In the New NHS, GP principals and non-principals share the same quality agenda and will depend on each other to meet the requirements of both clinical governance and revalidation. By subscribing to clinical excellence all GPs will also be committed to clinical effectiveness and will need to work at bringing best evidence and clinical practice closer together. In practical terms every individual GP non-principal and their principal colleagues will be required to measure, understand and account for the outcome of their clinical and educational activities.

As a consequence, the future for the unaccredited and non-revalidated GP to work will be limited. However, many non-principal GPs are not prepared for the challenges ahead and could find themselves in jeopardy without appropriate resources and support. Conversely, the NHS might find it is unable to provide the necessary quality workforce to deliver its agenda if it fails to anticipate and respond to the new needs it has created for all GP non-principals.

Old relationships and boundaries between GPs are to some extent preventing the integration of non-principals and their ability to undertake continuing professional development and audit.

Non-Principal GPs: A NHS Resource explores the barriers to non-principal participation in the New NHS and outlines some basic requirements. It is hoped the document will stimulate discussion and debate to help the NASGP promote the welfare of all GP non-principals and help secure their future.

The vision is one of choice, opportunity and equity for all GPs and NHS stakeholders.

Tony Downes
Secretary (Wales) NASGP

Profound changes in the wider environment are now impacting on the NHS leading to significant structural and cultural changes within it.

The emergence of GP non-principals as a distinct group testifies to the force of these changes. The term non-principal is more than just a collective name for a range of GP contracts outside of the independent contract; it represents a new GP culture that embraces the future and a new NHS. The NHS reforms respond to a desire for change in a world where the expectations of both consumers and providers have been raised.

The government is under political and economic pressure to deliver a NHS that can sustain middle class support, reduce health inequalities and contain costs. Improving the quality of NHS services and narrowing the health divide without raising taxes will mean making the very best use of NHS resources and developing a positive relationship with the private sector.

The new definition of health includes all of its known determinants and all stakeholders in healthcare, including patients, will be expected to collaborate and work in new ways to meet specific health targets and demonstrate benefits through a new system of health outcome measures.

The new emphasis on public health together with evidence based medicine will form the basis of Health Improvement Programmes and impact on the future structure of primary care teams and individual professional development. Contractor and non-contractor services will need to work together with unity of purpose.

Although devolution gives four blue prints of the NHS, setting standards of clinical care through the National Institute for Clinical Effectiveness (NICE) and maintaining the quality of healthcare through the Commission for Health Improvement (CHI) will apply throughout the UK.

During 1998, well-publicised lapses in the quality of clinical care have put pressure on the medical profession to demonstrate that it can restore public confidence in professional self-regulation. Clinical governance gives clinical control for improving the quality of healthcare and the process is fully inclusive with no opting out. The General Medical Council is establishing a fully inclusive system of revalidation for GPs that will be operating in two years time. The Royal College of General Practitioners is developing its role as the standard setter for revalidation by fixing the criteria for good practice and supporting Accredited Professional Development.

Today, it is estimated that 20% of the GP workforce are defined as non-principals; some 7,500 medical practitioners who undertake one in five patient consultations. The training of a GP is expensive to the taxpayer and an investment for the NHS. Non-principals are an important human resource for the NHS that are both part of, and a solution to, the problem of GP recruitment and retention. GP non-principals impact on the quality of services in both primary and secondary care and are well placed to work in innovative ways to address service deficits. The demand for flexible and clinically orientated work opportunities by an increasing number of GPs fits well with a new NHS that needs an adaptable and flexible workforce.

Despite this, GP non-principals remain disenfranchised finding themselves excluded from many of the structures and processes of the NHS. This large group of qualified GPs has become marginalised, undervalued and vulnerable to discrimination and exploitation. GP non-principals are invisible to the old NHS establishment, including health economists and policy makers.

This situation is no longer tenable. It is unacceptable that the government should lose contact with, and fail to maintain, its valuable assets. Wasting taxpayers' money at a time when resources are limited and when rationing has become a major issue will be regarded as bad practice under corporate governance. Also, cost has been included as a marker of quality and such waste, by increasing costs to the NHS, should be regarded as evidence of poor quality.

A worrying situation has arisen whereby the processes involved in clinical governance and revalidation seem only to be geared to include GP principals. This will put a substantial number of GPs in jeopardy because the independent GP contract excludes GP non-principals participating in clinical audit by denying them full professional responsibility. Patchy support and resources for continuing professional development (CPD) disadvantages non-principal GPs when compared to their principal colleagues and also increases inequalities between non-principal GPs.

The transition from general practice to primary care will change the role of GPs who must find a new place in a culture of inter and intra-professional collaboration. The independent contract will become part of a continuum of contracts and its' ultimate fate will be decided by the shaping forces of the NHS reforms.

However, the notion of a GP is still that of an independent contractor GP principal and primary care is considered as comprising GP practice based, registered populations. Patients generally 'belong' to a GP by registration that works against the notion of collaboration and equality. This paternalistic relationship comes between GPs and is the fault line between principal and non-principal GPs. The independent contract divides GPs by a master-servant relationship under English law that has more to do with post war Britain than the 21^st century.

There is no relationship between the independent contract and clinical expertise or performance; it merely reflects business interest and managerial responsibilities. Arguments to justify superiority of this old contract, through special advantages for patients such as 24 hour responsibility and continuity of care, do not hold in a world of GP out-of-hour co-operatives, GP group practices and trends towards part-time working. Greater patient mobility and changing medical practice has led to less 'cradle-to-grave' care and, together with other social changes, have all altered the notion of a 'family' practitioner.

The two main barriers to enfranchising GP non-principals are mindset and the financial conflict of interest of independent contractor GPs. The problems of mindset with regard to implementers and monitors of health policy have exacerbated the problem of GP non-principal exclusion. Efforts made so far to integrate non-principals GPs do not address the fully inclusive and compulsory nature of clinical governance and GMC revalidation. Change is viewed through a practice based, GP principal led perspective that encourages a voluntary approach and token participation for GP non-principals.

As a result, there has not been widespread implementation of the recommendations of the Standing Committee for Postgraduate Medical and Dental Education Report (SCOPME). The Calman Report on Continuing Professional Development fails to include locum GPs except as 'cover' to allow other GPs to participate in Professional and Practice Development Plans (PPDPs). The Royal College of General Practitioners, although trying hard to include non-principals and unite all general practitioners, is finding difficulty accommodating locum GPs in their membership and Fellowship by Assessment procedures. Token non-principal representation on the General Practitioner Committee and Local Medical Committees impede their emancipation. The last minute inclusion of non-principals in primary care groups and local health groups created an unfair and undemocratic electoral system preventing their proper inclusion in these structures.

The government sets a ten-year period to fully implement its NHS programme. However, the reforms will falter unless a pro-active approach is taken to the impending GP recruitment and retention problem. Lessons can be learned from the present crisis in NHS nursing and dentistry. The continuing drift of dentistry to the private sector could happen to GPs. Disaffected non-principals and GP registrars could be seduced by the private medical initiatives unless the NHS becomes responsive to their needs.

GP principals are concerned that attractive non-principal contracts might threaten their capital investment causing' meltdown' for investing practitioners. This financial conflict of interest is perhaps the main cause of concern for independent contractors, who will resist non-principal enfranchisement. The government must reassure GPs about their capital investment and also ensure it retains the goodwill of non-principal GPs.

Non-principal GPs are members of the NHS family and are entitled to participate fully in the structures and processes of the NHS. A way to overcome the barrier of the 'master servant' relationship caused by the Independent GP contract is urgently sought as is modernisation and upgrading of the current locum contract.

Appropriate resources for Accredited Professional Development and inclusion of non-principals in the information technology revolution are needed if all GP non-principals are to be clinically effective. Also, clinical governance and revalidation by the GMC demand that all GP non-principals must demonstrate the outcome of their activities and undergo peer review. This implies the ability to perform audit and the proper representation of non-principals in NHS and GP structures.

Research into the cost-benefits of non-principal GPs and proposed ways to integrate this new GP practitioner is urgently needed. The opportunities given by the health reforms for NHS family members to shape the New NHS must also be extended to non-principal GPs. And finally, financial support is needed to promote and maintain the enthusiasm and good will that exists amongst non-principals to work towards a better and fairer National Health Service for everyone.

Although some progress has been made by the efforts of the National Association of Non-Principals (NASGP) and more progressive individuals and institutions, it is imperative that full integration of non-principals into primary care occurs as soon as possible. In Wales, the University of Wales College of Medicine (UWCM) has implemented many of the recommendations of SCOPME and forms the basis of a model for how the process can take place. Because of devolution there are now four blueprints for the NHS and each country can adapt and develop their own system to suit their own circumstances. The following points outline the general requirements for full integration.

Human Resource Management.

• A national register of non-principal GPs for each country/defined smaller population.
• A unique identifying number for every GP non-principal.
• An 'address' or ‘virtual practice’ for every GP non-principal.
• A new professional title to be separate from the contract of employment to improve status.
• A non-principal educational facilitator/mentor for a given non-principal population.
• A new equitable relationship between GP principals and non-principals based on qualification and experience not on capital investment and administration.
• A universal GP career structure

• For full participation in the processes of clinical governance and GMC revalidation, all GP non-principals will need CPD, to demonstrate the outcome of their activities through audit and be subject to review by peers and others.

• Decision support material such as the BNF and clinical effectiveness material.
• Inclusion in the information technology revolution.
• Essential information from primary care groups, public health, hospitals and government.
• Financial support for costs incurred by participation in CPD.

• Prescribing number for all non-principals.
• Full professional responsibility including for patient complaint systems.
• Non-principal hospital activity such as referrals and use of laboratory facilities.

• Full participation in the Royal College of General Practitioners in all aspects of its work.
• Full democratic representation and inclusion in LMCs/GPCs
• Appropriate representation and participation on primary care groups.

• Seniority and time working as a GP non-principal that includes eligibility for GP training.
• A NHS pension for GPs working as a NHS 'locum'.
• A fair pay-structure that eliminates a market that divides GPs.
• Health Authority uniformity with regard to inclusion criteria to their lists e.g. obstetrics.

• Inclusion of non-principal related issues in research and development.
• Inclusion of non-principal in GP vocational training schemes and career counselling.
• Inclusion of non-principal perspective in the consultation processes at all levels.

Quality

Primary care practices, Trusts and other organisations that commission non-principal GP services will be assured of more consistent standards in order for them to meet the requirements of clinical governance. This will be very important to chief executives of Trusts and Health Authorities who will be ultimately responsible for the quality of their services, including costs, under the new legislation.

Inequality

A registered population of non-principals will help PCGs and LHGs address service deficits identified by Health Improvement Programmes. A flexible and adaptable workforce can meet spikes of demand in secondary and primary care in the most cost-effective way. Waiting lists could also be influenced and improved.

Patients

Patients will benefit in both primary and secondary care from all the changes invoked by the new GP structure. The standard of GP will be quality assured and improved communication and information will ensure better continuity of care. Patients will be given choice and their needs will be better met.

Taxpayer

Identification of all qualified GPs and encouragement to stay in the NHS to maximise their input will reduce costs due to staff shortages. Encouraging quality will reduce inefficiencies and eliminate waste.

Government

A well organised and high calibre non-principal GP workforce will be important for the government to meet its pledge to the NHS to improve quality and reduce inequalities in a cost-effective way. The government could realise its stated aim to bring unity of purpose to all stakeholders in the NHS.

1. Future NHS Staffing Requirements, Health Committee, House of Commons, March 1999
2. Educating GP Non-Principals, Education for General Practice, volume 9, February 1998
3. Lost Doctors Project, Public Health Resource Unit, Institute of Health Sciences, June 1998
4. Flexible Working Patterns, Professor Ruth Chambers, Great Careers Debate, RCGP, October 1998
5. GP Tomorrow, Dr Jamie Harrison, Radcliffe Medical Press, June 1998
6. Clinical Governance and the drive for quality improvements in the new NHS in England. BMJ 1998, 317; 61-5
7. Working Together, Securing a quality workforce for the NHS, DoH, 1998
8. A First Class Service: Quality in the new NHS, DOH,1998
9. Quality Care and Clinical Excellence, Welsh Office, 1998
10. Independent Inquiry into Inequalities in Health: Sir Donald Acheson, 1998
11. Consumer concerns 1998: National Consumer Council
12. Going for Gold. Julian Tudor Hart. 1998
13. SCOPME Report, The educational needs of general practitioner non-principals, 1998
14. A Review of Continuing Professional Development in General Practice: A Report by the Chief Medical Officer for England, 1998
15. Professional and Practice Development Plans for the Primary Care Team. BMJ1998, 316:1619-1620. Jones Elwyn G.
16. General Practitioners Career Counselling Project. NHS Equality Unit, UWCM, 1998
17. Duties of a Doctor, Good Medical Practice, General Medical Council 1998
18. National Association of Non-Principals - A Handbook for Non-Principals in General Practice. The Limited Edition Press, for the NASGP, 1998. Editor Shaun O’Connell