Practice Formation: GP Assistantships

Introduction

General practitioners join established practices in a variety of ways. With the exception of assistantships/partnerships in the GMS, there is no standardised approach.

This guide highlights the main issues that need to be addressed when contemplating general practice assistantship. It is a matter then for each party to negotiate on the specific terms applicable to their own circumstances and intentions. A separate guide is available on progressing to partnership.

Business Relationship

There needs to be an explicit decision and agreement on the business relationship intended and the terms of the agreement expressed in writing. If there is no intention to progress with the option of full partnership this should be stated at the outset. Where the 'business' relationship decided and agreed upon is to be that of an employed assistant than an employment contract, a contract of service should be drawn up.

Where the intention is not to create an employed assistant position then the assistant is an independent individual and the contractual relationship is a contract for services. Expressing the terms of the business relationship in writing is of advantage to both parties, but it worthwhile noting that a legal contract exists once there is offer, consideration and acceptance, whether or not the contract it is expressed in a written form. A written contract will not of itself prevent disputes occurring but it will help avoid many common problems and can frequently resolve those which occur by specifying the procedures to be followed when a dispute arise.

Contract Contents

Each of the following clauses should be considered, discussed and negotiated and agreed:

Date, Name, Title, Address and Nature of the Business

The key date is the date of commencement of the assistantship. The agreement must be signed by all parties. It is also important to state the nature of the business and specify the limitations of the agreement, e.g. that the assistant is/is not employed to work on other parts of the business e.g. occupational health contracts.

Duration

The duration of the agreement should be specified. Note: Where the contract is one of employment - the contract will either be one of fixed duration, specific purpose or the intention is create a permanent post. If the intention is to progress to partnership after a predefined and agreed interval the planned date of cessation of agreement and commencement of new arrangements should be stated. Excessive waiting periods are counter productive giving rise to assistant dissatisfaction, frequent turnover and disruption to both the practice and to patients.

Practice Location
Where the practice operates in more than one location it is important to specify where GP assistant (GPA) is to work.

Premises

Taking on a new GPA can have implications for the premises, is there adequate consulting and treatment facilities to accommodate the new doctor? Are health and safety issues covered in the induction period?

Practice Assets

An inventory should be drawn up of assets of the practice in advance of any new arrangements.

Working Hours

Expectations about working hours, including commencement and finishing hours, should be clarified and agreed. Out of hours arrangements/expectations should be thoroughly discussed and agreed in advance. Where the practice is part of a rota/cooperative arrangements need to be in place to ensure there is no obstacle to the GPA participating.

Remuneration

The rate of remuneration will obviously be a matter of negotiation between the parties. Expectations regarding remuneration will be informed by a number of factors: number of years experience, additional qualifications, special skills, going 'market' rates e.g. for locums and current remuneration levels of GPs in training. How will payment be made to the GPA? Weekly, monthly? It is recommended that the remuneration (and expenses) be paid out of the practice bank account not out of cash.

GPA and Practice Expenses

It should be clear how expenses are to be dealt with. What expenses are to be covered by the practice and which are to be paid by the assistant. Expenses may include travel, medical indemnity, professional registration fees and training. Basic internal accounting arrangements such as a petty cash, maintenance of receipts should be explained and adhered to.

Taxation

Where the GP assistant is an employee the principal will have a liability to deduct tax PAYE and pay employers PRSI. Where the GP assistant is contracting his/her services it is important that the principal has proof of the GPA's tax registration status. The principal should also seek the advice of the practice accountant /tax adviser in relation to potential exposure to tax or penalties in relation to the proposed arrangements. For example, it is important that the principal does not have exposure to employers PRSI/PAYE if the Department of Revenue assert that the GPA does not come within the definitions of a self employed person.

Practice Income

Arrangements regarding the collection of private fees and other income should be made clear to all in the practice including practice staff. Where the GPA generates additional income in practice time and/or while using practice facilities an agreement should be reached as to the retention/distribution of this income.

Allocation of New Patients

There needs to be agreement on, and consistency in, the allocation of new patients registering with the practice and it important that reception staff understand and are enabled to implement the agreed policy.

Clinical Protocols

Clinical protocols should be elaborated and agreed with the GPA. These should include protocols regarding clinical record keeping, prescribing and referral. The arrival of a new assistant can create an opportunity for the practice protocols to be reviewed and developed.

Practice Decisions

It is predictable that some dispute and disagreement will occur between the partied therefore it is important at the outset to agree how both routine and major decisions are to be taken and how disputes are to be resolved e.g. agreement on mediation if required.

Practice Management
The GPA needs to be made aware of all relevant practice administration and management procedures and protocols. Where the GPA is expected to take on some practice management responsibility this should be stipulated in detail from the outset. How the GPA is to integrate with the normal running of the practice should also be discussed, together with the limitations on authority and responsibility e.g. supervision and management of practice staff. It is important that the reporting structure is defined - this is of benefit to the new assistant, to the existing principal(s) and to practice staff.

Banking Arrangements

If the GPA is to have any involvement with the practice financial management e.g. lodging money, these arrangements need to be specified.

Leave Entitlements

Where the GPA is an employee the statutory minimum leave entitlements apply. Leave in excess of the minimum entitlement is a matter of negotiation. Where the contract is a contract for services there is no legal obligation regarding leave entitlement. In this case the length of leave must be negotiated as well as the whether payment will continue during period of absence. The issue of payment for locum cover must also be addressed - who pays and who has responsibility for making locum arrangements. These same issues must be address in the context of:

• Sickness: notification, locum, payment and certification are issues which should be addressed in advance.
• Maternity Leave: where the GPA is an employed assistant the normal statutory maternity and parental leave entitlements apply. Where the contract is one for services maternity leave arrangements need to be addressed at commencement.
• Study Leave: anticipating this at the outset and agreeing on terms is advisable.

Locum Provision

The provision of locum needs to be addressed - with regard to both the securing of locum cover and for payment/costs of locum for periods of the GPA's absence.

Notice

Periods of notice to be given by either party should be stipulated and agreed. Where it is the intention of the parties to progress the relationship towards partnership then dates should be specified and agreed in advance for when negotiations are to commence to achieve this objective.

Restrictive Clauses/Covenants
A principal may seek to protect their business by writing in a restrictive clause in the agreement. It is important to obtain specific professional advice as to whether such a clause is legally enforceable.

Confidentiality

An expressed term of confidentiality should be included in the agreement.

Professional Medical Indemnity

It is important to seek written evidence that the GPA has adequate medical defence insurance. It is a matter of negotiation as to the payment of the premium for this cover. It is advisable for both parties to inform their respective indemnity organisations about their new arrangements/roles.

Qualifications/ Certification

Qualifications of relevance will include:

• Evidence of full registration with the Medical Council.
• Evidence of registration on the Specialist Register.
• Evidence of EU/Certificate of Specialist training .
• Evidence of specialist GP training - certification of membership MICGP.

Principals should look for evidence of the qualifications required.

GP Assistant with a View to Partnership in the GMS

A Certificate of Specific Training/Acquired Rights in General Practice (EU Directive 93/16) is an essential minimum requirement for all general practitioners applying for GMS posts.

In addition the conditions for the employment of a GPA with a view to partnership in the GMS are stipulated in the Modified Conditions to GMS entry 1975, Paragraph 23)

a) The doctor recommended by the selection board shall serve as an assistant for a trial (probationary) period of six months. The arrangement may be terminated by either party, or by mutual agreement, during this period.

b) If the arrangement is terminated a new competition may occur with a new appointment of an assistant but if a partnership is not created within two years of the first assistant taking up duty the agreement of the health board to the employment of an assistant with a view to partnership in the GMS shall lapse.

c) During the trail period an assistant will not be entitled to enter into an agreement with the health board to provide services for eligible patients. He may, on behalf of the participating doctor, provide services for such patients but he shall not be assigned sole responsibility for any specific patients or group of patients.

d) The participating doctor shall retain responsibility for the provision of all patients on his list and shall also be generally responsible for the visiting and prescribing patterns of the assistant.

e) At the conclusion of the trial period the participating doctor and the incoming 'assistant with a view', enter into a partnership agreement. This statement of partnership witnessed by a notary public is submitted to the health board. The assistant shall then be awarded a GMS number and is entitled to enter into an agreement with the health board to provide services for eligible patients as a member of the partnership and acquire their own list.

f) Where such a partnership is dissolved with five years the junior partner shall lose his GMS contract and the panel of GMS patients shall revert to the senior partner. Ref to Appendix 3 regarding exceptions to these provisions.

Conclusion

Given the gender and age profiles, restrictions on training places and manpower difficulties, higher expectations of those graduating from training (and external factors such as the cost of housing) it is likely that established practices wishing to attract GPAs, whether as employees, self employed or with a view to future partnership, will of necessity, have to make the position more attractive. Flexible working hours, part time partnerships, better practice supports, less on call commitment and higher remuneration rates can be anticipated.

In a 'seller's market' established GPs can expect that prospective assistants will look for matters to be handled in a business like manner, with written terms and conditions, definitive dates and deadlines if it intended to proceed to partnership.

A number of conflicting issues will need to be reconciled:

• How much can the practice afford to pay?
• How is the principal to be rewarded for their investment in building up the practice?
• Is there any value to be placed on goodwill?
• How can the incoming potential partner acquire a position without exploitation?
• Will the single handed general practitioner/practice be able to support the remuneration expectations of the GPA, given the cost/revenue ratios of the business?

The key issue is whether by working together the practice can grow to support the desired return for both for their investment of time, work, effort and finance. Whatever format of assistantship/business relationship is agreed upon if it is to succeed it must:

• Be based on equitable working relationships.
• Governed by a written agreement.
• Follow sound accounting procedures and ensure that any liability for taxation if provided for.
• Ensure that good communications between the parties are maintained through regular formal partnership meetings as well as regular informal contact.
• Be based on appropriate professional advice and information, which has of necessity to include detailed financial data.