General practice: basic facts
How many GPs are there?
There are 36,000 GP principals in the UK divided between 11,000 practices. A “principal” is a self employed independent GP.
In addition there are up to 7,000 qualified general practitioners who are non principals, working as locums, assistants, salaried doctors, and a variety of other GP posts.
The UK is experiencing a severe shortage of GPs. In most parts of the UK practices are having great difficulty filling vacant posts. As a result practices are closing their lists to new patients in an effort to preserve the standard of care to existing patients. Nevertheless these practices are forced to take on additional patients allocated to them by the local Primary Care Organisation.
There are two types of contract in UK general practice: GMS and PMS
Roughly 70% of GPs have a GMS contract and 30% have a PMS contract.
GMS stands for General Medical Services.
The GMS contract is the traditional one, dating back to the start of the NHS. It is administered through the Red Book which contains a complicated set of regulations supported by legislation.
The GMS contract has nationally agreed terms, negotiated between the Department of Health and the British Medical Association.
It is the GMS contract that is currently being negotiated. The proposed new contract will be radically different to existing arrangements. The new contract negotiations are conducted between the BMA and the NHS Confederation acting as agents for Departments of Health in the four countries of the UK.
The radical nature of the proposed changes to the GMS contract make this the biggest shake-up of general practice since the 1960s.
PMS stands for Personal Medical Services.
It first appeared in the form of PCAPS (Primary Care Act Pilot Schemes) under the Conservative Administration in the 1990s. Since the Labour Government came to power, PMS Pilots, as they became known, have been rapidly expanded in successive waves. In April 2003 wave 5a will start followed by wave 5b in October 2003.
The PMS contract is locally negotiated. More recent waves have included a “national core” of service terms, in addition to the locally agreed elements. The PMS contract is said to be more flexible than the old GMS contract in responding to local situations. It lacks the protection of nationally negotiated funding flows and is financed through the local primary care organisation’s (PCO) cash limited budget. Doctors in a PMS pilot practice can elect to return to a GMS contract, having given appropriate notice.
Independent contractors
In both GMS and PMS, the majority of family doctors are independent contractors, not NHS employees. They are self employed and therefore it is misleading to talk of their remuneration as a “salary”.
A minority of GPs are salaried doctors. Some of these are employed by GMS practices, but the majority of salaried GP posts can be found in PMS positions. These salaried doctors are either employed by the GPs who run the practice where they work (Independent contractors) or are employed directly by the PCO.
Male versus female
Overall, just over one third of GPs are women, but in the younger age brackets the situation is very different.
The National Survey of GP Opinion published by the BMA in November 2001 was based on responses from 23,521 completed questionnaires. It showed that 38.2% of GPs responding were women.
In the age range under 30 years, 76.5% of the GPs were women. In the 30-34 age range the % of women was 59.7%. In the upper age range of 55 to 64 years, only 20.3% of the GPs were women.
Women GPs are more likely to work as locums and other non principal jobs than male GPs. The survey results show that just over 75% of women GPs are principals and 93% of male GPs are principals.
Full time versus part time
Women GPs are more likely to work part-time than male colleagues. In the BMA survey, 59% of women GPs were full time compared with 94% of male GPs. However, in the BMA survey, four out of every 10 doctors aged 34 years and under said they wanted to reduce their hours of work within the next five years. This covered both men and women.
Training to be a GP
It takes a minimum of nine years to become a GP at a cost of approximately £250,000.
In order to become a GP, candidates first have to qualify as a doctor via a five year undergraduate degree. Like all new doctors, the 12 months after graduation is spent in hospital as a House Office in a pre-registration year. The new doctors then become Senior House Officers for, typically, a two year period. If they choose to specialise in general practice, the doctors then becomes a GP Registrar and completes a training programme in a GP setting lasting 12-18 months.
Although it is not compulsory, many doctors choose to take the examination for membership of the Royal College of General Practitioners in addition to their vocational training.
On successful completion of training, the doctor can practice independently as a fully qualified GP.
Trainee GPs are called Registrars. There are more women GP Registrars than men. In 2002 there was a rise in the number of doctors applying for certificates to practice as GPs. Of the 1,781 UK-based applicants, 1,117 were women doctors (62.7%).
GP Income
Most GPs are self employed. Their income is determined by the statement of fees and allowances for their work set out in a document referred to as the Red Book. Many own the surgery premises they work in.
The pay of doctors including GPs is determined by the independent Doctors and Dentists Review Body (DDRB). The DDRB’s recommendations are put to the Government which chooses whether to implement them.
In the financial year 2003/3, the intended average net income for a GP is £61,218. New GPs can now receive a golden hello payment. If these are averaged out across all GP income, the average intended net income (IANI) per GP rises to £61,618.
The new contract will be largely practice based. The money going into practices will no longer be based on the number of GPs, but on the weighted needs of the patients registered with the practice. In addition there will be other new sources of money such as funding related to delivering higher quality care in general practice. The new structure of income to practices means it will not be possible to provide an IANI figure for GPs under the new contract.
Timetable leading to the new contract
1911 Health Insurance Act. For the first time Government money is paid to GPs to look after patients. Prior to this all GP work was private. Poorer patients can pay a national insurance subscription which entitles them to be on a GP’s “Panel” and receive state financed treatment.
1948 NHS Begins
1966 The New Deal - reform of the GP contract. Introduced the basis of the current payment system for GPs known as the “cost plus contract”. Every time a new GP was appointed he/she brought to the practice a package of resources to cover both GP pay and the staff and infrastructure costs of delivering GP services. Over time this has proved a relatively inflexible system which allows an unlimited expansion of workload without adequate resourcing that extra work. When a practice loses a GP it loses the resources. If the practice can’t recruit a replacement, it faces the double whammy of losing funds while the remaining GPs look after the missing doctors’ patients.
1990/1 Government imposes contract changes on profession. These include target payments eg for childhood immunisation and preventive measures regarded by GPs as poorly researched and inadequately funded.
mid-1990s Out-of-hours services: GPS are allowed to arrange (and pay) for other doctors to provide cover for patients out-of-hours, but individual GPs retain overall 24 hour responsibility.
July 2000 NHS Plan for England introduced by Government. Includes expansion of primary care services and promises 2000 extra GPs by 2004. BMA calculates we need 10,000 extra GPs to implement the NHS Plan.
April 2001 BMA’s General Practitioners Committee (GPC) announces stalemate in negotiations to improve the working lives of GPs.
May 2001 Every UK GP balloted on whether they would be prepared to consider resigning from their current NHS contract if a satisfactory new contract ,and representation rights for all GPs could not be secured by BMA. On a turn out of 66%, 86% of GPs voted “yes”.
June 2001 Agreement to negotiate a new contract for GPs
Autumn 2001 Negotiations on a new GP contract begin between the BMA GPC Negotiating Team and the NHS Confederation (acting as agents for the Departments of Health throughout the UK countries).
April 2002 Framework of the proposed new contract published, followed by roadshows explaining it to GPs around the UK.
June 2002 Second ballot of all UK GPs asking if the framework of the new contract is acceptable.
July 2002 Ballot results published: seven out of 10 GPs voted yes. Detailed negotiations leading to a priced contract commence.
February 21 2003 Final GP Contract published.
March 2003 Three weeks of roadshows around the UK explaining the contract
March 20 2003 Ballot papers sent to all UK GPs asking if the new contract is acceptable
April 11 2003 Ballot closes
To be announced: Publication of Ballot results