MANY DELEGATES at the 1997 GMSC Non-Principal conference, and the '96 and '97 GP Registrar Conferences expressed interest in becoming salaried doctors. Fixed salaried partnerships have existed for a long time but have led to opportunities for exploitation in the past.

Just before the 1997 general election the NHS (Primary Care) Act 1997 gained Royal Assent. The Act paves the way for new salaried service posts in general practice. It was intended to:

• increase local flexibility;
• promote consistently high quality services;
• provide opportunities and incentives for primary care professionals to use their skills to the full;
• provide more flexible employment opportunities in primary care.

One of the ways of fulfilling the latter aim is to allow the salaried service option for GPs, either within partnerships or other bodies such as NHS Trusts. This means that there will be new posts created for non-principals from April 1998 which many will find attractive.

Salaried GPs posts will initially be within ‘pilot’ posts. Such GPs will have to provide the full range of personal medical services to their registered population. The pilots may pave the way for separate practices to work more closely together, to share resources and to offer a wider range of services to patients. However there have been reports in the GP press that pilots may reduce the viability of non-participating, neighbouring practices.

Pilots are able to provide dedicated services to specific population groups, e.g. the homeless or drug mis-users. They can be used to replace a vacancy within a practice. However they are set up, pilots require significant changes to the way medical services are provided.

All pilots will require the development of a new local contract between the practice and the health authority. This may provide an opportunity to better target services to meet the needs of patients. The contracts for such pilots are practice based, that is they are negotiated at practice level, not nationally by the GMSC. If a practice wishes to start a pilot, even for one doctor, the whole practice has to move from Part II of the National Health Services Act 1977 to Part I of the Act. This means leaving the current regulations and the ‘Red Book’ agreements on fees and allowances and re-negotiating with health authorities. The consequences of doing this are unknown but could be far reaching. If things go wrong, it is not certain that practices will be able to return to their old way of working, and more importantly, being paid. It is expected that such GPs will be able to remain in the NHS Pension Scheme but the method of calculating their pension may be altered (so they receive a pension related to their final year earnings rather than to lifetime earnings as principals currently receive).

Practices interested in undertaking such a pilot had to submit applications to their health authority in November 1997. There are two types of Personal Medical Services pilot:

• PMS pilot - provides general medical services (traditional GP services for individual patients including out of hours care);
• PMS Plus - traditional GP services plus elements of some hospital and community health services. (These are intended to link GPs with community nurses and others together in a single integrated clinical team).

Before being approved, ‘pilots’ have to demonstrate clear objectives, clear benefits to patients and professionals and have the approval of the Secretary of State.

Only members of the ‘NHS Family’ are able to apply to provide services under the act. These are:

• NHS Trusts;
• GPs who do or could provide general medical services under the NHS Act 1977;
• an NHS employee (eg nurse or practice manager);
• a qualifying body (a company owned by one or more of the groups above or a partnership of similar people.

Participation in the pilots is voluntary. Health authorities are not forcing GPs to take them on but by the same token the effect of pilots on neighbouring practices may not be their highest priority. Pilots will be evaluated in the first three years and reviewed by the Secretary of State. Following successful reviews the Secretary of State may provide for more permanent schemes and the introduction of others.

The approval of applications was notified in December 1997 and nearly 100 pilots begin in April 1998.

Doctors interested in obtaining more detailed information about pilots can obtain the guides that were produced for those interested in applying. These are:

• A Guide to Personal Medical Services Pilots under the NHS (Primary Care) Act 1997;
• Personal Medical Services Pilots under the NHS (Primary Care) Act 1997, A guide to the application and approval service and A guide to local evaluation.

They are available from the NHS Response Line on 0541 555455. Those interested in actual jobs should ask health authorities for details of local pilots, read the GP press and keep their ear to the ground. These posts are likely to be attractive but applicants need to be sure that the workload is commensurate with the salary. An open ended clinical commitment may lead to increasing workload with no ability to increase income. Local BMA offices, LMCs and the GMSC secretariat may be able to advise prospective applicants, particularly on the details of a contract and the terms of service. GP reported in February 1998 that pilot schemes contacted by them were offering salaries between £20,500 - £45,000. The GMSC is at the time of going to print reviewing the mechanism by which it can represent such pilot scheme doctors who have become known as P- CAPs doctors (primary care act pilots).

Other ways of being salaried
There are other ways in which doctors can provide general medical services in a salaried post. Assistant, associate and retainer scheme doctors already do this. The latter is being re-negotiated at the time of writing and there have been reports that the GMSC is pushing for other ways within the security of the Red Book.

One innovative post for GPs who wish to work at the primary/secondary care interface has been set up at one London hospital. (BMA News Review 2/97). Here GPs have been employed to work regular shifts in the A&E Department. GPs are believed to be more efficient at diagnosing without requesting expensive and time consuming investigations. They are also a cost effective solution to inappropriate attendances. The posts help hospital SHOs gain experience from GPs and GPs to keep up to date with advances in emergency medicine. Other hospitals are beginning to copy this initiative.

The County Durham GP Career Start Scheme
County Durham GP Career Start began its life as a response to a perceived recruitment crisis in an area near Durham City. A local practice appeared to be facing extinction back in 1994, and questions were asked about the apparent disintegration of the service in the Houses of Parliament!

In the event, rumours of the practice's demise were somewhat premature, and indeed, the practice currently boasts a Career Start GP on its books. Nevertheless, crystal ball gazing into the needs of the future GP workforce indicated that a 2-year scheme, for post-VTS salaried doctors, funded by the Health Authority, might be a good idea.

In September 1996, five female and two male GPs joined the inaugural year of Career Start. The ex-Retainers worked four sessions in a mentor practice, the others worked eight sessions in their practice, and all met up for a weekly self-directed group activity. Some feared the group session would be glorified VTS "Play School" but these fears were unfounded and the reality is much more interesting!

The first year is nearly at an end, and already one of our number leaves to join a local practice as a 4-day per week partner. She has discovered what is for her a 'do-able' job - 9.30 a.m. to 2.30 p.m., having gained in confidence during the year, and received great peer support from the group. Year 2 offers an equal share of more varied practice-based placements, balanced by educational activities. Options include doing an MSc or Therapeutics Diploma; others will use the time to visit out-patients or a local hospice, or gain accreditation for the obstetric list etc. Each doctor will continue to be salaried by the scheme, and hence have no service commitment to the organisation in which they will gain learning and experience.

The second intake of eight GPs started in September 1997. The scheme's continued desire is to provide personal and professional development for vocationally trained doctors who are not working as principals. In addition, the hope is that GPs leaving the scheme will want to stay in the local area. We believe County Durham offers great opportunities - for culture, scenery, and GP career development. GP Career Start is but one element in the Health Authority's plan to change the culture of general practice to make it a more flexible, fulfilling, and doctor-friendly beast!

For further details, please contact Jamie Harrison. Telephone 0191 333 2807 (This section was first published in the NASGP’s Summer 1997 newsletter)

Expansion of the number of formal salaried non-principal posts is inevitable given the recruitment crisis and changes in the ways that doctors want to work. Readers are advised to keep abreast of local developments through the GP press and non-principal representatives on the LMCs.

Two schemes (similar to the Durham one) were announced as the handbook went to press, in Sunderland and Tees health authorities. Ten two-year contracts with salaries of £36,000 and protected time for education were being offered with each year being spent in different practices.