, often with fixed working hours and no out-of-hours commitment. In consequence, the number of salaried GPs has soared.

There is also some grassroots pressure from within the Labour Party for GPs to be salaried, prompted partly by concern about the standard and accessibility of primary care in inner cities, but also by a dislike of the way in which GPs can benefit from owning their own surgeries.

The Welsh Assembly is expected to look at a countrywide salaried option aimed at tackling recruitment problems and health inequalities, particularly in the valleys. But the government is unlikely to shift suddenly from its position of encouraging salaried service as just one option for GPs.

Probably fewer than 1,000 doctors in England - outside the retainer scheme - are salaried, compared with 27,031 working as unrestricted principals.

In 1988 the GP assistant scheme was virtually the only way for GPs to be salaried and there were just 254 English GPs on the scheme.

In 1998 there were 701 GP assistants, 52 'paragraph 52' GPs (working under a new salaried scheme), 65 salaried GPs employed in Primary Care Act pilots, and others working on short term contracts designed to give newly qualified doctors a taste of life in general practice (see box, below).

In addition, some trusts and health authorities employ GPs for specific tasks - for example, two salaried GPs in Sheffield take on a citywide role in working with drug misusers. In some cases these GPs may be working alongside GP principals in their practices, but it is more likely they will be staffing a practice themselves.

About 1,000 GPs are on the retainer scheme. Although they are technically salaried, the scheme is intended primarily to keep GPs in touch with practice life and offer educational opportunities while they take a career break.

And some long-term locums - covering prolonged sickness or maternity leave for example - may be paid a salary by a practice rather than sessional fees.

This growth in salaried opportunities has been prompted by a shortage of GPs in some areas - especially in the inner cities - and growing demands from the profession for different career structures and opportunities.

'The main reason is demographic change - there are more women GPs and women have babies, ' says Dr Peter Harvey, deputy chair of the British Medical Association GP committee's non-principals sub-committee.

Combining the open-ended nature of a GP principal's post with family life is not easy, and fixed hours with no out-of-hours commitment are attractive. Of the 701 GP assistants, 439 are women, as are 36 of the 52 paragraph 52 GPs.

Another attractive element is relative freedom from bureaucracy. GPs can escape the complex system of claiming fees and allowances and the administrative side of running a practice. The responsibility for organising out-of-hours cover or holiday locums may move to the employer.

But Dr Harvey also points to a cultural change among young professionals, including doctors, who no longer see jobs as being for life and may want to experience different forms of working. Another factor is that investing in a partnership's property is no longer seen as an automatic passport to riches.

Some newly qualified GPs have been attracted by schemes which allow them to experience general practice without entering partnership immediately. In County Durham, for example, CareerStart has offered a two-year contract with protected time for personal education and development. Mersey regional health authority set up a three-year scheme in 1994, which was successful in attracting applicants, some of whom stayed in the area as principals afterwards.

Many observers believe that salaried service will become an alternative to traditional general practice, if not the dominant model. Dr Michael Dixon, chair of the NHS Primary Care Group Alliance, foresees a mixed economy of independent contractors working alongside salaried GPs, even within the same practice. 'In 10 years' time I would not be surprised if almost half of GPs are salaried, ' he says.

In the short term, the expansion is likely to be through Primary Care Act pilots, with a second wave due to start later this year. But the development of primary care groups and especially primary care trusts, which have the power to employ salaried GPs directly, is likely to be more significant in the long run - even if doctors running PCGs tend to be independent contractors who may not want to change the system.

At the moment it is uncertain whether a PCT could be established against the wishes of local GPs. This prospect is already causing concern among some GPs, with a raft of motions to the local medical committees' annual conference calling for independent contractor status to be maintained.

Dr Steve Gillam, head of the primary care programme at the King's Fund, suggests that the very structure of PCTs, with the management load falling on a few doctors, will create opportunities for salaried GPs to replace them part time. He suspects there may be geographical variations, with a salaried service being stronger in inner cities and independent contractors surviving in the leafier, wealthier areas where GPs are happy to practise.

Cathy Hamlyn, associate director at the NHS Confederation, believes that a salaried service may eventually replace traditional general practice - perhaps in a generation. She points to the different focus of PCGs and PCTs - on a population rather than a traditional list system - which could lead towards a salaried service. 'All the moves towards a managed service, looking at consistency and so on, point in that direction, ' she says.

Many doctors fear HAs and PCTs will have enormous power over salaried GPs and will be able to impose their own priorities. This could end the role of the GP as the patient's advocate.

Dr Jonathan Reggler, a keen supporter of independent contractor status for the majority of GPs, and a member of the BMA's GP committee, says: 'PCTs will be very uncomfortable with independent contractors - a salaried doctor is more manageable and malleable.'

One common criticism of the present system is that the funding structure does little to reward 'good medicine' - a salaried service may free doctors to spend more time doing the work they were trained to do, rather than worrying about whether they have claimed the appropriate fee.

But there are hurdles which could hold back the push towards a salaried service. The existing salaried schemes have been criticised as inadequate, often offering only short-term jobs and little career structure or progression.

This may change if PCTs become involved. Positions such as 'doctor in charge' may arise, offering the chance of promotion.

Funding is another area of concern. Primary Care Act pilots have a three-year lifespan. This may change if PCTs start employing GPs, but doctors may still want reassurance that they have a job for the foreseeable future before giving up independent contractor status.

Sum totals: how much is a GP worth?

Few health service managers have ever had to ask themselves how much a GP is worth. GPs' income has been controlled by a system of fees and allowances, over which health authorities have had little control. But a salaried service raises questions of terms and conditions.

There have been no centrally set pay levels for GPs working under the 1997 salaried scheme or for Primary Care Act pilots.

Consequently, pay for advertised salaried posts has varied greatly. In some cases, it has been as low as£30,000 a year -£50,000 is more typical.

Dr Steve Gillam, from the King's Fund, suggests that salaries generally have crept upwards and may now bear some relationship to a consultant's salary.

But very few of the posts advertised so far have been intended as a long-term career. GPs may need considerably more to tempt them into a permanent post - especially if they are to forfeit the chance of a substantial return on investment in their practice premises. A form of salary progression may be necessary.

Some trusts have recognised this. Newcastle City Health trust is already looking at a merit awards scheme to echo that of consultants.

It already pays GPs the equivalent of consultant rates and they are eligible for discretionary points, which can boost their incomes.

Rosemary Lawson, director of development and primary care at Community Health Sheffield trust, says a salary scale may be viable if there are large numbers of salaried GPs working within a primary care group or primary care trust, but is unlikely to work where there are just a few.

Her trust had two GPs who converted to salaried status, which obviously sets a bottom line for their salaries. But she points out that salaried GPs have a guaranteed income and generous maternity and sickness pay.

Moving to a salaried post takes away one of GPs' incentives to work harder - being able to claim more item-of-service fees.

But according to Cath Allen, director of primary care at Newcastle, this has not been an issue: 'Relieved of the burden of some of the bureaucracy, the doctors focus on patient care and service development.'

A sense of freedom: the salaried GP Five years ago doctors at the Ethel Street surgery in Newcastle's West End shocked the medical establishment by becoming employees of a local trust - probably the first salaried practice in the country.

Today the practice has converted to a Primary Care Act pilot, but its five part-time GPs are still employed on a consultant's pay scale. Their 3,200-strong shared list includes patients from particularly deprived areas and a high proportion of Croatian and Middle Eastern refugees. They also provide medical services to a local hostel for homeless people.

The key attraction for Dr Cameron Edgell, who joined the practice two-and-a-half years ago, was the opportunity to concentrate on clinical care. 'We can focus on the delivery of care and don't have the distraction of running a small business, ' he says. 'There is also better team working - it is not so hierarchical.'

He enjoys the freedom from worrying about premises and staff employment issues, which are dealt with by Newcastle City Health trust. But this does mean a slight loss of control for the GPs and an extra layer of decision making, he adds.

Like many areas in the north, Newcastle still has a negative equity problem, which can make moving between traditional practices difficult. But Ethel Street has had no problems recruiting replacement GPs.

Dr Edgell has no regrets about moving to salaried status and says he and his colleagues see it as a permanent career move. But he warns that much may depend on the employer and its commitment to quality in primary care. 'Newcastle City Health trust does seem to have a genuine commitment to the practice. I would not say issues such as loss of clinical autonomy or a lack of understanding of primary care have been problems for us - but they could be for some salaried GPs. I would want to feel very confident that the employer is committed.'

Old for new: from assistants to Primary Care Act pilots When Alan Milburn, the then health minister, launched the salaried scheme in November 1997 it was claimed to be the first time salaried family doctors had been employed in the NHS. But in reality salaried GPs have existed in the health service for far longer, in a variety of guises.

Assistants are fully trained GPs who are employed by principals to work within their practices. The number of assistants has varied but has generally increased.

Some assistant posts have been offered through health authorities, but others are practice-based and may be a route to partnership. The London Initiative Zone led to a large increase in the mid-1990s and was a popular option with young GPs just out of vocational training. A similar scheme in Scotland employs GPs as associates.

Even before the 1997 salaried scheme - which allows practices to employ GPs under paragraph 52 of the Statement of Fees and Allowances - a number of salaried GPs were employed in innovative schemes developed by HAs. At the time these schemes were pushing the boundaries of how NHS money could properly be spent, although recent regulation changes have allowed funding of many posts.

The 1997 salaried scheme was greeted with derision by many GPs, who felt it did not offer a career structure. The government's own statistics suggest that only 52 GPs were employed through the scheme last year.

The 1997 Primary Care Act opened the way for doctors to be salaried in pilot sites. They could either be employed by a practice providing personal medical services or by a trust.

According to the Department of Health, around 350 GPs are involved in Primary Care Act pilots, of whom 65 are salaried.

Trailblazers: making job-share a positive experience GP Elizabeth Walker is one of the trailblazers of general practice, working as a salaried GP in a trust-led Primary Care Act pilot.

She job-shares with another GP, Dr Michelle Nunes, at the newly established Isleworth Centre Practice in London.

Both have young families and wanted to work part-time - Dr Walker had previously worked in a partnership which broke up.

The practice offered them four sessions a week clinical work, a half-day for academic study and a guaranteed income from Hounslow and Spelthorne Community and Mental Health trust. This salary is based on GPs' intended net average remuneration (£50,760) although any money earned through non-general medical services work has to go back to the trust.

'My experience has been very positive and I would be quite happy to stay in a salaried post, ' says Dr Walker. 'I do like booking my holidays and being able to say it is not my responsibility to find a locum, it is the trust's.'

One of the major attractions for her was the opportunity to concentrate on clinical work, rather than the administrative side of running a practice.

Although, inevitably, there has been more administrative work than anticipated, she welcomes being able to draw on the resources of the trust when dealing with issues such as information technology and personnel matters. Freedom from the 'Red Book' system - which determines a large part of GPs' income - has also allowed her to concentrate on clinical priorities.