What can GP Partnerships learn from other professional practices?
Although we are very supportive of the GP partnership model, we believe that it needs to evolve to meet changing demands. The ongoing GP Partnership Review has issued a call for evidence and we are delighted to respond in this blog with further thoughts on some of the ‘Key Lines of Enquiry’. We would encourage our readers to also respond to this important review.
We explained in our previous blog why we believe partnerships have proven to be good business models for the professions, and also our belief that LLPs should be permitted for GPs – as they already are for solicitors and accountants.
Some of the challenges faced by GPs are industry specific, whilst others are not. Those common to all the professions include a very significant increase in female participation rates; a perception that Millennials have different values compared to previous generations; an increased demand for work-life balance; a changing competitive and regulatory environment; and a feeling that technology is on the verge of disrupting the profession. Challenges which are more GP-specific include the need to move towards more integrated models of care; the risks involved in financing increasingly expensive and specialised buildings which cannot easily be re-purposed; and a chronic shortage of GPs.
What are some of the key differences?
GP Partnerships are surprisingly homogenous in their structure. They generally comprise partners who jointly run the practice on profit shares reflecting sessions worked; employed GPs on BMA model contracts or similar; and locums on call to fill sessional gaps. This has been the model for as long as anyone can remember, albeit that the balance between the categories has altered significantly over the last decade.
Other professions have sought to develop multiple career paths, and more varied remuneration models. Senior partners will be responsible for management of the business, but other partners and senior staff will have little direct management responsibility and instead be focused on matters like ensuring technical expertise or service delivery. More junior staff will have the opportunity to develop their skills through close working with a variety of partners, and through a structured career progression path. This path may change over time as someone focused on technical expertise may, for example, later decide to move into business or delivery management. In essence, they are seeking to turn generalist professionals into specialists.
Reward typically comes in the form of both recognition and pay. Recognition is typically in the job title, and there have historically been many levels both below and within the partner grade. Pressure from the Millenials is leading to flatter structures, but there is generally still a clear structure. As the structures have flattened, variation in total pay at each grade has increased significantly. This has been helped by an increased focus on performance related pay – at level of the individual, the department, and the business.
In this way other professions seek to encourage and reward developing particular deep skills, and to recognise that business management is a separate career path which requires appropriate training and experience to achieve. By offering multiple roles and career paths, it becomes easier for individuals to see paths for personal development as well as options for changing their role as their life situation and their personal definition of work-life balance changes.
How could this be translated into Primary Care?
Whilst many of the models common in other professions are easier to achieve in larger practices, the GP partnership model will not survive unless being a partner is considered aspirational, and the rewards reflect both the importance of the role and the real risks and commitment required to do it well. At the moment all too many GPs have no desire to become a partner and who can blame them when the job can be little different from being a salaried GP or locum but with lots more risk and responsibility?
Part of the answer is to find ways to reduce real and perceived risk. Permitting LLP structures could help, as could carefully constructed working-at scale models. However, the biggest risk is usually the surgery building, and it is hard to see how this risk can be reduced without the State acting in some way as guarantor of last resort. Whilst this might upset some ideological purists who would argue that this ‘benefit’ is not afforded to other professions, it is in reality more a recognition that the buildings are increasingly specialised and the State will therefore be funding NHS services from the building whoever happens to be occupying it from time to time.
The other part of the answer is making the role more attractive by disrupting the current uniformity. Larger practices (or potentially innovative GP Federations) could develop more varied and interesting career paths as routes to develop through the organisation, and smaller practices could be encouraged to innovate by, for example, sharing clinical resources, developing specialisms, involving non-GPs in the running of the practice, and encouraging greater staff involvement in the business (sometimes described as the John Lewis model). Practices could also experiment more with performance related pay, particularly for salaried staff. Over time a variety of models for a career in General Practice would develop, and practices with the more successful approaches would find it easier to attract and retain staff.