The independent contractor model: importance to GPs’ autonomy, culture, and practice

Armando Henrique Norman is a family physician and professor in family and community medicine at Federal University of Santa Catarina, Brazil.

The general practitioner independent contractor model was already in place before the inception of the NHS through the Health Insurance Act in 1911. It was also a prerequisite for GPs to support the creation of the NHS and was portrayed as a “freedom of practice issue” (p.7).¹ In this way, GPs managed to remain outside NHS’ hierarchy and bureaucratic structures, as compared to hospital doctors, by holding a contract for service and not a contract of service. Medical service contracts symbolise a reciprocal-supported political relationship, where different powerful members negotiate their interests as documented by GPs’ three main contract agreements: 1966, 1990, and 2004 (Table 1).

Table 1.  Summary of three main contracts’ characteristics.

  Source: elaborated by the author.

Table 1 shows a progressive increase in control over clinicians’ autonomy and specification of their activities. This article discusses the importance of contracts in shaping GPs’ autonomy, culture and practice.

The 1966 contract: quality as a professional duty

The 1966 contract strengthened general practice specialty framed around GPs’ patient-advocate role and doctor-patient relationship. Different from hospital-based biomedical model, that created focused specialists (e.g., Cardiologists, Endocrinologist, etc.), GPs developed a holistic and community-based patient care approach in medicine.  Balint’s biographical model and Engels’ biopsychosocial model contributed to pave the way of general practice distinctiveness coupled to GPs’ traditional 24/7 care commitment and personalised patient lists.⁸ Thus, the 1966 contract was so successful  that by the 1980s’ general practice had become a very promising career, as documented by: (a) a steadily increase in the number of GPs; (b) the women doctors constituted ‘nearly a third of those under 35 compared with 9% of those aged 65 or over’; and (c) doctor/patient list ratio went down due to the increase in the number of GPs (p. 201).⁹ Additionally, most preventive procedures including cervical smears, immunisation, family planning, chronic and acute care were being delivered with the expansion of healthcare teams, i.e., practice nurses, community nurses, and health visitors.⁶ Thus, 80-90% of clinical issues could be managed in primary care.¹⁰

The 1990 contract: quality as an ‘accountancy’ model

The 1990 contract inaugurated Margaret Thatcher’s new management style for running the public sector. It represented a clear attempt to control GPs’ autonomy by an increase in accountability within the NHS newly created internal market. For Gramsci (p.371)¹¹ the free-market ideology is ‘a form of State “regulation”, introduced and maintained by legislative and coercive means. It is a deliberate policy, conscious of its own ends, and not the spontaneous, automatic expression of economic facts.’ In other words, the market risk-taking and entrepreneurism ideology require greater control, specification, standardisation and measurements at its meso- and micro-institutional levels. GPs’ reaction to the 1990 contract can be summarised by BMJ editorial: ‘[It was] one thing to have clinical advice issued as guidance, but to be told when to measure blood pressure, test a urine sample, or ask for a family history in the regulations of an act of parliament is another dimension altogether’.¹² The introduction of some preventive and health promotion targets was government attempt to evaluate quality of general practice. These included checks on new patients, on those over-75s, on those who have not seen a GP within the previous three years, as well as the provision of advice on smoking cessation.² However, the absence of a unified scientific model prevented a robust quality contractual framework.  It would take more than 10 years for policymakers to have a strong control over general practice.

The 2004 contract: quality as a ‘scientific-bureaucratic’ model

The 2004 contract denotes a major cultural change in the UK general practice due to the inclusion of the Quality and Outcomes Framework (QOF): a monetary incentivised ‘scientific-bureaucratic’ model of practicing medicine.⁷ The rise of Evidence-Based Medicine (EBM) – a new way of teaching and practicing medicine – co-opted GPs by, apparently, producing a framework that levelled all physicians, independent of their specialty.¹³As a ‘gold standard’ for assessing quality and effectiveness of a biomedical intervention, EBM contributed to portray science as ‘neutral’ and ‘objective’.¹⁴ Nevertheless, EBM’s population and probabilistic reasoning differs from GPs’ individualised and crafted approach, as they manage more complex cases frequently excluded from randomised controlled trials. In EBM context, holism and patient-centredness have been relegated as they are difficult to measure or to put in a template. Thus, the subjective and subtle aspects of general practice have, to some extent, suffered with the EBM model.

As shown in Table 1, the pursuit of ‘quality’ in primary care has changed from an individualised type of care to a population model of care over the years. The 2004 contract prioritised QOF targets over patients’ main concerns and agendas, strengthening a fragmented model of care by commodifying patients and their measurable components.⁴ Indeed, the NHS clinical governance framework foisted ‘…a Fordist labour process, featuring increasing degrees of specification, standardisation, and centralisation of control’ (p. 475),¹⁵promoting a standardised-mechanistic type of care rather than a holistic, personalised and crafted one.⁸

The politics of culture itself

Culture – defined by Gramsci as “how class realities are lived” –¹⁶ is equally important as economy. As Crehan (p. 96)¹⁶ explains, to reach a hegemonic culture requires the incorporation of ‘at least some of the interests of subordinate classes so that it appears to represent the interests of society as a whole’. In this regard, intellectuals have a relevant role as GPs have historically fought to overcome their low status in medicine.  McDonald et al., (p.1200)¹⁷ have highlighted that ‘QOF component was largely informed by the input of academic advisers (Roland, 2004) or, in Freidson’s terms, medical (knowledge) elites.’ Therefore, the intellectual influence of EBM-best practice,  the coerciveness of the NHS clinical governance system and monetary incentives have helped to persuade large number of GPs to incorporate a new ‘convention and practice’, i.e. a new culture.¹⁸  For instance, the coerciveness of the 2004 contract was considered by some GPs as a ‘bribe to implement a population-based disease management programme’ (p 435).¹⁹ To illustrate this statement, the first three years of “QOF era” have represented 58% of GPs’ economic increase as the 2004 contract has also embedded a ‘monetary incentive’ to drop out the 24/7 care commitment.²⁰ Furthermore, to circumvent the 2004 contract power imbalance, policy-makers have framed it as voluntary. This has conveyed a feeling of horizontal rather than a vertical agreement, helping dissipate oppositions and favouring those unsure to gradually accept the new contract scheme.¹⁴ Nevertheless, the enthusiasm for and voluntary nature of technological innovations usually change post-implementation, ‘when a technology, together with the supporting infrastructures, becomes institutionalised, users often become captive supporters of both the technology and the infrastructures (p. 94).’²¹ The QOF scheme has gradually diminished over time, but to some extent,  it ‘…has become embedded as part of the identity of primary care in the UK’ (p. 394).²²

Final comments

The independent contractor model of UK general practitioners is a “…working example of social democracy…” providing GPs with autonomy and flexibility to adjust to population’s diversity and health needs.²³ However, Young and Leese have highlighted that ‘…the balance of independent contractor status’ has been tipping ‘from autonomy towards bureaucracy…’ (p.832).²⁴ This might be one of the contributing factors for the significant decrease in GP partners (nearly 25% in a decade), practices closure (20% less in 2024 as compared to 2013), and struggle in GPs’ recruitment and retention.^24,25 Thus, in the battle for preserving the independent contractor model, GPs should carefully scrutinise the nature of the contract itself, otherwise it might jeopardise the more subtle aspects of what means to be a general practitioner in the UK.

References

1. Addicott R, Ham C. Commissioning and funding general practice: making the case for family care networks.; 2014. Accessed August 18, 2025. www.kingsfund.org.uk
2. Lewis J. The medical profession and the state: GPs and the GP contract in the 1960s and the 1990s. Soc Policy Adm. 1998;32(2):132-150. doi:10.1111/1467-9515.00093
3. The King’s Fund. Improving the quality of care in general practice. 2011. Accessed August 18, 2025. https://www.kingsfund.org.uk/publications/improving-quality-care-general-practice
4. Norman AH, Russell AJ, Merli C. The quality and outcomes framework: body commodification in UK general practice. Soc Sci Med. 2016;170. doi:10.1016/j.socscimed.2016.10.009
5. Shields PJ. ” The best is yet to be ” – an evaluation and comparison of general-practitioner medical services. BMJ. 1965;1(January):49-52.
6. Pereira D, Marinker M, Maynard A, Volume MLJ, Gray P. The doctor, the patient, and their contract: I the general practitioner’s contract: why change it ? BMJ. 1986;292(6531):1313-1315.
7. Harrison S, Moran M, Wood B. Policy emergence and policy convergence: the case of “scientific-bureaucratic medicine” in the United States and United Kingdom. The British Journal of Politics and International Relations. 2002;4(1):1-24. doi:10.1111/1467-856X.41068
8. Checkland K, Harrison S, McDonald R, Grant S, Campbell S, Guthrie B. Biomedicine, holism and general medical practice: responses to the 2004 general practitioner contract. Sociol Health Illn. 2008;30(5):788-803. doi:10.1111/j.1467-9566.2008.01081.x
9. Iliffe S. The modernisation of general practice in the UK: 1980 to 1995 and beyond. Part I. Postgrad Med J. 1996;72(846):201-206. doi:10.1136/pgmj.72.846.201
10. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. doi:10.1111/j.1468-0009.2005.00409.x
11. Gramsci A. Selections from the prison notebooks of Antonio Gramsci. Edited and translated by Quentin Hoare & Geoffrey Nowell Smith. London: ElecBook.; 1999.
12. Primary health care: an evolutionary agenda. BMJ. 1986;292(6529):1159-1160. doi:10.1136/bmj.292.6529.1159
13. Harrison S. Co-optation, commodification and the medical model: governing UK medicine since 1991. Public Adm. 2009;87(2):184-197. doi:10.1111/j.1467-9299.2008.01752.x
14. Roland M. Linking physicians’ pay to the quality of care – a major experiment in the United Kingdom. New England Journal of Medicine. 2004;351(14):1448-1454. doi:10.1056/NEJMhpr041294
15. Harrison S. New labour, modernisation and the medical labour process. J Soc Policy. 2002;31(03):465-485. doi:10.1017/S0047279402006694
16. Crehan KAF. Gramsci, culture and anthropology. London: Pluto Press; 2002.
17. McDonald R, Checkland K, Harrison S, Coleman A. Rethinking collegiality: restratification in English general medical practice 2004–2008. Soc Sci Med. 2009;68(7):1199-1205. doi:10.1016/j.socscimed.2009.01.042
18. Napier AD, Ancarno C, Butler B, et al. Culture and health. The Lancet. 2015;384(9954):1607-1639. doi:10.1016/S0140-6736(14)61603-2
19. Mangin D, Toop L. The Quality and Outcomes Framework: what have you done to yourselves? Br J Gen Pract. 2007;57(539):435-437. https://bjgp.org/content/57/539/435
20. NHS Pay Modernisation: New contracts for general practice services in England. The Stationery Office; 2008. Accessed August 18, 2025. https://www.nao.org.uk/reports/nhs-pay-modernisation-new-contracts-for-general-practice-services-in-england/
21. Franklin UM. The real world of technology. CBS Massey Lectures Series. Revised edition. Toronto: House of Anansi Press Limited; 1999.
22. Ashworth M, Marshall M. Financial incentives and professionalism: another fine mess. Br J Gen Pract. 2015;65(637):394-395. doi:10.3399/bjgp15X686005
23. General Practice’s independent contractor model must be fought for or risks being undermined by lack of political support – BJGP Life. Accessed August 17, 2025. https://bjgplife.com/general-practices-independent-contractor-model-must-be-fought-for-or-risks-being-undermined-by-lack-of-political-support/
24. Young R, Leese B. Recruitment and retention of general practitioners in the UK: what are the problems and solutions? Br J Gen Pract. 1999;49(447):829.
25. Hawthorne K, Ellenby R, Keeling C, Blythen C. The GP partnership model: how can we retain its benefits while evolving to meet new challenges? Br J Gen Pract. 2025;75(757):340-341. doi:10.3399/BJGP.2025.0372

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