Tag Archives: independent contractor status

Sick leave in general practice

Ahmed Rashid

Ahmed Rashid

Ahmed Rashid is an academic clinical fellow in general practice at the University of Cambridge. He also writes the regular monthly column “Yonder” in the BJGP: a diverse selection of primary care relevant research stories from beyond the mainstream biomedical literature.
Ahmed Rashid

On my journey to being a grown-up GP, I completed placements in four different practices as a junior doctor (FY2, ST1, ST3 and ST4). As you might imagine, each placement introduced me to a host of intriguing colleagues – both clinical and non-clinical – who each taught me something different and between them, showed me what good (and bad) healthcare teams look like. Above all, over the course of these placements, I became convinced that the ‘independent contractor’ model of general practice needs to change. One important reason for this was the way in which practices struggled to cope with GP sickness.

Perhaps by coincidence (and perhaps not, given the huge pressure on NHS general practice at present) but on each of these four placements I encountered situations where doctors were away on long term sick leave. The causes of the sickness varied from cancer to coronary heart disease to mental health problems but in each situation, doctors were left to cover for their colleagues. This meant considerable increases in workload and often, due to the partnership model, it also had repercussions on doctors’ personal incomes due to the need to pay for locum doctors.

Team members were openly insensitive about their missing colleague

As I look back at the four practices, the ways in which the doctors reacted to sickness in their colleagues were in many ways a barometer for how effective and cohesive the teams were. Amidst a lot of genuine care, there were often glimpses of dark humour, curt looks among colleagues in meetings and forced smiles. In the surgery I least enjoyed working at, team members were openly insensitive about their missing colleague and in the surgery I liked best, they were deeply concerned and committed to offering support in any way possible.

I don’t believe, though, that those who were less sympathetic were necessarily bad doctors or even team members. Rather, their organisations were simply not set up to be able to absorb the pressures that come from unavoidable sick leave and were systematically unable to be as compassionate as they would want to be.

Of course, the factors causing doctors’ ill health and the general financial strains on practices are broader issues that have political origins and federations and practices working at scale may help to alleviate some problems. Nevertheless, though, it is ultimately the independent contractor status that is responsible for doctors’ incomes to be linked to their colleagues in this way. If GPs were to become salaried to the NHS like hospital doctors, their income and workload would not be affected by their colleagues’ sickness in the same way and they could focus on being the supportive and caring professionals that they invariably are.

The Locum: Assassin of Independent Contractor Status

DSC02665Adam Staten is a GP trainee in Surrey and is on Twitter @adamstaten.

In the June issue of the BJGP there was a debate as to whether GPs should maintain their status as independent contractors. To me this seemed like a macrocosm of the decision that all newly qualified GPs have to make when it comes to finding a job.

Since the new contract for general practice it seems to have become the norm for a new GP to take a salaried job which provides stable employment and predictable pay without the burden of extra responsibilities born by partners. Generally this is considered a stepping stone to partnership.

But the status quo is being upset by the increasing popularity of locuming. Dr Larry Locum seems to be the man who has his cake but eats yours. Advocates of this way of working describe it as a Nirvana of convenient working hours, minimal responsibility and good pay. The appeal is obvious and, as the pay for salaried roles gets squeezed, the appeal is growing. Although this life has potential to be unstable many of my cohort feel that this is more than offset by the flexibility and the remuneration.

Whilst many still see a period of doing locums as a prelude to seeking permanent employment there is a growing number of GPs who feel no compulsion to take either a salaried role or a partnership after years of enjoying locum life. Interestingly, medical chambers are also filling up with GPs who have been partners but now wish to locum.

Could this way of working pose an existential threat to the partnership model?

Without wishing to sound mercenary, a big part of the problem is pay and, in particular, the complexity and opaqueness of partner pay. Ask a salaried doctor how much they get paid and they can tell you their pay per session. Ask a locum and they can tell you the going rate. But ask a partner and their eyes glaze over and they start talking in tongues, using phrases like ‘notional rent’, ‘local enhanced services’ and, of course, the ‘QOF’. Meeting the shifting targets of the QOF alone seems as fiendish as a battle of wits with Professor Moriarty. This complexity, combined with the fact that partners often seem to work harder and bear more responsibility than their colleagues, makes partnership seem daunting and uncertain.

Clearly there are less tangible rewards in partnership. People talk of the ability to guide your practice in the direction you wish it to go, or the emotional satisfaction of nurturing your own business but, to the uninitiated, these rewards can seem fairly trifling compared to the possibility of losing your house if things go really wrong.

Compared to becoming a locum, where the pay can be closer to that of a partner, becoming a salaried GP is increasingly seen as an under rewarded role and yet it is still the predominant job type on offer in the jobs market. Whilst many practices seek to employ salaried doctors the logical choice from the perspective of a GP registrar is between seeking one of the few available partnerships or doing locums, or at least having time free in the week in which to do locums on top of a part-time salaried role.

This tension between the demands of new GPs and the supply from practices is in danger of making the locum role the norm with the attendant possibility of sleep walking the partnership model of general practice out of existence. Without partnerships the debate over the independent contractor status of GPs will be moot, it will simply cease to exist.