This guidance provides advice to those considering taking up a post as a Salaried GP within a Trust-run practice, specifically looking at areas where there may be differences between traditional general practice and a Trust-run practice.

How the practice operates

When deciding whether to take up a Salaried GP position in a Trust-run practice, some key points to consider include:

• whether the Trust uses the BMA model salaried contract and to what extent surgery structures, workload management, and unforeseen events are considered in the light of the model contract (such as whether they operate in sessions or hours)
• whether the practice can configure its services and processes to suit its list size, rurality and team structure, or whether this is managed in a centralised way
• the extent to which practice and Trust operations, processes and management have been integrated and the impact this may have on ways of working, responsibilities and workload
• whether salaried GPs are already represented on the Local Negotiating Committee, whether/how the practice liaises with their Local Medical Committee, and whether GPs are represented at senior management level within the Trust to ensure the GPs' voice informs how the practice runs
• whether the practice is a GPDF levy paying practice represented by your Local Medical Committee
• you might also seek out some information about the current practice staff and whether they are from the original practice, so you can better understand the history and workforce.

Contracts and employment

BMA policy states that all Salaried GPs must be employed on terms no less favourable than the BMA model salaried GP contract.

If the Trust uses the BMA model salaried contract, use our guidance to make sure you understand your rights and responsibilities.

If the Trust is using an amended version of the BMA model, use our guidance to identify if the terms are no less favourable.

If the Trust is using a different contract, use our contract checking service to identify if it is appropriate, and contact the BMA to get support in negotiating terms no less favourable than the BMA model salaried GP contract.

Remember - your employer won’t be at the practice and you may be reporting to someone who is also at a remote location. Make sure you know who to contact and how when you have queries about your contract, or for contract-related processes, like taking time in lieu, claiming overtime, and flagging where overtime is a regular problem.

Roles and responsibilities

Your roles and responsibilities should be listed on the job description or job plan. It is important to understand whether the role has a managerial component more akin to a partner role, or whether it is purely clinical like the traditional Salaried GP role.

If the role has a managerial component, you may be responsible for the provision of services and managing staff in the same way as a hospital department might operate, but with support from wider management, HR and financial functions.

Unlike in traditional general practice, the Salaried GPs might be the most senior people at the practice, with line managers and those responsible for the service and staff at a different site. Make sure you know the arrangements for who you report to and how, and what to do if you have concerns about your roles and responsibilities – it will not be as simple as speaking to a partner in the practice.

It is important to clarify the levels of general responsibility and degree to which you have supervisory or line management responsibility for other practice staff. These may be parts of the role you have not experienced before so you must be sure you are able to undertake these responsibilities and receive any related training from your employer.

Where tasks are delegated to other clinical staff (like pharmacists doing medicines reconciliation for discharged patients or home visit triage done by paramedics or nurse practitioners), you will need to ensure you understand your role in supervision of these colleagues (which should be set out in the role profile). You should also find out what cross-cover arrangements are in place when the duty person (for example duty pharmacist) is off sick. The work may revert back to the GP on duty who holds overall clinical responsibility, or it could be covered within that health practitioner’s team.

There may be opportunities for varying levels of management responsibility to suit different interests and experience. For example, Senior GP roles with additional responsibilities such as becoming the 'clinical' or 'executive' lead for a practice or across practice sites for specific activities like safeguarding, complaints or training. These roles tend to be appointed on a 3-year basis.

It is worth finding out about the internal appraisal processes and to what extent they focus on career development and support, or on Trust priorities like reducing emergency admissions or outpatient waiting times. It will be important to know if the appraiser is a GP themselves. It will also be important to understand how the annual appraisal process links to the contract you would be employed on.

If possible, speak to existing and former post holders from these practices to understand the role. Ask for some context about why the vacancies have arisen: is there a specific reason, or is it a general vacancy?

The size and variety of services provided may offer greater opportunities for GPs to take on a varied portfolio at the outset. This could involve combining GP work with some hospital based clinical work like Emergency Department, or with non-clinical roles like training, education and research. Find out to what extent these portfolio sessions are protected from general day-to-day workload pressures.

Salaried GPs may be able to access leadership courses which other Trust-employed (hospital) staff can access – find out if this is possible when enquiring about the role.

Ways of working and technology

Make sure you understand how decisions around technology and ways of working are made and influenced in an integrated system.

Hospitals may not have adopted the digital solutions that might be the norm in traditional general practice, such as electronic records or digital voice dictation. The technology in use at the practice will depend on whether the Trust is involved directly in the running of the practice, whether it is the practice staff that manage this, and whether the existing technology (before the core contract moved from the practice to the Trust) has remained in place.

For example, the adaptation to a digital first model in April 2020 to assist with the COVID-19 pandemic, and the reversal back to more face-to-face consulting in Spring 2021, are worth discussing to understand how changes were agreed, implemented and monitored.

Be clear around processes for IT changes, especially where there are IT failures or downtime – including who to contact, what level of priority the practice might receive (in line with A&E for instance) and other considerations.

The movement to implement high-impact actions in primary care which can significantly reduce workload for GPs and increased efficiency may have been slower in Trusts where there may be a comparatively reduced understanding of the GP role.

When joining a Trust-run practice, make sure you are familiar with the technology and process for dealing with correspondence, coding, generating reports, and management of prescription requests. Although these are increasingly delegated to other staff in traditional practices, they may be handled differently in a Trust-run practice.

The impact of vertical integration (of primary care with secondary care) may have a significant impact on the technology and process, but also on your workload, ways of working, and potentially on clinical pathways. Ensure you understand the extent to which the practice has integrated within secondary care.

It could mean, for example, a more onerous home visiting role, or it could mean better supported discharges and more access to ambulatory care advice. It can be rewarding to have better access to other practitioners within the Trust (such as MSK practitioners) and helpful to be physically co-located near specialists whom you can approach informally for advice.

Some integrated systems may offer extra lines of support and communication between GPs and specialists, which may make managing challenging patients less stressful. For example telephone advice lines, joint educational sessions for all Trust doctors, cross-interface working groups, feedback on (or development of) clinical pathways, and collaboration on piloting new care models.

Find out whether the organisation encourages and supports continuity of care for patients – a fundamental element of clinician fulfilment, over access targets – and whether this is a Trust decision or something they delegate to the practice. GPs have told us that the promotion of continuity of care over simple access is a means of preventing burnout, so this is to be encouraged.

Complaints and SEAs (significant event audits)

Complaints processes are generally managed through legal departments or through PALs (patient advice and liaison services); this may remove the personal burden on the clinicians to respond within the necessary timescales, but may also remove you somewhat from the process.

Your indemnity should be provided through either CNSGP (Clinical Negligence Scheme for General Practice) or through CNST (Clinical Negligence Scheme for Trusts) – you will be employed by a Trust but also operating under a primary medical services contract. Make sure you confirm this is the case and that you do not need to seek further clinical indemnity cover. You should purchase additional indemnity from a medical defence organisation for support with complaints, investigations and clinical disciplinary matters. Make sure you are also covered for private or fee paid work.

You should always be able to access independent advice from your medical defence organisation and use this in a response to any complaints pertaining to your practice.

The arrangements for clinical indemnity will have an impact on how to respond to complaints and SEAs.

SEA discussions are a key part of improving quality and protecting patients and clinicians. It is essential to include frontline staff along with those who have the authority and influence to effect system changes. Find out how the Trust manages primary care SEAS, and ensure the process involves the correct individuals and that any changes are introduced in a timely way.