Keeping the GP workforce model afloat

Authors: Michael Ingram 

Publication date:  13 Dec 2012

The proposed new general medical services contract could have unforeseen effects on the workforce, says Michael Ingram

Just like surfers, general practitioners always feel that the next one might be the big one. In this case, however, the monster wave is not to be sought but dreaded, as the economic storm hitting the NHS seems to be throwing up a swell that could well swamp general practice and cause widespread destruction to the workforce model on which primary care relies.

It comes down to this year’s negotiations over the general medical services contract. All seemed to be drifting on as expected, with negotiators from the BMA’s General Practice Committee and NHS Employers gradually formulating a set of proposals that would be acceptable to both parties. There were warning clouds on the horizon, but that is not unusual as there is nothing that focuses purposeful negotiations as much as the occasional far-off threat of a takeover by the Department of Health and their overlords in the treasury.

This year, however, a storm broke when the Department of Health imposed contract changes on the profession. As a result, practices all over the United Kingdom will see a massive loss of revenue. Money will be lost from quality and outcome framework domains, and it will be harder to achieve the quality and outcome framework points that remain. The loss of the minimum practice income guarantee and historical funding will see practices stripped bare of the payment “lifebelt” that allows them to stay afloat.

The result of this financial storm on the GP workforce has yet to be felt, but it is safe to say that the landscape that remains will not be bucolic. To start with, there is the issue of partnerships. If financial bedlam breaks out, the whole model of independent GP contractors falls.

Partnerships are based on profit sharing, and sufficient profit is needed to justify the extra responsibilities that come with a partnership position. Holding down the jobs of manager, financial director, human resources officer, compliance inspector, and recipient of regulations is a weight worth bearing as long as the rewards are sufficient to justify these increasingly burdensome responsibilities.

When profits fall income falls and the attraction of partnerships vanish. Watching a practice decline and partners’ personal income shrink is hardly likely to encourage new GPs to join up as partners. Colleagues locally are talking about having to reduce the income they take from the practice (their drawings) by 25% just to keep the practice cash flowing. Reduced income makes banks nervous and eager to call in loans.

Severe financial constraints are likely to have more far reaching effects on employment patterns in general practice than the erosion of partnerships. Salaried posts could become the norm as doctors seek to limit their commitment and, for that matter, liability in a practice’s finances. However, this move could backfire because the reduction in funding will mean that practices cannot afford to pay their salaried colleagues the current salary levels. After all, if partners are seeing their income reduced, they are hardly likely to resource salaried posts generously.

Add to this mixture the simple laws of supply and demand. New medical schools are opening and the government is committed to the expansion of medical training. If you increase supply of an item, the price of it falls; in the case of doctors, this means not just the price of their labour but also of their negotiating power. Am I being Machiavellian in suspecting that this potential oversupply is designed to weaken doctors and to replicate the situation in much of mainland Europe? Many in the specialty have witnessed the migration of GPs to the UK from several European countries due to the poor employment prospects in their home state.

The simple fact that cannot be overlooked is that GP partnerships are small businesses, and to survive in the financially barren future they must constrain their costs, with the highest of all these costs being the wages partners pay themselves and their staff. An alternative future is where GP services will be provided not by GP run businesses but by private companies awarded alternative provider medical services contracts, many of whom will be large corporate organisations.

Either way, when there is a bountiful supply of trained GPs looking for work and little money with which to pay them, it does not take much imagination to envisage doctors working on a sessional contracted basis on an hourly rate for whichever practice or company needs to fill slots. Like peripatetic sessional musicians, will the GP of the future be working for whoever needs them whenever they are needed?

Such pessimism might be entirely misplaced and the intrinsic workforce pattern of general practice—buttressed and bulwarked by years of experience of adversity—may well plough through the rough seas the new contract will throw up. The question is, will the crew stay true to the (partner) ship?

Competing interests: None declared.

Michael Ingram GP partner The Red House Surgery, Radlett, Hertfordshire, UK

Cite this as BMJ Careers ; doi: