30
aug
2

Too Much Liability

Posted by Blogs, The General Practice Blog2 Comments

One of the main arguments for giving up the independent contractor model is that the level of liability it requires partners to take on has become intolerably high.  Partners would be able to sleep much more easily in their beds at night if they were relieved of this burden in a nationalised model.  But is it really such a black and white choice?

Partners of GP practices take on unlimited liability.  This means that the costs of any successful claims against the practice that are not covered by any insurance that is in place will need to be met by the partners.  This includes via the personal funds and assets of the partners, i.e. including their homes and savings.

In recent years the level of exposure for individual partners has gone up.  There are less partners and so the total value of the businesses is divided between fewer individuals, making personal exposure higher.  Property costs have risen, which means as well as the buy-in costs being much higher now than 20 years ago so too are the associated liabilities.  And lurking away in the background is the risk that any individual partner may become the ‘last man standing’ and be left on their own holding all of the practice liabilities.

Then there is the emergence of PCNs.  Partners remain ultimately liable for the extended work that the PCN takes on (unless the PCN has incorporated), as well as for the actions of the much extended workforce with the introduction of the additional roles.

It is no surprise, then, that this level of liability facing individual GP partners is putting many new GPs off from the prospect of becoming a partner.  This is at just the time when the service desperately needs GPs to take on partnership roles.  So surely moving away from the independent contractor model and bringing GPs into the full indemnity protection of the NHS is the obvious solution?

But freedom to operate independently is a function of taking on liability.  If someone else is ultimately liable then it is their prerogative to determine the actions we must take.  Hence the lack of freedom that many hospital clinicians complain about when working in that environment.  The cost of not having the liability is giving up independence.

So is the independence worth it?  The questions for partners to consider is whether they are being properly compensated for the liabilities they are exposing themselves to, and whether they are prepared to give up the freedom that a reduction in their liability would mean?

But it does not have to be quite so black and white.  Outside of general practice things have evolved considerably.  Now when entrepreneurs in this country set up new companies, they do so under the protection of a limited company, which means their liability is always limited to the level of their capital contribution to the firm.   The personal assets of the entrepreneurs are protected.  Now while there are costs and complications of using a limited company model, traditional partnerships in other sectors such as accountants and solicitors have been replaced by limited liability partnerships, where the liability is similarly limited as for limited companies but with less technical complications.

At present limited liability partnerships are not permitted business vehicles for those holding a GMS or PMS contract.  This seems an archaic and unnecessary restriction, and one that it is encouraging to see the incoming Chair of the GPC already being vocal against.  Making technical changes that enable the liabilities that partners face to be in line with those faced by those working in other sectors feels is not just a step in the right direction, but one that is long overdue.

 

The level of liability that partners of GP practices are currently faced with is too great.  It is a problem that needs to be addressed, both to support existing partners and to make the profession more attractive to potential new entrants.  The most obvious solution is to enable GP practices to become limited liability partnerships.  A far less obvious solution, and one that would be both more expensive and disruptive to implement, would be to nationalise the service, and it makes no sense for the liability issue to be the main driver for such a move.

23
aug
0

Does the Independent Contractor Model Mean More or Less Resources for General Practice?

Posted by Blogs, The General Practice BlogNo Comments

One question that is largely ignored in the debate as to whether the independent contractor model has run its course for general practice is what the impact of its existence is on the totality of GP resources.  Does the model increase or decrease how much funding goes into the service?

This is a different question from that of whether sufficient resources are being invested into core general practice.  Overall underfunding aside, the question for today is whether the total amount invested would be more likely to go up or down if we were to move away from the independent contractor model.

At present there is national contract for general practice that is agreed with the BMA and the funding at a national level is then ringfenced.  Local areas can introduce local enhanced service contracts that are in addition to the national funding that has been agreed.  For the last two years there has been no negotiated agreement between the BMA and NHS England, but instead the agreement reached in 2019 has stood, and so there remains a ringfenced fund for the service.

Without the independent contractor model this national ringfencing of resources for general practice would be lost.  The funding instead would be transferred to local ICS areas, who would then in turn decide how much of that funding to pass on to general practice.  Or, the funding would go to the host organisation of local general practice, and they in turn would decide how much to pass on to the local practices.

Of course, in both these scenarios the amount passed on to general practice could be greater than the nationally identified total.  The ICS and local plans for a shift of resources from the acutes into primary and community care could result in an even greater investment in general practice, and should such a change occur I am sure promises of this ilk would be made.

However, it has long been a complaint of the system that when system savings have to be made (remember there is now a system financial control total that has to be delivered, rather than ones for individual organisations) that general practice has been exempt from taking “its share of the pain”, because of the way its national funding is protected.  Once this is removed it seems highly likely that cuts to general practice funding would form part of local financial recovery plans, given the system financial pressures that exist.

We have seen this scenario play out with community services many times over the years.  Originally acute and community services were in unified organisations, but were separated in many places when NHS trusts came into being because the resources intended for community services were being sucked in by the hospital services.  Even now as they start to come back together we are yet to see any big new investments into community services, and doubtless that wheel will have to turn again.

While the totality of the investment into general practice through the national contract is clearly lacking, the argument that this investment will be increased with a shift to a model of funding via the local NHS does not hold water.  The ringfencing would be lost, and the system pressure to use the funding elsewhere would be hard to resist.

If the independent contractor model was abandoned individual practices would no longer have the pressure to sustain themselves as organisations.  However, that pressure would still exist up the line at the level of a bigger and more distant organisation, and the most likely result would be a stripping of resources from local practices to meet a corporate cost pressure elsewhere.

16
aug
0

The Grass isn’t Greener

Posted by Blogs, The General Practice BlogNo Comments

One of the questions I am most regularly asked is why I am so supportive of the independent contractor model of general practice.  Wouldn’t life be easier and simpler for GP partners if they were free to operate as clinicians, without the almost full time distraction of trying to run a small business?

For many the grass does look particularly green on the other side of the fence, where GPs as part of NHS organisations could work reasonable hours, take annual and sick leave like any other employee, and be free from all the stresses of income, cash, staff, property, and unreasonable partners.  Life looks like it would be so much simpler.

Why, then, do we prize the independent contractor model so highly?  Well, as with any situation where we are looking to move away from problems instead of towards something we want, life on the other side will always contain its own set of (albeit different) problems.

Peter Muchie summed it up really well when he described his own experience of making this transition,

“And then I surrendered my independent contractor status to become a salaried employee with an NHS out-of-hours service. To me this now equates to a surrender of power and the right to self-determination. I can no longer organise my work to best meet competing demands. I can no longer negotiate with equal partners, but must accept the impositions of a cost-cutting management which seems to work toward the lowest common denominator. I can no longer decide what to accept and reject…

I no longer have total freedom to develop my skills according to personal interest or to best meet the demands I perceive. I must instead undertake ordained ‘mandatory’ training on such delights as information governance, and diversity in the workplace. This is boring, irrelevant, and time-consuming, the main purpose appearing to be to protect the monolith for which I work, not to improve the care I give.

When I identify a real opportunity for workplace improvement I have no real power to address it. I pass it up a non-responsive bureaucratic chain to a distant and removed manager, focused on budgets and generalities. My concern is either ignored or cursorily acknowledged and placed at the bottom of a list of priorities with cost cutting, and not service improvement, at the top.” Peter Muchie, BJGP Should General Practice Give Up the Independent Contractor Status 2015.

It is easy to think that we would just turn up for work, see the patients we were asked to and then leave at the appointed hour.  But what we miss is how soul destroying this lack of autonomy will feel, how frustrating the constant interference of a middle manager with a corporate agenda and no insight into the needs of our population will be, and how being at the receiving end of decisions made at an organisational level many layers away will make us want to scream.

The independent contractor model offers freedom for practices to choose how they operate, to flexibly adapt to meet the needs of the patients they serve, and to respond quickly to any new situation that arises and requires action.  This has been a key strength of general practice, one that is not well understood, but one that would be lost if the model was replaced.  It not only enables practices to adapt and thrive in even the most testing circumstances, but also provides partners that Maslowian need for self-determination that a salaried model would take away forever.

9
aug
0

The Danger of Integrated Primary Care

Posted by Blogs, The General Practice BlogNo Comments

General practice is currently being swept along on a tide of change, all based on the premise that what we need is ‘integrated primary care’.  But what is integrated primary care, and is it really what we need?

Despite the status of the Fuller Report not being clear when it was first published over a year ago, it is now being treated as the policy document for general practice.  If you ask anyone working in the system what the plan is for general practice they will say it is to implement the recommendations of the Fuller Report.  But when you read the Fuller Report it is a wordy document that is light on analysis and heavy on pushing ideas, with little clarity on how these new ideas will make things any better.

At the heart of all this lies the idea of integration.  We have moved away from the internal market and now have integrated care systems.  The four stated aims of this new system are to improve outcomes in population health and healthcare; tackle inequalities in outcomes, experience and access; enhance productivity and value for money; and help the NHS support broader social and economic development.  Having reiterated these aims Fuller states,

“The ICS CEOs believe that achieving these aims will only be possible if we support and develop a thriving integrated primary care system” p4.

And that is the only rationale that is given.  Primary care needs to be integrated because ICS CEOs believe that is what is needed, and this apparently should be enough because no other justification is given throughout the whole document.  All the NHS CEOs even put their signatures to the report, an act Fuller describes as, “an extraordinary and welcome display of common purpose across health and care” p3.

But could it be that the enthusiasm of the NHS CEOs for this report comes not from a passionate belief in unlocking the power of local communities, but rather because it would increase the span of their direct control to include primary care?  NHS CEOs do not like primary care because the independent contractor status prevents them being able to tell it what to do, so it is not surprising they are all in favour of any move to give them more control over it.  This hardly feels like a sound justification for making such major changes.

A key problem is that nowhere is ‘integrated primary care’ defined.  Without definitions we are in trouble because what I think it means, what you think it means, what Claire Fuller thinks it means, what the 42 NHS CEOs who signed the document think it means, and what the government think it means are all likely to be very different.

Does it mean primary care working effectively in partnership with local health, social care and voluntary sector colleagues in local neighbourhoods?  Does it mean general practice becoming a formal part of the NHS?  Does it mean GP practices becoming part of existing NHS organisations?  We know that this whole range of views already exists.

I am actually a fan of integration, where it means all health and social care providers working more closely together.  It makes sense.  But the notion of “integrated primary care” is actually very dangerous, because it is so nebulous.  It is behind the calls for the nationalisation of general practice, and the end of the independent contractor model.  It is an enabler for centralist CEOs who want to expand their empires.  It is also creating a system blindness to the challenges being faced at an individual practice level.

So what do we do?  In local conversations push for clarity as to what is trying to be achieved and how will we know that we have got there, before getting into the details of actions.  “Implementing Fuller” should not be an end in itself.  If we are implementing an integrated neighbourhood team then what success measures are we using?  What outcomes will it achieve?  Simply ticking the box that we have one does not constitute success.

Challenge the idea of integrated primary care when it is used without clarity of meaning, and push for a local definition that everyone can sign up to.  General practice can support integration, but it mustn’t come at the cost of the service itself.

2
aug
0

A Cause for Concern: the Government response to the HSCC Future of General Practice Report

Posted by Blogs, The General Practice BlogNo Comments

One of the few slithers of hope that we have had in general practice in recent months came from the most unlikely source.  Jeremy Hunt, in his stint as the Chair of the Health and Social Care Committee, commissioned an Inquiry into the future of general practice, and the report the committee published was surprisingly sensible.

The report contained a call for the government to acknowledge the crisis general practice faces, to recognise and prioritise the importance of continuity of care, and to strengthen rather than undermine the partnership model.  You can read the full report here.

The report was published in October last year, and the usual requirement is for the government to respond to such reports within 2 months.  However, in an indication of what was to come, the response took 9 months to arrive, and if I was to use one word to summarise the response it would be “disappointing”.

Maybe it was unrealistic to have any expectation that the report would carry any real influence, but it did seem to have been championed by Jeremy Hunt, who then went on to become Chancellor of the Exchequer, so there were some legitimate grounds for hope.

Unfortunately, you don’t need to get far into the report to realise that it is going to result in no actual change of direction.  Recommendation 1 was that the government acknowledge there is a crisis in general practice.  The response?  The Department “partially accepts” this recommendation, only in so far as some people are facing challenges in accessing an appointment, and the Delivery Plan for Recovering Access to Primary Care has been published to address this.  And that’s it.  If the problem won’t be acknowledged, you can be pretty sure there will be no support to follow.

Essentially the response says that if you take the Fuller Report, the Plan for Recovering Access, the Hewitt Review and the Long Term Workforce Plan, everything that needs to be done for general practice is already being done, and no further action is required.

It explicitly rejects the call to prioritise continuity of care (the main call of the initial report), and responds with, “we note that continuity of care needs to be pursued alongside a parallel focus on access” p13.  The government’s prioritisation of access over continuity isn’t going anywhere soon.

In response to recommendation 26 that the government should reaffirm its commitment to the GP partnership model, it says “The Government confirms there is currently no policy to abolish the partnership model” p21, but then goes on to say, “we wish to support a range of models of primary care provision, including the partnership model”.

In the introduction to the report (p2) it goes a bit further and states, “Realising this broader vision may require significant changes to the way general practice operates and is contracted today. Over the course of the year, we aim to engage with the professions, patients, ICSs, and key stakeholders, on a broad range of themes including contracts, operating models, funding of GP IT and estates, to help inform how to shape general practice for the future.”

There is no doubt, it seems, that further change for general practice is on its way.  The document continually refers back to the Fuller Report as the blueprint for this change.  The Fuller report called for “national partners/DHSC and NHS England” to undertake changes to “the existing legislative, contractual, commissioning, and funding framework, which were out of scope for this stocktake”, and it looks like this process is about to begin.

What this response really highlights is that we are about to have a problem.  Its authors don’t believe a sustainability problem exists in general practice.   They do not value personal lists, continuity of care, or manageable list sizes.   Instead the issues they want to address are those of integration and access. This dissonance as to the issues that need to be tackled between the profession and policy makers is where the root of the conflict to come will lie.

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