The promise of a GP partnership review has not been kept

Amidst the high hopes and hard work surrounding the NHS long-term plan and accompanying GP contract reform framework since early 2019, the publication of Nigel Watson’s GP partnership review: final report on 15 January might be considered somewhat overlooked.  

The topic that the review attempts to cover – the challenges of the GP partnership model of general practice provision – is as crucial, however, as the formation of primary care networks for shaping the next 70 years of primary care services.

GP partnerships underpin the model of the vast majority of general practices in Great Britain and it is difficult to see genuine reform without addressing the grave challenges facing GP partnerships today.

Deterrents to GP partnership include an unattractive work-life balance coupled with financial and premise risks, all for a reducing differential in remuneration between partners and salaried and locum GPs.

The NHS long-term plan might successfully introduce 20,000 “additional roles” into general practice with the intention of decreasing dependency on GP, yet under the current model, GP partners are still needed to hold General Medical Services and Personal Medical Services contracts, employ practice staff and be accountable to commissioners and regulators.

With the numbers of GP partners declining, the fear of being the “last man [or woman] standing” is increasingly becoming a reality that compromises the future of many general practices.

Shortcomings of the report

So what does the GP partnership review offer?

The starting assumption that it would be unfortunate if the GP partnership model were lost as it is better than the “alternative salaried model”, and therefore must be saved, is inherently restrictive.

By defining this purpose from the outset via the Terms of Reference of the Review, the secretary of state for health and social care of the time arguably set up Dr Watson and colleagues to fail to deliver a candid or meaningful review.

If the aim was to genuinely help general practice in perhaps its darkest hour at a crucial turning point in its long history, such a review would necessarily have to freely explore all of the options for revitalising the general practice delivery model.

The main body of the review is peppered with arguments for the GP partnership model that are subjective conjecture or simply incorrect.

Equating owning the practice to a commitment to the practice can be easily challenged by the many committed and hugely devoted hospital doctors, nurses and myriad other healthcare professionals who give 100 per cent to their patients without being owners of the hospital or other healthcare organisation.

The starting assumption that it would be unfortunate if the GP partnership model were lost as it is better than the “alternative salaried model”, and therefore must be saved, is inherently restrictive

The assertion that the GP partnership model fosters innovation is not really true either. A GP partnership can make it more difficult for partners to gamble on new ways of working, in both small practices where there is less financial leeway for errors, or in large practices, where more partners need to be convinced to take risks.

Together with the security of an in-perpetuity contract, general practice is often conservative and traditional, with excellent examples of innovation being the exception, not the rule.

Stating that the GP partnership model delivers value for money and leads to cost-effective healthcare offers food for thought; one could argue that GP partnership – owning the business from which the profits are the self-employees’ remuneration – introduces perverse incentives to draw profit at the expense of robust patient care, relying only on opaque systems of accountability for partner drawings and trust in a sense of morality that profits will be reinvested into the practice in fair proportion. 

Similarly, to call GP partners “independent advocates for patients” when both the payments for and profits from general practice are channelled through their bank accounts is hardly credible.

Under a salaried GP model, akin to hospital doctors, GPs would be freer to advocate for patient care without the perverse incentives outlined.

Recommendations

So what can we logically conclude from what we know?

Recommendation 1a of the paper is a strong leading point after which the climax of the “review” goes rapidly downhill in value: “NHS England’s review of primary care premises should develop proposals to mitigate the personal risk associated with being a lease holder or property owner…”.

Premises that are converted houses and old shops can be (as well as a significant disincentive to GP partnership, rightly concluded here) a restraint on both the quality and quantity of care being provided by the general practice.

I hope the NHS England review of premises will therefore live up to the promise of open and unfettered exploration of all options beneficial to the future of general practice, as such a review should be.

Perhaps the only recommendation from the GP Partnership Review that is not a repetition of long-term plan ambitions, is recommendation 1b: “The government should introduce the option of GP Partnerships holding a GMS or PMS contract under a different legal model, such as Limited Liability Partnerships or Mutuals”.

Most of the recommendations of the GP Partnership Review are duplicative of the aims and aspirations of the NHS long-term plan or the GP Forward View

The rationale being to reduce the risks of being a GP partner. However, if different legal structures are being scoped as alternatives that reduce the level of “skin in the game” that GP partners have, then why not go a step further, towards a salaried model that removes the risks and disincentives entirely?

Questions of ownership removed, doctors can be free to focus wholly on patient care and doing what they have been trained to do and are passionate about; medicine.

Most of the recommendations of the GP Partnership Review are duplicative of the aims and aspirations of the NHS long-term plan or the GP Forward View, and are rather agreeable as such.

No one familiar with the current struggles of general practice would disagree with growing and supporting our workforce, better managing workload or promoting digital enablement, for example.

However, this does not add much value to the expansive discussion about the likely future of the GP partnership model. The promise of a GP Partnership Review has not been kept.

I implore NHS England colleagues to commission a robust review of the general practice delivery model, complete with options for alternative salaried models and any other inventive (or perhaps old school) suggestions for securing a sustainable future in the brave new world of primary care networks.