Should GPs in England be employed by the NHS?

The intense micromanagement of general practices by NHS England since the start of the Covid-19 pandemic in early 2020 has shattered the illusion that NHS general practitioners are truly “independent”. For example, during the pandemic, NHS general practices have often received weekly updates from NHS England on how they should provide primary care services.[1] The opening hours and working arrangements of general practices are also highly regulated by NHS England. And general practitioners are not independent contractors in the same way that professionals working in other fields or indeed primary care physicians working overseas would recognise. General practitioners are not even able to offer private medical services to their patients in the same way as NHS Trusts or dentists are able to do. In effect, they have all the disadvantages of being self-employed contractors and none of the benefits of being NHS employees.

For more than a decade, primary care in England has suffered from under-investment, and a lack of key staff such as general practitioners and practice nurses. The NHS hospital sector in contrast – although it also has its problems – has seen its funding and medical staffing increase at a much quicker rate than in NHS primary care.[2] And yet despite this, more NHS work continues to be shifted to primary care without being followed by a commensurate increase in funding and staffing. Attempts by NHS England to prevent this – such as the introduction of the NHS Hospital Contract – have failed.[3] It’s very clear that NHS England is not going to invest adequately in the current independent contractor model of general practice, making being a GP Partner increasingly unattractive for younger general practitioners.[4] It’s time therefore to look seriously at the alternative – GPs becoming salaried employees of the NHS.

Of course, being employed by the NHS is not a panacea. Many NHS staff employed by NHS Trusts suffer from stress and over-work, just like those working in primary care. But they are not personally responsible for the ownership of their employing organisations, and their income does not depend on how well their organisation performs financially. Their working hours are also better regulated than those of self-employed GPs.

If GPs had employment contracts similar to those of NHS consultants, they could then have job plans with time allocated for activities such as quality improvement, NHS management, teaching, training, and research. Currently, these activities are often done on top of their regular working hours. Working in organisations that employed large numbers of GPs would also create opportunities for a better career structure. For example, it may be possible to create posts for GPs who specialise in areas such as the care of the elderly or in child health; and for GPs who take on clinical leadership, quality improvement and NHS management roles in addition to a clinical role.[5]

Finally, GPs becoming NHS employees would make NHS England directly responsible for the delivery of primary care services, in the same way they already are for specialist services. It would be the responsibility of NHS England – not GPs – to ensure that patients had timely access to a comprehensive range of high-quality primary care services and the infrastructure needed to deliver this care.

An increasing proportion of NHS GPs are already salaried. The future for GPs therefore looks to be heading in this direction. The question for GPs is do they want to be employed by the NHS with similar terms of employment to consultants; or do they want to be employed by private companies and “mega-partnerships” with the inevitable variability in terms of employment that they will offer?

A version of this article was first published in the British Medical Journal.

DOI: https://doi.org/10.1136/bmj.o406

References

1. Majeed A, Maile EJ, Bindman AB. The primary care response to COVID-19 in England’s National Health Service. Journal of the Royal Society of Medicine. 2020;113(6):208-210.

2. Anderson M, O’Neill C, Clark JM, Street A, Woods M, Johnston-Webber C, et al. Securing a sustainable and fit-for-purpose UK health and care workforce. The Lancet. 2021 May 22;397(10288):1992-2011.

3. Price A, Majeed A. Improving how secondary care and general practice in England work together: requirements in the NHS Standard Contract. Journal of the Royal Society of Medicine. 2018;111(2):42-46.

4. Rimmer A. GPs move towards industrial action after rejecting “rescue plan” for general practice BMJ 2021; 375:n2594

5. Majeed A, Buckman L. Should all GPs become NHS employees? BMJ 2016; 355:i5064

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