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MedEconomics: What next for GPs in salaried posts?

The rise of APMS and changes to practice make-up could spell bad news for salaried GPs, finds Jane Feinmann.

Salaried GPs were not top of the agenda at last month's LMCs conference but perhaps they should have been. For a growing number of GPs, the future of salaried employment is an important issue.

Will they be in a seller's market, able to negotiate a quality framework-related package with plenty of perks and long holidays? Or are salaried GPs more likely to become cheap labour, hired and fired by an alternative provider of medical services (APMS) contractor?

With self-employed GPs making headlines based on distorted data alleging record profits, there is concern that salaried doctors are about to become an underclass.

Free market

The growing interest of APMS providers in tendering for practices in the primary care market is fuelling fears that the BMA's ability to effectively represent and protect employee GPs is in danger of breaking down.

'There is a lot of money to be made from APMS and the profits will be all the greater if they can put the cheapest bums on seats,' says Dr Richard Fieldhouse, chief executive of the National Association of Sessional GPs (NASGP) whose membership includes salaried doctors.

'It is a free market and there is nothing to stop hard-nosed bosses offering poor rates of pay and conditions.'

The NHS Alliance's GMS lead Dr David Jenner is particularly concerned about rumours that low-priced APMS tenders are based on bringing in EU doctors who might be overly impressed with salaries in the UK. Dr Jenner fears this might be especially true of doctors from Eastern Europe.

'Apart from anything else, there is a risk that an increasingly salaried profession could give the government more control of primary care. Doctors could become slaves to the NHS machine rather than patient advocates,' he says.

Avon LMC chief executive Steve Mercer says the number of salaried GPs has increased dramatically in seven years, providing scope for tension between salaried GPs and their employers - even in a conventional GP partnership.

Supply and demand

'For some time now, salaried GPs have been in demand and able to negotiate good contracts.

'But there is the question of whether they should be entitled to a share of quality framework payments, as many practices nurses are, for instance,' says Mr Mercer.

Working for APMS contractors also raises questions about terms and conditions of employment, including whether the employer can offer salaried GPs the NHS Pension Scheme.

Employees can contribute to the scheme if their employer is a GMS or PMS practice or if the employer is an APMS provider and is eligible to provide GMS or PMS services.

Representation of salaried GPs is also an issue. Birmingham LMC medical secretary Dr Charles Zuckerman says some APMS employers will be outside the LMC's sphere of influence, creating an uneven playing field.

'We will of course be encouraging salaried doctors to join the LMC independently. Apart from anything else, we can provide unparalleled pastoral advice,' he said. 'But there is nothing to make them join - and they could find themselves isolated.'

Salaried GPs are clearly concerned about their security and representation.

Few of more than 20 salaried GPs contacted by GP were willing to speak publicly and some claimed that they faced the sack if their names appeared in print.

There are also rumours of growing dissatisfaction with pay and conditions among salaried doctors working for APMS providers and at GMS and PMS practices.

While there are salaried GPs who have been rewarded for for their contribution to achieving quality framework points, others have not.

On the record, there seems little basis for concern. When Care UK contracted to take over a 7,000 patient GP practice in Barking and Dagenham PCT's area from the start of this month, health minister Lord Warner greeted the deal as: 'Good news for NHS patients who cannot rely on existing GP practices to provide them with a good standard of service.'

According to Care UK's spokesman Chris Rudolph the company has wide experience in operating community-based services, including patient-focused primary care services.

Negotiating standards

'At all times, we are obliged to maintain the highest standards of employment, offering at least as good a package as the NHS. We will begin by employing one GP and building up the list slowly,' Mr Rudolph adds.

Meanwhile, the NASGP's website states that the 'vast majority' of the correspondence the association receives from its members is from dissatisfied salaried GPs.

GPC deputy chairman Laurence Buckman is confident, however, that existing structures for representing GPs will be able to cope with these new challenges.

'The GPC has substantial safeguards to ensure that all types of GP are fully represented at local and national level,' he says. 'Whether they write the cheque or have the cheque written for them, all GPs in the UK have more in common than not - most importantly, in providing a good standard of health care for patients.'

The NAPC's advice to members is that any GP taking up a salaried post should use the BMA's 'model terms', which is available at www.bma.org.uk.

If the prospective employer refuses to agree to this contract 'our advice is quite simple: look elsewhere for a job.'

GMS and primary care organisation employers - but not APMS - are obliged to offer these terms and conditions. This means that for GPs seeking salaried jobs with APMS employers the onus is on the applicants to negotiate terms and pay.

The BMA advises that GPs considering working for an APMS provider should be offered the terms set out in the salaried model contract as a minimum.

They should also be aware that not all APMS providers can offer the NHS Pension Scheme benefits and private pension arrangements might be less favourable.

'Us sessional (salaried) GPs are not necessarily renowned for our individual negotiating skills', says the NASGP site.

YOUR PRACTICE 2010

Your views on salaried GPs

- Are salaried GPs the future of UK primary care? Or do you a predict a swing back towards partnerships?

- Will APMS practices find themselves stuggling to recruit as the retirement bulge hits?

- Whether you are salaried or a partner join the debate by writing to GPletters@haynet.com

CASE STUDY - A SALARY IS NOT ALL BAD NEWS

Becoming a salaried GP can be a positive move, according to Exeter GP Dr Mark Selman. Living in Totnes with his GP wife and three young children, he joined the 19-doctor St Thomas' Medical Group (13 principals and six salaried GPs) in January 2005.

Dr Selman had worked at St Thomas' as a locum for the previous seven years and joined via the now defunct Flexible Career Scheme. Under his five-sessions-a-week contract, Dr Selman runs a diabetes clinic and takes internal referrals for rheumatology, as well as holding normal surgeries.

His work at the practice is just one element of a portfolio career, combining locum work, teaching clinical skills to medical students in Plymouth and a clinical assistantship in rheumatology at Torbay Hospital - plus a three-day weekend starting every Friday.

'I work hard and might well become a partner in a GP practice eventually, but at the moment, things couldn't be better, ' Dr Selman says.

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