The present state and future direction of primary care: a qualitative study of GPs' views.

BACKGROUND Over the past decade there has been a sharp increase in the number of non-profit-sharing salaried doctors employed by practices. This has been accompanied by the introduction of mechanisms to facilitate the entry of other providers into the primary care market. AIM To explore the views of GP principals and salaried doctors on current working practices and the future direction of primary care in England. DESIGN OF STUDY Qualitative study using semi-structured interviews. SETTING Twenty-two nationally representative practices across England, between February and August 2007. METHOD Interviews were conducted with 22 principals and seven salaried doctors. A topic guide included questions on motivations for working in primary care, descriptions of working lives, the way in which clinical time was spent, and predictions for future working conditions. RESULTS Significant changes to GP working arrangements were identified, including increasing pursuit of specialist clinical interests by GP principals and increasing employment of salaried GPs. These developments were reported as improving the working lives of principals but also creating a hierarchical structure at practice level that led to resentment among salaried doctors. Many of the salaried GPs felt disenfranchised and disillusioned by the difference in status and autonomy in decision making and the type of work they performed in the practice. Almost all GPs felt uncertain about the future of primary care and were concerned about the potential threat of private providers delivering primary care within the NHS through a largely salaried workforce. CONCLUSION By failing to recognise the problems of employing an increasingly disenfranchised salaried labour force, GP principals may be undermining the very ethos of general practice they otherwise advocate and recreating smaller versions of the private provider organisations they suggest threaten to corrode NHS primary care.