GENERAL practice in Scotland should scrap the independent contractor model which enables family doctors to set their own incomes and be paid salaries like hospital consultants instead, MSPs have been told.
Retired public health consultant and Scottish Government adviser, Dr Helene Irvine, said the current system has deterred governments from investing the sums needed into general practice because of the risk that GPs can use the funds to boost practice profits and increase their own take-home pay.
Dr Irvine said the effect can be clearly seen from a decline in the proportion of NHS spending allocated specifically to general practice, which has dwindled from 9 per cent in 2005/6 to a record low of 6.8% by 2017/18.
In a submission to the Scottish Parliament’s Health and Sport Committee, which will take evidence on the future of primary care on Tuesday, Dr Irvine stressed that most of the GPs she has encountered during research are “extremely hard-working, ethical and committed to their patients”.
However, she said the independent contractor model – which means GP partners run their practices like small, private businesses – has protected them from scrutiny over how taxpayers’ money is used.
She wrote: “I believe the public would be very interested in this component of the NHS if they actually knew more about how the independent contractor model works, including the fact that GP partners themselves decide how much they work, how much to spend on service provision and how much to they spend on their own income, and what are the associated problems of these freedoms.
“An obvious problem is the extremely wide variation in both performance and personal income of GPs, with no measurable relationship between what the GPs earn and the work they do, and the outcomes for patients.
“Another less obvious problem with the independent contractor model is that it is very difficult for any government, via the health boards or [Health and Social Care Partnerships], to invest in general practice…without risking leakage of that additional investment into personal incomes that do not correlate with workload, patient satisfaction or outcomes.”
She concluded: “After years of work and analyses of hundreds of datasets, my view is that we need to move to a salaried model of GP provision. Even if it is imposed on GPs.”
The Herald previously reported on unpublished research carried out by Dr Irvine into NHS Greater Glasgow and Clyde, which revealed evidence of profiteering among some GP partners who receive extra public funding to run ‘Deep End’ practices in the region’s most deprived areas.
Dr Irvine, who retired from NHS GGC in August, was also a member of the expert panel, TAGRA (Technical Advisory Body on Resource Allocation), which advised the Scottish Government during negotiations for the new Scottish GP contract, introduced in 2018.
However, she has been highly critical of the funding formula eventually used because it saw GP partners in urban affluent practices with high elderly populations share in the vast majority of the Scottish Government’s £23 million funding boost, while those in rural Scotland – where GP shortages are worst – received little or no extra cash.
She argues that this was done because the new contract needed a majority of GPs to vote for it, which was more likely if those in the Central Belt knew they would get an uplift which they were then free to invest in their practice or take as salary.
She believes a salaried model would help to alleviate the funding gap between rural and urban general practice.
Dr Irvine’s proposals will be extremely controversial for the profession, however, and other experts disagree.
Professor Phil Wilson, a GP and director of the Centre for Rural Health at Aberdeen University, said he had once advocated a salaried model for GPs but now believed it would be counterproductive.
He believes forcing GPs to publish their salaries would be more effective at eradicating profiteering, but he stressed that “very few” GPs – less than 2% – earned more than £200,000.
Prof Wilson added: “Realistically, there are far fewer overpaid GPs than there are overpaid consultants.
“Independent contractors are also more likely to deliver continuity of care because the GPs are invested in the practice, and the autonomy they have means they can be faster and more innovative about changing how they run things and what services they offer to patients.”
He added that existing GP practices where partners pulled out and health boards were forced to take over their running, with GPs employed on a salaried basis, have been shown to cost around twice as much to taxpayers as independent practices.
Prof Wilson added that the real reason investment had flowed to hospitals instead of general practice was because they are “sexier”.
“There’s emergency surgery and all this glamorous stuff that tends to appeal more to the politicians,” he said.
BMA Scotland and the Royal College of GPs Scotland are both calling on the Scottish Government to increase the share of funding for general practice to 11%, while retaining the independent contractor model.
Dr Andrew Buist, chair of BMA Scotland’s GP committee, said: “The GP workload is higher than ever, and with ongoing underfunding, providing patients with the best care is only getting more difficult.”
He added that there is “considerable evidence that salaried practices are more costly to the taxpayer to run” and that the independent contractor model “provides better continuity for patient care as doctors stay in one place longer”.
Dr Carey Lunan, chair of RCGP Scotland, said it “allows for the flourishing of a personalised service, flexibly tailored to the needs of local communities in a way that allows for the benefits of continuity of care”.
A spokesman for the Scottish Government said it was committed to investing 11% of the NHS budget into primary care as a whole – not specifically to general practice – but that it would invest an extra £250 million in direct support of general practice by 2021.
He did not comment on Dr Irvine’s recommendations to scrap the independent contractor model, adding that salaried GPs – those who opt to be directly employed instead of buying into a GP practice partnership – already work in a “wide range of circumstances in our health service”.
He added: “We developed the most recent GP contract in partnership with the BMA, which puts the role of GPs as expert medical generalists at its heart.
“The contract also ensures that all partner GPs in Scotland have a minimum income guarantee for the first time, providing far greater income security.
“The contract also underpins the enhanced the use of multi-disciplinary teams in practices to ensure GPs are able to spend more time with patients, and less time on bureaucracy.”