Burnout: 4 legal issues to consider if one of your GP Partners “Burns Out”
Partner burnout is a growing problem for GPs – up to 50 percent are at high risk due to stress, high demands and funding cuts.
If one of your partners is suffering from stress, careful consideration should be given to these four key issues:
- Disability discrimination;
- Professional conduct, including patient safety;
- Partnership obligations as defined in the partnership agreement; and
- Fulfilling one’s obligations under the core medical services contract.
1. Disability discrimination
If stress results in a partner being unable to carry out their work properly on a long term basis, an Employment Tribunal may decide that the partner is suffering from a disability within the meaning of the Equality Act 2010.
The Equality Act says that dismissing someone or subjecting them to some other detriment because they have a disability, or otherwise failing to make reasonable adjustments to allow that person to remain engaged, gives rise to unlimited liability for disability discrimination.
GPs are usually aware that the Equality Act protects partners as well as employees. They can then bring or threaten disability discrimination claims where they feel that their colleagues have forced their retirement because of stress related illness or are trying to engineer their removal for this reason.
As set out below, appropriate support should be provided to any partner who is suffering from stress. This will prevent their condition becoming a disability and/or limit liability for discrimination, should it become necessary to terminate their engagement.
2. Patient safety
If at any time GPs have concerns that a colleague’s condition affects patient safety, they are obliged to act in accordance with their obligations to safeguard patient and the GMC guidance on Good Medical Practice. This states that you must ask for advice from a colleague (e.g another partner or GP at the LMC), your defence body or the GMC. If you are still concerned you must report the matter in line with GMC guidance.
All practices should have a properly drafted whistleblowing policy to ensure that guidance and laws relating to the disclosure of what is likely to be confidential information is adhered to, with legal advice also being sought in this regard.
It is essential that any report should be carefully documented in case your actions are later alleged to be discriminatory or you are accused of acting in bad faith towards your partner.
Providing there are no concerns about patient care, in the first instance the troubled partner should see their own GP or otherwise seek specialist professional guidance. It would be appropriate for the senior partner colleague who has responsibility for HR issues to address such matters informally (but confidentially) with the individual, keeping themselves appraised as to progress made.
3. Partnership obligations
In situations where the stressed partner does not seek treatment, or their condition continues or worsens, you should consider their rights and obligations as defined in the partnership agreement.
At the outset, when faced with a partner suffering from stress, you should be wary of relying on any provisions in the partnership agreement allowing for compulsory retirement due to absence or a failure to carry out duties. You should first establish whether the partner in question has a disability and what steps might be taken to limit liability in this regard.
An appropriate independent expert (not the partner’s GP) should examine the partner, and provide a report that sets out:
- A diagnosis;
- The condition’s effect on the partner’s ability to carry out their duties;
- A prognosis;
- The steps that might reasonably be taken to assist the partner.
An independent health report may recommend that a partner take periods of rest and then return to work in a phased manner. A failure to allow for this, even if a threshold set out in the partnership deed providing for compulsory retirement after a given period of absence is crossed, or a provision requiring that all duties are carried out is breached, could give rise to a claim under the Equality Act for failing to make reasonable adjustments to allow for the partner to remain engaged
If a medical report provides evidence that supports a retirement on ill-health grounds, the partners may discuss the possibility of voluntary retirement. In situations where this is not agreed and legal advice has been sought to confirm that compulsory retirement would not constitute unlawful discrimination, then the partners would wish to rely on a provision allowing for compulsory retirement after prolonged absence. It is common to allow for compulsory retirement after a period of absence of between 9 and 12 months. Practices with partnership agreements that do not include such clauses will be unable to retire a partner in this situation.
In any event, compulsory retirement may well give rise to a partnership dispute, notwithstanding the provisions of the partnership agreement. A well-drafted partnership deed will include provisions allowing for dispute resolution. Arbitration is often preferred over the courts as it provides confidentiality and can be quite flexible, but if part of the dispute alleges discrimination this will be heard in a public employment tribunal. Disputes where there is no partnership deed allowing for private dispute resolution, however, must be heard in the courts.
4. Medical services contract obligations
An important consideration when a partner is unwell is the implication for the GMS/PMS/APMS contract. If you seek to terminate the relationship by dissolving the partnership, you risk terminating your contract too, so it is critical to follow procedures for retirement (link to retirement checklist post) set out in a valid partnership agreement. In the current environment, dissolution would almost certainly lead to your contract being re-tendered, possibly even the possible closure of the practice. You could also be sued for breach of contract.
If a partner’s condition has given rise to fitness to practise concerns, this could lead to a suspension or erasure from the register. The full consequences of this lie outside the scope of this article but this would prevent a GP from being party to a core medical services contract.
It is critical that this is considered in the partnership agreement. Practices are advised to check that the partnership agreement takes account of the consequences of burnout, as the problem is growing.
As with any legal agreement, it is always advisable to seek the advice of an experienced legal team, who can help with your specific case and personal circumstances.
For more info about this, or any other legal issue relating to your practice, please contact Daphne Robertson on 01483 511555 or d.robertson@drsolicitors.com.
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GP surgery lease – managing your repair and reinstatement obligations
When you’re negotiating a lease for your GP practice it is important to ensure that you are aware of all the potential costs you may incur throughout your tenure – especially when you could be faced with bills running into many thousands of pounds.
One key area where costs can quickly mount up, and where disputes between tenants and landlords are common, is repairs, maintenance and reinstatement of the premises. This is particularly true if you are signing a full repairing and insuring lease (FRI), which places full responsibility for all such costs on your shoulders, as tenant.
Here we take a closer look at how you can best manage your obligations and minimise any potential for dispute.
- What is a Full Repairing and Insuring lease?
As the name suggests, under this type of lease the full cost of all repairs and insurance will be borne by you as tenant. This is true whatever the repairs may be, whether external, internal or structural. It is also established law that as part of your FRI obligations you must repair the property even if it is in a poor condition at the start of the lease.
If you are the sole occupant of a building on an FRI lease (a ‘lease of whole’), you will normally have full responsibility for the maintenance of the whole property. If you occupy a surgery which forms part of a larger property (a ‘lease of part’) you will be responsible for repairing the interior of the surgery, and will share with the other occupants the cost of repairs to the structure, exterior and common parts of the property through a service charge.
In addition to keeping the property in ‘good repair’ throughout the term, you may have to return the interior and/or the exterior of the building to their original state at the end of the term.
If you are in breach of any of your obligations during the lease, then your landlord may be able to claim damages, including the costs of repairs, loss of rent and any other damages. At worst, your landlord may seek to terminate the lease.
What are repair and reinstatement obligations?
Your responsibilities should be clearly set out in your lease. Typically, they will include:
- A responsibility to keep the premises in good condition throughout the term of the lease, not just at the end of the term (such as maintaining the roof, the heating system, the windows and doors etc)
- An obligation to clean and redecorate at regular intervals through the term and/or at the end of the term
- An obligation to remove and reinstate any alterations you have made
What do you need to be aware of?
The main problem you face with an FRI lease is that irrespective of the cause of the damage, as tenant you will be responsible for funding any repairs to the property – even if the damage was due to negligence on the part of the landlord. One rare exception may be if the landlord has already insured against a certain risk, details of which you should be able to find in the buildings insurance documentation.
A common cause of dispute is interpreting the extent of this repairing obligation. Leases can use phrases such as ‘the Tenant shall keep the Property in good repair and condition’, or ‘in a tenantable condition’. Even the word ‘repair’ can mean different things. This type of terminology is subject to endless legal wrangles between landlords and tenants.
Some lease agreements even include an obligation to rebuild. This carries a far greater potential risk to you as tenant, so is something to avoid, especially when signing a relatively short term lease.
Taking steps to protect yourself
If you are going to enter into an FRI lease then there are steps you can take to better protect yourself:
- Prepare a Schedule of Condition
Enlist the services of a specialist surveyor, who can examine and record the present state of the surgery. Your legal team should be able to help point you in the right direction with an introduction.
The surveyor will put together a ‘Schedule of Condition’ (SoC) for you, which may be written or even better, photographic. This will give you a detailed record of the state of the premises at the beginning of the contract. It may also highlight any important structural concerns or existing damage to the property that you may need to repair. You should then seek to limit the lease obligation to maintaining and reinstating the building to the same state and condition that it is in when you move in.
The SoC should be attached to and form part of the lease before it is entered into. If your landlord doesn’t want to agree to one at first, then persevere, as they will usually accept one eventually. But even if your landlord won’t agree, you should arrange to have one drawn up for your own records, as it could still be a useful piece of evidence when negotiating ‘dilapidations’ at the end of the lease.
- Ensure you understand the extent of the obligations in the lease
The extent of your obligations can turn on a single word or phrase in the lease. Since this is such a controversial (and expensive) area, the meaning of these terms has been clarified over the years through case law. The ‘real’ meaning is often not obvious to laypersons, so you would be well advised to have them explained by a specialist solicitor.
- Understand and negotiate the Service Charges
Ensure you understand what you will be paying for through the Service Charges, and negotiate accordingly. For example, why should you contribute to maintaining the lifts if you are only using rooms on the ground floor?
- Consider holding a sinking fund
As partners approach retirement, they have an incentive to leave the repairing and maintaining obligations for later generations to pay. This can cause some very nasty surprises for incoming partners. Best practice is to allocate an appropriate share of the rent reimbursement to a repairs and maintenance sinking fund.
Also, bear in mind that the less you spend on maintenance and service charges during the course of a lease, the more you may end up paying to reinstate at the end of the lease. This can create problems, especially for joining and retiring partners who will want to understand what the obligations are likely to be – particularly if there aren’t many years left to run.
Conclusion
Due to the huge responsibility and cost that an FRI lease places on tenants, it should always be entered into with caution and only after taking legal advice. Remember that a tenant has obligations for the full term of the lease and not simply whilst a partner in their practice.
And one final word of advice: no matter how good a relationship you may feel you have with your landlord, never rely on good faith or memory. Landlords move on and the landlord in situ when your lease eventually comes to an end may well view things differently to your current landlord.
For more advice on lease negotiation, please contact Daphne Robertson at DR Solicitors:
Tel: 01483 511555,
E-mail: d.robertson@drsolicitors.com
You may like to download our free eBook ‘Top ten tips when agreeing a surgery lease‘.
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Where will future practice income come from?
So how are you faring since the Health and Social Care Act 2012 came into force on 1 April 2013? After a stormy start (which included delays in contract payments for many practices and complications around the new rent reimbursement processes created by a change in landlord for those practices in NHS Property Services owned buildings) the dust has well and truly settled – leaving many GPs grappling to get onto the ‘GP Federation’ ladder in order to supplement their somewhat diminished income stream.
No longer able to rely solely on funding from NHS England, GPs are now, more than ever, having to become entrepreneurs in business – negotiating terms and bidding for new services contracts from the CCGs and Local Authorities.
The tendering process can be long-winded and time-consuming (unless you are unusual enough to be the only potential provider of a particular service). You may well have concluded by now that your best (and maybe only) chance of success in the new world of competitive bids and tenders, is for you to join forces with your neighbouring Practices. You can share the responsibility, liability and workload (both during the bidding process and after the contract has been won) and when done well you can better protect yourself, your colleagues and your patients from the vagaries of the health commissioners.
Many GPs have concluded that federating is the way forward and it goes without saying that you shouldn’t rely on the goodwill of your GP acquaintances and a handshake to seal the terms of your joint working. There are a number of options available to you when setting up a joint venture company and I will be exploring these in more detail in future blogs.
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<p>For more information about GP practice funding and any other related issues, please contact Daphne Robertson on 01483 511555 or email d.robertson@drsolicitors.com</p>
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Is a Mandatory Retirement Age for GP Partners Enforceable?
Many older partnership deeds include a compulsory retirement age for partners, often specified as aged 65. Should a GP wish to continue working beyond this age, annual written approval from the other partners is commonly required.
On the face of it, such a clause is discriminatory, in breach of the Equality Act, and therefore unenforceable. But if you are looking to include the clause in your current partnership deed, or if it is already in your deed and you are considering taking action to enforce it, what are the chances of success?
Case study: A law firm’s business needs vs discrimination
A long-running case regarding mandatory retirement ages for partners has set a precedent for future allegations of age discrimination. The retiree in question was the senior partner at a law firm in Kent, who was asked to retire at age 65 in compliance with the partnership deed. The courts found that in most circumstances, it would be discriminatory to attempt to enforce such a clause. This is consistent with the normal position for employees.
The tribunal did however distinguish the situation for partners, and concluded that in certain circumstances it would be acceptable to enforce a compulsory retirement age where the overall benefits to the business merited doing so: “Any determination has to weigh up the needs of the partnership against the harm caused by the discriminatory treatment”.
The key features of the ‘business benefits’ considered by the tribunal were enabling career progression for junior lawyers and, to a lesser extent, avoiding awkward conversations with ageing partners about their deteriorating performance.
This is in some ways a surprising outcome, since in most progressive law firms aspiring partners are expected to achieve partnership by winning new work rather than simply taking over someone else’s hard-won clients, and because a well-drafted partnership deed should already have addressed issues of underperformance.
Partner retirement from GP practices
Nobody has yet tested the case for mandatory retirement from a GP partnership in law, although we think it is only a matter of time before they do. Whether a judge would arrive at the same decision remains to be seen, but it seems clear to us that there are some significant differences between a GP partnership and a legal partnership.
The career progression argument will have particular resonance for a GP practice, because there is only limited opportunity for younger partners to ‘win new patients’. Also, the question of declining performance is likely to be accorded greater weight. It therefore seems likely that a GP partnership would have an even better likelihood of successfully defending a well structured compulsory retirement clause than the Kent law firm above.
Our recommendations
If you are considering implementing or enforcing a mandatory retirement age, we recommend the following:
- Ensure you clearly document the business reasons for your decision;
- Ensure that the retirement age is applied consistently across all partners and reviewed annually;
- Update your partnership deed to make clear what process is to be followed;
- Do not be tempted to copy someone else’s deed as it will almost certainly be out of date;
- Consider whether you want to tie any compulsory retirement age to the NHS pension age, which will soon be increasing to 68.
Bear in mind that the default position is that such clauses are unenforceable, so if a compulsory retirement clause were challenged a judge would want to see some very sound and consistently applied business reasons before allowing it to be used. The best advice is to simply avoid such clauses altogether, but if you are still keen to include one in your partnership agreement, make sure you seek the appropriate legal advice to ensure it meets the test.
If you or a colleague are planning on retiring soon, or indeed on taking 24 hour retirement in order to trigger your NHS pension, we discuss both matters in our recent article, ‘Planning to Retire as a GP Soon?‘
For more information about GP retirement and any other related issues, please contact Daphne Robertson on 01483 511555 or email d.robertson@drsolicitors.com
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Planning to retire as a GP soon?
The unprecedented pressures on General Practice combined with the age profile of the profession are creating a wave of partner retirements. What should you be thinking of before drawing your pension and booking your extended holiday in the sun?
1. Transferral of your NHS contract
The way you go about transferring your NHS contract will depend on your contracting route. A GMS contract can only be transferred through a partnership agreement, so it is important there is a valid partnership agreement in place on your retirement date. If you are a single hander, you will need to go into partnership with another eligible person in order to transfer the contract to them. Changing to and from a single hander requires 28 days’ notice to NHS England.
A PMS contract can only be transferred with the consent of all parties, so NHS England will have to agree to it in writing, and they are able to refuse regardless of anything written in a partnership agreement. Remember that if you remain named on a primary care contract after retirement, you may find yourself held responsible for its delivery.
If you are planning a ’24 hour retirement’, you will need to ensure that you and your partner are both able to come off the contract and come back onto it again afterwards. This will require a carefully drafted partnership agreement and, in the case of a PMS contract, the consent of NHS England.
If you cannot find anyone to take over your contract upon retirement, you may ultimately need to give notice to NHS England. You should generally ensure that this is a minimum of six months’ notice.
2. The surgery
The next major issue is usually the fate of the surgery. A freehold surgery will probably need refinancing, and a lease will need assigning (transferring). Both transactions can be time-consuming and problematic as they require the consent of the bank or landlord. This may not be forthcoming unless you are able to find an acceptable replacement partner to take over your obligations.
An option being explored by many practices is a sale-and-leaseback, but these transactions take time and are not suitable for everyone. Legal assistance should always be sought for any transfer of property, and early planning is vital to minimise the tax implications of the transaction.
Remember to always get a professional valuation of a freehold disposal to avoid any allegations of a sale of goodwill, and ensure your name is removed from the land registry and any property ownership deeds or declaration of trust.
3. Other valuable assets
If you and your partners own any other valuable assets, such as shares in a GP Federation or an interest in a pharmacy, you may well also need to transfer these. These will need to be valued in accordance with your Shareholders’ Agreement, and finance may need to be raised to buy you out. You will then need to complete and sign a stock transfer form.
4. Your accounts
You will want to instruct your accountant to draw up a final set of accounts, and take particular care around the cut-off date used for annual payments such as the QOF, which should normally be spread equally over the year. It’s important to ensure that you have agreed who is liable for settling debts (or collecting credits such as superannuation overpayments) which fall due after your departure.
5. Housekeeping
Last but not least, you should ensure that you are no longer ‘held out’ as a partner by coming off the bank mandate, the website, the letterhead and the nameplate, and you may want to seek an indemnity from the ongoing partners against any future problems being attributed to you.
Once you have made sure that any other Partnership Agreement obligations are complied with (such as for example transferring appointments where possible), you can return the keys, attend the retirement party, and bid a final farewell to patients and colleagues.
For more information about GP retirement and any other related issues, please contact Daphne Robertson on 01483 511555 or email d.robertson@drsolicitors.com
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Beware the ‘Last Man Standing’ Issue in GP Practices
The ‘last man standing’ issue refers to the concern that one or more partner(s) will be unable to retire from a GP practice when they want to, because they are unable to divest themselves of the various liabilities and obligations of the practice.
The issue tends to arise when there are problems in recruiting GP partners, significant numbers of GPs looking to retire or emigrate, or when there are particularly onerous practice liabilities.
The most common type of last man standing problems are associated with surgery leases and mortgage redemption penalties, but they can be triggered by any onerous contractual obligation or unfortunate event such as a death in service or a property market crash.
How the ‘last man standing’ issue destabilises practices
A useful analogy is with a run on a bank. Normally you are happy to deposit your money, confident in the knowledge that you can get it back on demand. However, if enough people want to withdraw their money at the same time the bank cannot raise enough cash to pay them all out and it goes bust.
Similarly, if a GP partner gets concerned that one or more of their partners may be considering leaving and there is no obvious succession plan, they will start thinking about the likely costs of closing the practice and consider leaving while they still can.
Well-drafted partnership agreements normally seek to restrict their ability to do so by requiring a gap between retirements. If a retiree is not replaced in that gap or a partner leaves on other grounds however, the remaining partners may find themselves part of a rush to be the next to resign.
Once this process starts, it is difficult to get confidence back. It becomes even harder to find replacement partners, and ultimately the accountants start wondering whether the business is still a going concern, i.e. able to survive. They may then decide that it is prudent to accrue for the potential liabilities, worsening the financial position of the practice and hastening its demise.
Look after number one: beware the ‘last man standing’
There are multiple ways to reduce the risk of a practice suffering the last man standing problem:
- Be part of a larger practice; small practices only need to lose one or two partners to be at risk, whereas larger practices offer more room for manoeuvre
- Ensure the partnership agreement defines a minimum 6 month gap between permitted retirements
- Maintain a sinking fund for repairing obligations under the lease and other unfunded practice obligations
- Try to negotiate a break clause in your surgery lease for events such as termination of the GMS/PMS contract, but remember enforceability of such clauses can be an issue
- Ensure that you are always in compliance with the terms and procedures of your lease or mortgage; particular risk points are the arrival or departure of a partner
- Take out insurance against specific risks such as an inability to pay the mortgage
- Consider a practice merger to share and thereby reduce the risks
If the last man standing issue appears to be rearing its head in your practice, seek professional advice early. The sooner you get help, the more likely you can prevent it. Once it starts, it can quickly become like catching a falling knife.
Reducing the risk of the ‘last man standing’ is one of the issues which need to be considered when negotiating a surgery lease. Other issues are identified in our free guide, Top 10 Tips When Agreeing a Surgery Lease.