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The new General Medical Services (nGMS) contract and careers: a view from the Educationalists

• Examples of existing national support schemes
• GP Registrars
• GP Teachers
• How might we categorise the different career strands presently available?
• Introduction
• Salaried GPs
• The Model Practice under new GMS?
• What structures exist to support doctors in their development?

• Please read the Department of Health’s latest guidance on the GP appraisal process
• Please read the Scottish Executive Health Department’s latest guidance on the GP appraisal process
• The Department of Health has issued guidance to PCTs about appraisal funding for both GMS and PMS
• GPC guidance on appraisal can be found in GPC news of 22 October 2004
• Information about the appraisal process for GPs in Wales can be found at the Department of Postgraduate Education for General Practice Wales College of Medicine
• Currently, there is no specific appraisal guidance for Scotland. However, information for Scottish GPs can be found in the GMS Statement of Financial Entitlements

• Further information can be found on the General Medical Council’s website
• Please read further clarification and information relevant to Scottish GPs

3.3 GP Returners’ Scheme

This scheme benefits GPs returning to the NHS and includes salaried refresher training which is tailored to individual needs, receipt of up to £12,000 “golden hello” payments on taking up a first eligible post and flexible working options as well as advice and support on childcare. However those who become retainees or locums after completion of the returners’ scheme are not entitled to a “golden hello” payment.

More details can be found in the GPC’s guidance note available on its website (GP Returners' Scheme and Flexible Career Scheme, General Practitioners Committee, Briefing Paper (England), Revised March 2003). The GPC will also be working on a model contract for GP returners, which once finalised will be uploaded to the website. In the meantime, GP returners are advised to use the flexible career scheme model contract which is covered in the next section.

3.4 Flexible Career Scheme
As part of the Improving Working Lives initiative the Department of Health in conjunction with the GPC, developed the Flexible Career Scheme (FCS) (GP Returners' Scheme and Flexible Career Scheme, General Practitioners Committee, Briefing Paper (England), Revised March 2003). It provides doctors with an opportunity to work flexibly within mainstream general practice while being supported in maintaining their careers. This scheme has a number of benefits for a wide range of doctors including:

- doctors who want to work less than 50% of full time
- doctors who want to take time out or cannot work full time, but wish to keep in touch with the profession
- doctors retired or semi-retired from the NHS, or those nearing retirement, who wish to continue working but at a different pace
- doctors currently not working who wish to return to practice and need a period of supervised work.

GPs need to apply to their Director of Postgraduate GP Education and can work a minimum of 2 sessions and no more than 5 sessions per week up to 260 sessions per year. It is a 3-year scheme and includes a minimum of one session per week pro rata of protected time for Continuing Professional Development (CPD). Further details on CPD can be found in the Focus on…Salaried GPs guidance (June 2004).

Benefits for the practice include another contented member of the team, a percentage reimbursement of employment costs and eight of the educational sessions reimbursed in full.

Information on a model contract (Model Contract of Employment for a Flexible Career Scheme GP, General Practitioners Committee, October 2003, Paragraph 65 modified February 2004) for a flexible career scheme GP can be found on the sessional GPs guidance page in the GPC website.

The Flexible Career Scheme is not available in Wales.

Despite Scottish GPC having attempted to negotiate for a Flexible Career Scheme, the Scottish Executive Health Department were not minded to implement such a scheme. Therefore, the above section does not apply to GPs in Scotland.

3.5 Doctors’ Retainer Scheme
This scheme is designed to help doctors who are not working in general practice to keep in touch with general practice and a GP can remain on this scheme for up to 5 years, subject to annual re-approval and in exceptional circumstances, up to 10 years.

The GP retainer scheme is intended to ensure that doctors who wish eventually to return to general practice as a partner or substantive salaried and freelance locum GP (previously principal or non-principal) are able to keep up-to-date and further develop their skills. In short, it provides GPs, who because of their personal circumstances can only work limited sessions, with employment and training. Doctors on the retainer scheme can work between 1 and 4 retainer sessions a week (although this can increase to 6 sessions a week provided that the maximum average is 4 sessions a week). Within this time, a retainee must undertake at least 28 hours of education time per year but may have more as per the new minimum terms and conditions for salaried GPs. The practice is remunerated for each session to cover sickness, maternity and annual leave and education.

The GPC is currently revising its model contract for GP retainers, and once finalised this will be uploaded to the GPC website.

3.6 Higher Professional Education
Money for higher professional education is available to all new and returner GPs in their first two years. It is paid educational time and is costed via a “learning account”. GPs should apply to their Deaneries for this funding.

4. GP Teachers
There are four main groups of GPs involved in education.

4.1 GP Educators
These include GP Tutors, Advisers and Associate Deans. These doctors usually have contracts with the deaneries or the PCOs. Their brief has been to provide education in specific areas monitored by the deanery or the PCO. In the past, remuneration for this activity was very unsatisfactory and was frozen at the level of the second point on the consultant scale. In 2003 after tri-partite negotiations between the GPC, Committee of General Practice Education Directors (COGPED) and the Department of Health, there was an uplift in remuneration for these groups. The payscales range from the preparatory year (GP00) to a more senior educator at deputy director level (GP07). The scales are intended to reflect responsibility, experience and performance and to provide a ladder of progress for educators. Details of these payscales and the accompanying competency framework can be found on the GPC website.

4.2 GP Trainers
Payment for GP Trainers is separate from the new GP Contract and comes via the Medical and Dental Education Levy (MADEL). During the last year the GPC has been very active in attempting to increase the annual GP trainers’ remuneration which is currently £6,804. It is clear that this remuneration does not match the current workload implications of training registrars with its four components of summative assessment, and the new responsibilities for out-of-hours supervision and formal appraisal. As the government tries ever harder to solve the problems of a lack of GPs in the NHS, training practices are being asked to become involved in induction training for refugee and EU doctors. Trainers also look after remedial registrars, Pre-registration House Officers (PRHOs) in general practice and ‘senior registrars’ (extended training). Training practices are inevitably the first practices to be asked to undertake these activities and this puts further stress on the GP trainer and the GP training practice. Further details on the negotiations of GP trainers’ remuneration can be found in the Trainers Update available on the GPC website.

4.3 GP Undergraduate Tutors
The GMC document in 1993 "Tomorrow's Doctors" looked very critically at the teaching of medical students in hospitals. Hospital teaching was becoming narrower in terms of specialisation, hence the quality of exposure to a wide range of clinical material was found to be unsatisfactory. The response to this was an expansion of undergraduate teaching by GP teachers in Primary Care. Remuneration was provided by means of the Service Increment For Teaching (SIFT). Universities and Teaching Hospitals, in conjunction with GPs, developed innovative methods of undergraduate teaching and clinical exposure in Primary Care. As the universities continue to expand, there will be increasing opportunities for GPs to become involved in undergraduate teaching. Indeed, many GPs who wish eventually to become trainers use this as a first step to gain appropriate experience.

4.4 Additional Areas
As the delivery of clinical care evolves, further areas appear where GPs may become involved in teaching. Systems of appraisal have now been set up throughout the country. Although appraisal is not strictly a teaching activity, it was originally meant to be a formative activity and appraisers will need to have been trained for this particular role. A significant aspect of their duties will include the dispensing of educational advice.

Now that responsibility for signing off the Personal Development Plans (PDPs) of appraisees will rest with appraisers, their educational role becomes more significant. Another area of interest is the change in the Pre-registration House Officer (PRHO) year which has been replaced with the introduction of Foundation Programmes (as part of the Modernising Medical Careers initiative – see below) commencing in 2005. General practice will now be more commonly included in the foundation programme – in Scotland 20% of trainees in the second foundation year will spend four months in general practice. Similar plans exist for England and Wales and Northern Ireland.

The GMC is responsible for the structure of the PRHO year and in the past the regulations stipulated that each PRHO had to spend a minimum of 3 months in a surgical unit and a minimum of 3 months in a medical unit. More recently, attachment of PRHOs to Primary Care practices has been allowed and at present, a PRHO can spend a maximum of 4 months during the year in an accredited practice.

In 2002, the departments of health simultaneously published "Unfinished Business" and in 2003, after widespread consultation, the four UK Health Ministers in 2003 released the document "Modernising Medical Careers".

This proposed that medical students at the end of their training as students will enter a 2-year basic foundation programme to be followed by 3 years training in their chosen specialty. At the time of writing, it is not yet clear how the 2-year foundation programme will be structured although it was understood that exposure to general practice would take place in some form for all.

Recent developments suggest that GP exposure in the second year (F2) is not guaranteed in all parts of the UK. This is highly regrettable and is in part due to an absence of leadership and supervision from the Postgraduate Medical Education and Training Board (PMETB) at the present time. Currently, the GMC is consulting on how to amend and develop the previous PRHO year so as to fit into this foundation programme. There is also a UK-wide Modernising Medical Careers group which will oversee this work. What is clear though is that there will be a significant increase in the need for teachers in general practice to be responsible for PRHOs in the general practice component of the foundation programme in addition to all the current training needs.

5. GP Registrars
Whilst undertaking their training, GP registrars should begin to think about their short and long term plans once they have qualified as a GP. Careful consideration should be given to personal priorities and whether any future job has the potential to provide good patient care, a good working environment and a proper work life balance. As with choosing any new job, other factors to take into account are avoiding burnout, assessing the possibilities of academic success, and on a personal level ensuring that their income is sufficient to cover all outgoings.

We would recommend that GP registrars speak to their trainer or local deanery about career options, as well as consult fellow colleagues in practice. There is also a new GP career guide (General Practice, A Career not just a job, British Medical Association, July 2004) which gives a flavour of the various options available in general practice and is available from the BMA’s Publications Unit.

6. Salaried GPs
An increasing number of GPs opt to work under a salaried contract. The global sum under the new GMS contract gives practices new flexibility to appoint salaried staff. PCOs, with the new opportunity of direct provision, can now offer a salaried option. Further details on terms and conditions can be found on the sessional GP web pages of the GPC website and in particular, in a guidance note (Focus on ... Salaried GPs, General Practitioners Committee, June 2004) produced by the GPC, on salaried GPs - go there now. This guidance focuses on GPs employed by GMS practices and by PCOs.

In the future there will be an opportunity to work as a salaried GP for an Alternative Provider of Medical Services (APMS). The term "salaried GP" describes any GP who is employed by a practice, a PCO or an Alternative Provider of Medical Services (APMS). It includes assistants, associates, GP retainees, Flexible Career Scheme GPs, Returner Scheme GPs.

Funding for practice-employed salaried GPs will generally come through the practice's global sum payments. The exception to this is the salary of a Flexible Career Scheme, Returner Scheme or Retainee GP for which a practice receives varying degrees of reimbursement via their PCO. Funding for a PCO-employed GP comes directly from PCO-administered funds. GPs who are salaried by a PMS practice can use the guidance on terms and conditions as a model. GMS GPs will have to pay employer’s superannuation contributions and there are other factors that small practices should consider when employing salaried doctors and they would be best seeking professional legal and accountancy advice.

Practices should ensure that they offer the model contracts of employment as suggested by the BMA to their prospective salaried GPs so that they are employed on terms at least as good as those in the models. With the introduction of enhanced services under the new contract, more practices will run specialised clinics and some salaried GPs may find employment in these clinics.

A list of points to consider when weighing up terms and conditions of employment include continuing professional development, study leave, flexibility, golden hellos, maternity leave, paternity leave, annual leave, parental leave, pay, seniority, pensions, sickness benefits, appraisal and problems of isolation. One of the most important things to bear in mind is how to achieve a proper work life balance. PCOs should be looking to encourage a wider selection of salaried posts for new GPs. As opposed to peripatetic locum work these may offer a greater opportunity for continuity of care.

7. Finally - The Model Practice under new GMS?
The following is an interpretation of the effect the new contract could have on practices or more accurately how an ambitious practice could use the new opportunities to develop a progressive primary care business that encourages and promotes professional development. This is a contract for practices, not for individual GPs, and only a practice-based approach is likely to succeed, and to attract the right calibre of clinicians and other staff. One of the cornerstones in this strategy is Education and Training, not only because it is the correct professional approach, but also because it makes sound business sense. The new contract brings a complete change to the world in which practices exist, and those that react quickly and with enterprise are likely to be the ones who survive and prosper.

Stage One - Initial Planning
A basic (Strengths, Weaknesses, Opportunities & Threats) SWOT analysis, or similar approach, performed by partners or preferably by all senior staff allows a fresh look at the practice in its new environment. It should also inform or reinforce the strategic aims of the organisation. An example of a simple SWOT analysis in this context:

Strengths e.g.
- The range and quality of skills within the practice
- Teamwork and loyalty to the practice
- A secure or expanding list of patients
- Practice reputation in the community
- An ability to react to, and adapt to, change
- A record of professional development

Weaknesses e.g.
- Communication, external and internal
- Insufficient knowledge of the new contract
- Inexperience with GP, and other, appraisals
- Premises: space for expansion or teaching
- Financial uncertainty
- IT expertise
- Resistance to change within the practice
- Time management

Opportunities e.g.
- Quality and outcomes framework
- Control of workload
- Enhanced services
- Uncertain contacts/relationships with PCO and other organisations
- Use of appraisal etc to develop a learning culture
- The new contract specifically promotes GP careers

Threats e.g.
- Lack of information from PCO on local opportunities
- National/local staff shortages
- Competition for staff from other providers including Practices
- Financial problems at PCO level
- Lack of educational support
- Inability to control workload

Stage Two – Strategic Aims
The above illustrates the issues that will commonly affect a practice in today’s circumstances. The analysis should lead to a small number of strategic aims, agreed by all. For example:

Provide the highest possible quality of care to patients
Value and encourage all staff, including doctors
Build practice development on the personal development plans of partners

Stage Three - Planning for Success
The example given above illustrates how a practice might combine the new contract with a learning culture in order to develop the potential of all staff, provide high quality primary care, and attract new recruits in an uncertain market. Such an approach would be greatly assisted by a similar approach from the responsible PCO, and positive help from the Deanery.

Linked to this ideology would be a willingness to introduce flexible working patterns, enabling GPs and others to pursue a variety of roles both within the practice and beyond, and a determination to access support from all available sources.

The new GMS Contract provides a variety of opportunities to develop doctors’ potential, and the view from the educationalists is that we have the power to harness and develop these successfully, in order to deliver a higher standard of care to all our patients.