Summary of main findings and comparison with existing literature
Proportionately, salaried GPs are more likely to be at the extremes of working age (that is, the youngest and oldest), female, or overseas qualified, particularly from the European Economic Area. They are more likely to work part-time and hold PMS contracts. This contrasts with previous research which found younger men, those most noted for their risk-taking behaviour, predominated when salaried posts were first introduced.8 The evidence of this study supports the Williams et al prediction of an eventual salaried preference among females.8 Now, several years on, those most likely to be salaried are GPs seeking greater career flexibility (for example, part-time working), and who wish to be free from the roles and responsibilities of being a principal: including those trained abroad, women of child-bearing age, newly qualified GPs, and GPs nearing retirement.
These findings support the view that such GPs were previously under-utilised,9 and that salaried positions have enabled them to be more appropriately employed in patient care, perhaps leading to greater job satisfaction. An alternative explanation is that access to ‘principal status’ has become increasingly difficult. For example, practices could use salaried posts to negate the need to manage principal GPs not wishing to conform to a ‘traditional’ working model.
Unsurprisingly, salaried GPs are more mobile. This may be due to their shorter-term contracts and lack of long-term financial commitment to the practice as much as to personal preference (for example, those wanting mobility may prefer salaried status).6 The present data show that, overall, the number of GPs changing practice from one year to the next has almost halved. This is almost exclusively attributable to the increasing immobility of the GP principal population. Together these findings suggest that, before the popularisation of salaried posts, many principals who sought a more-flexible post had no such opportunity. However, when these opportunities arose, there was a large-scale movement to find a more suitable post. GPs who wanted to be principals remained so, whereas GPs seeking flexibility (including the expectation of being mobile) found salaried posts and continue to be mobile in a system that now facilitates this.
It was suggested that salaried posts may lead to improvements in practice performance; however, the present results are inconclusive. The data show that practices with salaried positions have only slightly higher QOF scores. Since the introduction of the QOF in 2004, GPs have surprised policy makers with their consistently high achievements on the QOF indicators.10 This lack of variability in performance limited the power of the present study to detect differences attributable to salaried status.
Originally, one objective of introducing salaried posts was to recruit GPs to deprived areas. Williams et al found limited evidence supporting this.8 The present results suggest that salaried positions now tend to be located in more affluent neighbourhoods. This may be due to the wider adoption of salaried positions by practices in more affluent neighbourhoods and/or better recruitment to those posts. An alternative explanation is that practices with higher QOF scores are located in more affluent areas. Wright et al found that practices in deprived areas tended to have markedly lower QOF scores than affluent practices,11 although Doran et al found the effects of deprivation on performance to be marginal.10 Whatever the explanation, it is clear that salaried GPs are now concentrated in affluent areas. Overall growth in the GP workforce may have increased the numbers in deprived areas, although at a lower rate than in affluent areas.
Introducing salaried posts has strongly appealed to particular subsets of GPs that did not fit well into the traditional model of principal status. Public health benefits, such as an improvement in practice performance and better recruitment into deprived areas, do not appear to have materialised. However, it is unlikely that only GPs have benefited. There may be benefits to patients of improved GP job satisfaction and workforce participation which could not be captured by this study.
Strengths and limitations of the study
This study delivers robust results as it provides an unbiased representation of the English GP population. It can probably be extrapolated to the rest of the UK. Its primary limitation is the inherent problem of cross-sectional analysis: for example, mobility analyses were performed on three cross-sectional snapshots. Ideally, GPs would be followed over the entire course of study, with no gaps. However, changes in administrative boundaries and data collection make this very difficult.
