ICGP Sign Posts To Success

Signposts
to Success
A handbook for the establishing General Practitioner
Dr. John Ball

Mr. Dermot Folan
Dr. Shane McKeogh
Signposts to Success
A handbook for the establishing General Practitioner
Authors
Dr. John Ball

Mr. Dermot Folan
Dr. Shane McKeogh
Published by ICGP September 2008

Copyright @ ICGP 2008
ICGP Network of Establishing General Practitioners
Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 1

“ To know the
road ahead ask
those coming
back
(Chinese Proverb)
Electronic Version
”
The electronic version of this publication is available online at www.icgp.ie (Members Section in PDF
format)
Feedback
Feedback is welcome on the content of the publication and in particular suggestions for future updates.
Please e-mail: info@icgp.ie.
Funding
This publication is an initiative of the ICGP Network of Establishing General Practitioners (NEGs) Project,
supported by the ICGP Education and Research Foundation and HSE-METR.
2 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

Signposts to Success – a handbook for the
establishing General Practitioner
Contents
Introduction 8
1. Basic Requirements for Independent General Practice 10
2. Roles, Titles & Job Descriptions 16
3. Establishing A Practice 22
4. The Business of General Practice 34
5. Providing for the Future 48
6. Taxation 62
7. Negotiation 76
8. Sample Models of Partnership 84
9. Practice Management 90
10. State Contracts held by General Practitioners 104
References and Further Reading 116
Appendices 118

Foreword
This publication by the ICGP-NEGs Project is both As General Practice changes so must the ICGP in
timely and aptly named. Timely, as it is a time of response to the needs of the members and our
great opportunity for younger doctors given the patients. It is appropriate that younger doctors
demographics of the current cohort of more- would become more involved in College activities
established General Practitioners. Aptly named in and take on some of the tasks of directing the
that this situation also allows for a greater number way forward. We as a profession should be
of choices, some of them in areas which could be proactive as well as responsive and it is vital that
described as unfamiliar territory. It is useful to be all age profiles are represented at a level within
able to refer to a resource which can both indicate the College where policy is determined.
potential directions but also outline the merits and
pitfalls of taking particular routes. It is my privilege on behalf of the ICGP to
acknowledge the foresight and huge volume of
One of the strengths of Irish General Practice work contained in this very significant publication
is its diversity. Each practice having its unique and to congratulate the authors who should be
characteristics developed over the years in proud of the fruits of their labour. I am confident
response to the needs of the local community it that it will serve the needs of both establishing
serves. Embarking on a career as an independent and more-established GP’s well into the future
General Practitioner poses many challenges. For and will strengthen the profession of General
younger GP’s completion of formal training has Practice.
equipped them with a high degree of competence
in clinical decision making but now they are faced
with choices outside this arena which will have
a profound influence on their professional and Dr. Mark Walsh,
family lives into the future. This publication will Chairman ICGP.
also be a valuable asset to GP’s throughout their
careers as the business and administration of
General Practice has to evolve in response to a
changing society. Reference to the issues outlined
in the document can only be useful in informing
decisions on an ongoing basis particularly as
it is intended that the electronic format will be
dynamic and responsive to the current perceived
needs.

Authors: Dr John Ball:
John started up his own practice with a partner in
2007 and is based in Fairview and Raheny in north
Dublin. He has become a G.P trainer with the
Mr. Dermot Folan: TCD/HSE (Dublin Mid-Leinster) Specialist Training
Dermot is the Assistant Chief Executive of the Programme in General Practice from which he is
College and it’s Director of the Management also a graduate.
in Practice Programme which provides advice,
information, training and consultancy to general
practitioners and practices. He is the author/editor Dr Shane McKeogh:
of several publications on practice management Shane graduated from the RCSI Specialist Training
themes including, financial, human resources, Programme in General Practice in 2006. Prior to
surgery premises and also the role of the practice this, he completed a General Medical training
nurse. A regular contributor to Forum, Journal of scheme attached to St. Vincent’s Hospital in 2003.
the Irish College of General Practitioners, Dermot He spent six months working as a GP principal in
is also a member of the editorial board. Perth, Australia and works now as a GP Assistant
in Dublin.
ICGP Network of Establishing General

Practitioners (NEGs) Project:
John and Shane are Joint-Project Directors of the
Network of Establishing G.Ps since January 2007.
The NEGs project was created in 2004 to enable
the College to focus on and address in a practical
way the unique needs of GPs who are establishing
their career in General Practice. Parallel with this
the project aims to foster greater involvement of
establishing GPs in College structures and affairs
thereby investing in the future of the College,
ensuring it remains more robust, dynamic and
effective.

Contributors: NEGs Steering Committee:
The authors are grateful for the expert input from Dr. John Ball, Dr. Shane McKeogh, Dr. Aisling Ní
the following contributors: Shúilleabháin, Dr. Shane McCarthy, Dr. Sinead
Murphy, Dr. Brian Osbourne, Dr. Sheila Stephens,
Mr. Joe McAvoy, Director, Tax Services, McAvoy Dr. Catherine O’Donohoe, Dr. Cliona Ryan, Dr.
and Associates, 10 South Bank, Darach Ó Ciardha
Crosses Green, Cork. Website: www.mcavoy.ie
Mr. Laurence Daly, Director of Financial Planning at

McAvoy and Associates.
Mr. Finbarr Murphy, Director of Industrial Relations Disclaimer:

Irish Medical Organisation, 10 Fitzwilliam Place, While every care has been taken to ensure the
Dublin 2, Website: www.imo.ie accuracy of the information contained in this
publication the reader is strongly advised to
seek legal and professional advice when making
Acknowledgements: decisions of a legal or financial nature.
The authors are indebted to the following people
for reviewing the initial draft:
Dr. Deirdre Burns, Dr. Daragh O’Neill, Dr. John
Farrell, Dr. John Ferguson, Dr. Gerry Mansfield,
Dr. Ben Parmeter, Dr. John Duignan, Dr. Pascal
O’Dea, Dr. Eimear M. McCarthy, Dr. Scott Walkin,
Dr. Yvonne Hall, Dr. Darach Ó Ciardha, Dr. Sinead
Murphy, Dr. Aisling Ní Shúilleabháin, Dr. Shane
McCarthy, Dr. Catherine O’Donoghue, Dr. Stephen
Hawkins, Dr. Naoimh Kenny, Dr. Aoife Cody.
Thanks also to ICGP staff especially - Ms. Margaret

Cunnane, Ms. Patricia Patton and Ms. Gillian
Doran, Ms. Orla Sherlock, Mr Shane Folan for all
their assistance, dedication and patience.

Introduction There are over 600 doctors who have registered
as members of the ICGP NEGs group. An ICGP
Newly qualified GPs sometimes finish their survey carried out in April 2008 showed that
training with a sense of anticlimax. Time flies by 62.8% were female with 37.2% male. 76.1% of
and suddenly, ten or more years have passed the group were working for less than six years in
and formal undergraduate and postgraduate General Practice and 91.2% were less than forty
medical training has been completed. The years of age.
MICGP qualification and Certificate of Satisfactory
Completion of Training have been attained, and The NEGs group aims to provide signposts on
one can call oneself a General Practitioner. The the journey from finishing formal training to
hospital years may have been prolonged and establishing as a principal in General Practice.
frustrating but they were also associated with The initiative has enabled establishing GPs to
a now much missed camaraderie. No longer is identify and meet colleagues at a similar stage in
one a PAYE employee of the HSE but rather, self their working life and thereby create local based
employed, and without a permanent job the future support structures.
can seem rather daunting. Having just moved from
a world of structure to a relatively unstructured The NEGs Project aims to
environment, the sense of change may, at times, • Clarify the needs of Establishing GPs
seem overwhelming. Whilst this time can be • Allow a forum for information exchange &
intimidating, and certainly represents a steep support
learning curve, the potential to use personal • Foster a greater involvement while
initiative to control the direction of one’s life and representing the views of establishing GPs
manage the future can be exhilarating. You are within College structures and affairs
trained to deal with anything and you look forward
to a life in general practice. Now, it’s time to make The Network has a national Steering Committee
some real decisions…. and two Project Directors. The committee
is made up of regional representatives who
organise local regional meetings on topics of
About the ICGP Network of Establishing interest to establishing GPs. Regional meetings
General Practitioners (NEGs) were found to be an effective medium for
The network was created by the college to better organising establishing GPs locally both in terms
meet the needs of doctors as they progress from of information dissemination and networking. At
training to establishment in practice. The initiative the time of going to press, regional meetings are
commenced formally in 2004 and is particularly being organised several times per year in Dublin,
interested in supporting and addressing the needs Cork, Galway, the Midlands and the South East.
of GPs including: Registrars, locums, sessional,
part time, job sharing, assistants (GMS or private),
new principals, and those who have recently
completed their training in other countries.

A particularly popular aspect of the NEGs Project Within each chapter, the reader will find
is the discussion board supported on the college information on the various non clinical aspects
website (www.icgp.ie/neg). This presents an of being a GP in Ireland today. The Handbook
easily accessed “sounding board” and support is intended to be a guide - and attempts to be
structure of their peers for establishing GPs. It was concise and accessible. Mention is often made
launched in 2007 and now represents one of the of other sources and ‘signposts’, online and
most popular discussion boards within the College. otherwise, for those requiring more detailed
Members of the committee have direct information on a particular topic. A topic may be
representation in the College and report to the considered briefly in one section but addressed
College executive and the Council. in detail in another, and as a consequence, the
reader will find some overlap.
A number of NEGs members also sit on the GP
Sub-Committee of the IMO and communicate It must be borne in mind, that many topics
back to fellow NEGs members on current covered in this guide are not “black or white”
developments related to IMO issues. just like in clinical practice. Equally each doctor
and indeed practice are unique and, as such, it is
difficult to define the “norm” in the absence of
Don’t know what we don’t know! objective data. Consequently, in some of the areas
Over the past few years, it has become increasingly we have not been prescriptive but have attempted
obvious to the NEGs group that it is the business to provide some examples which could serve as a
and organisational, rather than the clinical aspects, platform for further discussion between GPs.
of being a General Practitioner which may prove
most challenging for the Establishing GP. Most The publication is available online for ICGP
GPs have at least ten years training behind members as well as in printed form from the ICGP.
them in terms of clinical management of their Given that medicine, and indeed General Practice
patients but may have little, if any, training in itself, is an ever-changing field, it is envisaged that
the business of general practice. The consensus this publication will need updating periodically.
among establishing GPs is that they “don’t know This will occur in the on-line version.
what they don’t know”. By this, we mean that
they are unaware of the depth and breadth of We hope that this publication will serve as a useful
basic ‘business sense’ that is required in order to guide to the business and organisational world
function successfully as a GP. And often, this lesson of Irish General Practice. It will hopefully provide
is learned the long and the hard way. the establishing General Practioner with useful
signposts, help to avoid pitfalls and make easier
The NEGs group and the Management in Practice the steep learning curve of this aspect of general
Programme of the College, have to date provided practice!
advice and information on business management,
practice and career progression areas for GPs,
through a variety of media, most recently through John Ball, Dermot Folan, Shane McKeogh
the online NEGs discussion forum at www.icgp. August 2008
ie/neg. The College proactively commissioned the
production of this handbook as a practical point of
reference for the establishing GP.

1:
Basic Requirements for
Independent General
Practice

Introduction 509 132) for membership enquiries. Payments
can be made by monthly direct debit. For further
General Practice is an academic and scientific information log on to http://www.the-mdu.com/
discipline, and a clinical speciality with its own gp/index.asp
educational content, research and evidence base
and clinical activity, orientated to primary care.1 - The Medical Protection Society
This chapter outlines the basic requirements for The Medical Protection Society (MPS) is another
practicing as an independent general practitioner. UK based company providing indemnity cover
to Irish doctors. The MPS has a free phone
membership helpline (1800 509 441). Payments
1.1 Essential Requirements: can be made by monthly direct debit. For
a) Full General Registration further information log on to http://www.
In order to practice independently in any health medicalprotection.org/ireland/
care setting without supervision, a doctor must
hold a certificate of full registration with the Irish Both the MDU and MPS offer ‘occurrence or
Medical Council. The Medical Council provide incident based’ indemnity schemes which give
an annual Certificate of Registration following protection for claims arising from incidents that
the presentation of required documents and the occurred during the subscription period no
payment of an annual registration fee. matter when they are reported, even if it is many
years after that subscription period has ceased.
b) Professional Indemnity This provides ongoing protection at retirement
All doctors must have adequate professional or death - the latter prevents one’s estate being
indemnity for the work they perform.2 There are liable for claims.
three medical indemnity insurance providers
currently operating in Ireland. - Medisec
Medisec is an Irish company. It was set up by Irish
Subscriptions or premiums to medical defense GPs to provide indemnity for Irish GPs through
organizations are a significant expense for most a policy with Allianz Ireland plc. Medisec can be
non established GPs. The rate of subscription is contacted directly by free phone (1800 460 460).
based on income, whether one is in full time or Further information can be found at http://www.
part time practice. It is recommended to review medisec.ie
all available indemnity options to choose one that
best matches one’s current mode of practice. Policies with Medisec are currently on a ‘claims
made’ basis. This means the insured doctor is only
- The Medical Defence Union covered for claims arising from incidents which
The Medical Defence Union (MDU) is a UK based both occur and are reported whilst the policy is in
company providing indemnity cover to Irish force. Usually, therefore, when the policy expires,
doctors. The MDU has a free phone number (1800 so does the cover.
1 WONCA Europe. 2002.European definition of general practice/family medicine, adopted by ICGP. Available from:
http://www.globalfamilydoctor.com/publications/Euro_Def.pdf
2 Irish Medical Council, 2004.
A Guide to Ethical Behaviour and Conduct. 6th edition, Section 4.15, page 18,. Available from:
http://www.medicalcouncil.ie/_fileupload/standards/Ethical_Guide_6th_Edition.pdf

1.2 Register of Medical Specialists (RHS) The ICGP recommends that all general
– General Practice Division practitioners be registered on the Register of
The Medical Practitioners Act 2007 forms the Medical Specialist – General Practice Division
basis of all regulatory requirements governing the
practice of medical practitioners including general
practitioners. 1.3 Certificate of Specific Training/
Acquired Rights (CSTAR) in General
The Act was passed by the Oireachtas in May Medical Practice (Mutual recognition of
2007. At this point only certain sections of the Act professional qualifications in the EU)
have been ‘activated’. As yet this does not include This certificate is issued under Directive 93/16/
the section on competence assurance. However, EEC (Title IV), updated by Directive 2005/36/EC.
compulsory competence assurance will be a These directives facilitate the effective exercise of
requirement once the legislation is fully activated, the right of establishment and freedom to provide
the timing of which is not known at present. services as a doctor across the European Union.
Further information is available from the European
The Register of Medical Specialists is a voluntary Union website at http://europa.eu/scadplus/leg/
register at present. Specialists appear within en/lvb/l23021.htm
approved specialty divisions, in this case, the
Division of General Practice. Applications for
entry to this register are processed by the Medical In Ireland, the CSTAR is issued by the Medical
Council’s Registration Section. Council. A general practitioner is required to hold
this certificate in order to be deemed eligible
A specialist is a doctor who has completed to accept/hold a GMS contract in Ireland. This
their training and requires no further training certificate also entitles the bearer to work within
or supervision to practice independently in the state schemes in other member states of the
discipline of their choice. Specialist registration is EU. General practitioners are eligible for CSTAR
the best assurance to the public of the ability of a certification if they hold a recognised qualification
doctor to practice without supervision. in general practice in Ireland, i.e. the MICGP or
a recognised qualification from an accredited
Continuity on the Register of Medical Specialists is training body in another EU country and/or
directly linked to competence assurance structures have an acquired right to certification under the
and regulations governed by the Medical Council Directive.
(see 1.5 below for more detailed information on
Competence Assurance requirements). Doctors are also advised to be registered on the
RMS for the purposes of GMS appointments
(Refer to Chapter 10)

1.4 Membership of the Irish College of c) Membership/Fellowship Reciprocity – MICGP/
General Practitioners (MICGP) FRACGP
The MICGP is a recognised registerable Doctors holding the fellowship of the RACGP
qualification in the speciality of general practice (Royal Australian College of General Practitioners),
in Ireland. The MICGP qualification is an essential who intend taking up a GP post in Ireland, are
requirement for doctors completing general eligible to apply for membership of the ICGP
practice training in Ireland. The following are the under reciprocity agreements between the ICGP
routes to membership of the College: and the RACGP. Equally, members of the college
who wish to work in Australia may apply for the
a) Membership through Examination FRACGP qualification.
Applicants must hold a Certificate of Satisfactory
Completion of Training (CSCT) from an accredited d) Other qualifications/training/experience in
General Practice Training Programme in Ireland general practice
and have achieved a pass in all 4 modules of the Doctors who wish to become members of the
MICGP examination before being considered for College and who in the first instance, do not meet
election as a member by the College Council. the above criteria should contact the College
membership office, submitting a one page CV
b) Membership through Equivalent together with a formal request for a review of their
Qualifications qualifications and training.
Doctors applying for membership through
equivalent qualifications must hold a certificate
of completion of training issued by an accredited
training body within the EU and which includes a
form of summative/end point assessment.

1.5 Competence Assurance and who hold a recognised certificate of training in
Specialist Registration general practice obtained outside of Ireland may
In the past the remit of the Medical Council was also apply for entry onto the Register of Medical
to deal with regulating the quality and standards Specialists: Division of General Practice.
of undergraduate and postgraduate education
and training, as well as the implementation of On January 1st 2003, the Medical Council
disciplinary procedures and ethical guidelines. commenced the process of Competence
However, this latter function was less successful Assurance Structures (CAS) for all doctors on
in assuring the public about the competence of the Register of Medical Specialists. To date the
practicing doctors. It was felt that it was no longer Medical Council has invited approximately 1169
acceptable to identify and sanction bad practice GPs on the Specialist Register for General Practice
after the fact, and that proactive measures were to take part in a voluntary process of CAS.
needed to ensure continuing high standards
within the profession. This was very much in line GPs entered on the Specialist Register are
with similar thinking internationally. Competence expected to acquire a minimum of 250 points
Assurance (CA) therefore came into being. Its towards CME over a five year cycle, i.e. an
purpose is to ensure that doctors maintain the average of 50 credits per year. As a rule of thumb,
necessary knowledge and skills to function as one CME credit point will equate to one hour of
effective practitioners throughout their working educational activity. The Council of the ICGP has
lives. Thus, it aims to enhance the standard of adopted as policy that the role of the College
care provided by all doctors and to protect the is to facilitate and assist members to meet the
public from those who are performing badly. requirements, as set by the Medical Council, to
It is intended that CA will involve all doctors in remain on the Specialist Register for General
independent practice who are on a specialist Practice.
register. General Practice is recognised as a
speciality by the Medical Council and the ICGP With the implementation of the Medical
is accredited as the approved speciality body for Practitioners Act 2007, Specialist Registration
maintaining CA for GPs in Ireland. will become compulsory as will the process of
CAS. The ICGP will keep all members informed
The Register of Medical Specialities (RMS) was regarding any further developments, and will
established on 1st January 1997. For a GP to continue to assist its members in maintaining
be included on the register, they must apply Specialist Registration.
through the Medical Council.3 The ICGP, as the
regulatory body for general practitioners, assists CME credit points can be accumulated under four
its members on the register to meet the Medical headings:4
Council’s requirements. Doctors who have been
elected to membership of the ICGP are eligible to • Internal: to include case conferences,
apply to be entered onto the Register of Medical journal clubs and other educational
Specialist: Division of General Practice. Doctors activities that are department based,
3 Current fee is €180.

4 For details on current CME credit points refer to www.icgp.ie/cas and/or www.medicalcouncil.ie

hospital based or practice based. However, as GPs leave the public service domain
• External: to include attendance at on graduation, the question arises as to what to
regional, national or international do with the amount of money already paid into
scientific meetings, College faculty this superannuation fund?
meetings, and relevant courses,
workshops or seminars. There are two options:
• Personal Learning: to include
independent study, distance learning, a) Do nothing. Benefits become payable
computer-assisted learning, etc. on reaching minimum retirement age (as
• Research & Post-graduate Training and above) and if you do re-enter public sector
Supervision. employment at any stage prior to reaching
minimum retirement age you can accrue
While specialist registration and therefore additional reckonable service .
competence assurance is currently voluntary,
it will become mandatory in the future for all b) If superannuation payments have been made
practitioners to participate in Continuing Medical for less than 2 years, the facility exists to
Education (CME). reclaim the contributions paid through your
last employer. It is worthwhile noting this
refund will be taxable.
1.6 Financial Management
Commencing and maintaining basic financial Other essential areas for consideration which
management and record keeping is essential once are dealt with in greater detail in other chapters
one graduates from training. Even where the new/ include:
establishing GP remains as an ‘employed’ person,
addressing basic financial management is advised. • Financial Records
• Banking
The Non-Consultant Hospital Doctor (NCHD)
• Taxation
Pension
One issue which is of immediate relevance to • Income Protection
the GP Registrar on completion of training is the • Permanent Health Insurance
decision on culmination of previously accrued • Pension Planning
public service superannuation (NCHD pension). • Professional Advice
As former NCHDs and other public sector
employees, contributions will have been made to
an employee superannuation scheme. This will
have been deducted at source by your employer
(hospital/ HSE) and deductions recorded in
paycheques each month. All employees pay into
this scheme, which is a defined benefit ‘pay as
you go’ scheme with pension based on final salary
and payable at reaching minimum retirement age
(65 for new entrant or 60 for non new entrant).

2:
Roles, Titles and Job
Descriptions: Working
for and with others in
General Practice

Introduction In the long run, factors that define compatibility
are fundamental to a successful outcome in
There is a certain amount of ambiguity and working with other colleagues in general practice.
overlap surrounding the use of different terms Therefore, it is necessary to assess whether the
or job titles when describing a GP taking up practice has the potential to meet one’s needs and
work in an established practice. Titles such as whether mutual compatibility is a likely outcome
principal, partner, assistant (with or without a of continuing to work in the practice. Recognising
view), sessional GP and locum, may be misleading this in the early stages of settling in may save
in themselves, as different people define these many years of dissatisfaction.
roles in varying ways. Furthermore, there may be
a certain blurring of boundaries when it comes In this chapter, we attempt to outline the
to the work practices involved in these roles. For differences between various roles and try to
example, under what circumstances is a regular evaluate each one in terms of the advantages and
locum considered different to a sessional GP? The disadvantages they hold.
expectations pertaining to any, or all, of these
roles can vary between practices.
2.1 Locum GP
In any working relationship it is important that Working as a locum is a very flexible way to work
both parties have a clear understanding as to and can suit a lot of GPs, especially at either end
what is involved with regard to the work to of their career path. Directly after completion of
be undertaken, the remuneration involved, GP training, many people will undertake some
communication between parties, and as to form of locum work and it comes with many
whether the business relationship will develop and advantages, particularly in that it allows flexibility
change over time, e.g. in the case of a salaried and affords a broad range of experience. Locum
assistant progressing to partner status. As well work provides the opportunity for gaining both
as looking at how the parties to the arrangement clinical and practice management experience,
view one another, it is important that there is a e.g. in the use of different software systems.
clear understanding as to how one is perceived by As a locum, one has the chance to absorb the
others, e.g. colleagues and staff in the practice, best features of each practice. However, careful
Revenue, and also whether the law informs the planning is required to make the most of the
definition of the relationship, e.g. employee, self- experience.
employed etc.
With a top heavy age group in General Practice
There are a number of choices available when and an increasing female and part-time workforce,
working with other General Practitioners, each there is generally no shortage of locum work
having their own advantages and limitations. available at present. Positions can be found
Of course, the only real way of finding out if a through word of mouth and networking (including
particular practice situation is amenable is to the NEGs discussion board), CME meetings,
work within it for a period of time, in order to locum agencies1, and direct advertising, e.g.
assess if the practice has the potential to realise medical newspapers’ classified sections. In
one’s objectives and longer term career goals. relation to locum agencies, many do charge
1 See appendix 8 List of Locum Contractors.

commission to the locum and/or the practice, so relation to financial management, issues such as
it is important to clarify this at the outset. Out-of- recording income and expenses, the provision
hours services and GP co-ops also provide good for tax liabilties, pension contributions, income
opportunities for locum work to be undertaken. protection, permanent health contribution,
professional indemnity subscriptions, etc., are the
With locum work, one can generally decide the same for locum work as for other self-employed
time of the week that best suits their personal work2.
schedule, although working unsocial hours such as
nights and/or weekends may prove more lucrative. 2.2 Sessional GP
From a negotiation perspective, one needs to de- A sessional GP is one who can choose to work any
cide the rates/fees and rationale for charging such combination of sessions e.g. 2 days per week or 5
fees. This will be informed by current rates, both mornings per week. The first obvious advantage
nationally and regionally, the type of practice and to working on a sessional basis is job flexibility.
work load, the costs incurred in providing the serv- There is also the opportunity to work in more than
ice, the expectations of the practice and the rel- one practice. This can provide opportunities to
evant experience and qualifications of the locum. develop special areas of clinical interest. Sessional
For example, locum rates may have increased since work can explore different styles of practice
the last time the practice employed a locum. management, with a variety of GP teams and
personalities, allowing the establishing GP to
Flexibility can have its down side as there may not ‘mix and match’ practice types, to explore what
always be a supply of work to match one’s avail- form of practice is best suited to them. It can be
ability, with the consequence being a deficit in particularly worthwhile for newly establishing GPs
income. The lack of permanency and frequent to gain experience of working in practices where
changes of practice, location, patients and col- they may have an interest/prospect of a more full
leagues is the negative side and is perhaps the pay time commitment.
off for the freedom afforded by this type of work.
The obvious disadvantage is that the sessional GP
The day-to-day workload of the locum is usually is unlikely to have a “view” to becoming a part-
quite different to the sessional or full-time ner/owner in the practice. The sessional GP does
practitioner. It often involves controlling issues not have a share in the practice. As with locum
until the regular practitioner returns, rather than work, GPs who are paid per session do not have
solving problems. Repetitive work is another the security of a regular salary with paid sick leave.
feature, with repeat prescriptions and certification On the other hand, there can be greater freedom
a component of the work, which may not be regarding taking leave, be it annual, maternity or
professionally satisfying. One of the cornerstones other leave (this is likely to be unpaid leave). It is
of general practice, continuity of care, is also important however, that such issues are discussed
absent. Different management regimes may and agreed at the outset with principal/practice so
not always be conducive to working efficiently. that there is clarity regarding ‘entitlements’ and to
Additionally, a high standard of record keeping avoid misunderstandings.
- both clinical and financial - is required. In
2 See Chapter 4, ‘The Business of General Practice’

Serious consideration should be given to a formal Whether this is an advantage or a serious
contract outlining terms and conditions of the hindrance or even relevant depends on the
working relationship, especially if it is envisaged motivation and longer term objectives of the
that the position will be long-term. The sense of individual.
a lack of job security can and does arise in ses-
sional work if the practice considers that it can Patients’ perceptions are also important; they may
dispense with the sessional GP’s services at any not be aware of the internal practice arrangements
time and without notice. Following on from this, it and their need for continuity can be frustrated
is essential that the definition of the duration of a if the sessional GP does not have a long term
“session” and the associated rate of pay is agreed commitment to the practice. Equally, patients may
upon by both parties. While many sessional GPs perceive that a sessional doctor is not as good as
are employed and paid for working specific ses- the full-time doctors in the practice.
sion durations, they can find themselves working
beyond the contracted time in order to see all As with Locum work, sessional GPs are in the
attending patients without being reimbursed for short term essentially self-employed and the same
the extra workload. considerations and factors apply in relation to any
self-employed status3.
Generally speaking, sessional GPs are not
rostered for out-of-hours duties. Although not 2.3 Assistant General Practitioner
as big a problem as in locum work, the difficulty This is perhaps the title that causes most confusion
in providing continuity of care and follow-up for among those entering and working in General
patients is still an issue. This can be regarded Practice. An assistant is generally understood
as a significant disadvantage to sessional work. to be someone who has a commitment to the
Follow-up of investigations, processing of practice and takes on clinical responsibilities
incoming and outgoing correspondence when the similar to the principal(s). Although the assistant
sessional GP is not at work is very important and a is not a partner in the practice, this role should
specific member of the practice should be made be seen as one step in a progression towards
responsible for this follow-up. partnership. In the traditional assistant role in
a practice there are several issues that require
Many sessional GPs are employed to fulfil a clarification from the doctor’s point of view.
particular clinical need in the practice such as To start with, it should be clearly defined what
women’s health. While this may suit some, it can one’s employment status is within the practice.
lead to the GP becoming deskilled in other areas This will either be a contract for services, i.e. a
of clinical practice and becoming “pigeon-holed”. self-employed contractor providing services, or
a contract of service, i.e. an employee of the
Job satisfaction obviously plays a huge part in the practice.4
choice of work one undertakes and sessional work
probably doesn’t present the opportunity for full Revenue may take the view that locums, sessional
involvement in the management of the practice, GPs will be classified as employees, i.e. will be
or in decisions that will affect all personnel liable for PAYE, PRSI and will not be entitled to be
working in the practice. Sessional GPs may not taxed on a self employed basis. This and related
be involved in practice meetings or decisions and issues are discussed in more detail in chapter 6.
subsequently, a feeling of alienation can ensue.
3/4 See Chapter 4 ‘The Business of General Practice’.

Some Key Questions: 2. How are decisions to be reached between
The long standing joke that the only ‘view’ the two parties? How will conflicts be
available to assistant GPs is that of the car-park negotiated, arbitrated and resolved?
highlights the importance of clarity at the outset, 3. Overall, how does the practice operate,
in relation to what is on offer. It is a lot less regarding decision making, communication,
complicated and less sensitive to discuss and relative status of each partner/principal,
agree the reality of future prospects in a practice etc.?
from the outset. Some key questions to be
considered include: d) Earnings and entitlements
1. What is the specific earning capacity on
a) Partnership issues: offer now, and in the future?
1. How long is one required to work as 2. Will for example the new assistant
an assistant before the opportunity of commence on a fixed salary for an agreed
becoming a partner would arise? period and then progress to profit share?
2. Will this be with full parity? 3. What out-of-hours work commitment
3. Is it entry to the practice alone that is on is expected? What terms and payment
offer or will the prospective partner be rates relate to this work and what co-op
offered a share holding of the premises requirements, if any, will impact on the GP
(and/or rights to any lease arrangements)? assistant?
4. What are the provisions for exit of any of 4. What are the entitlements, maternity pay,
the partners, including the new partner/ pension and medical indemnity available?
prospective partner? Will the practice cover a percentage or all
5. How will entry to partnership/taking over of medical indemnity costs?
of the practice occur? Is it a ‘work in’, ‘work
in/buy in’ combination, or a straight ‘buy in’ e) Contractual Questions
deal that is anticipated by the practice? 5 1. Is a written agreement/contract to be
offered by the practice to the new/
b) GMS Issues prospective incumbent?
1. Is there a GMS list involved now or in the 2. Is the detail of such an agreement sufficient
future and can /will the GP assistant be to protect the interests of both parties?
nominated as prospective candidate?
f) Management Issues
c) Communication and Decision Making 1. What is the management structure in the
1. Is there also a phased entry to the roles of practice?
decision making and management in the 2. What are the relative levels of authority
partnership both between partners and partners and
the manager
5 See Chapter 7, ‘Negotiation’

In addition to the above the prospective assistant contract is in question, with a formal selection
should also seek answers to the following: process and is externally regulated after
• Why does the practice need a GP assistant at appointment. Note: the GMS principal must be
this point? at least 5 years from date of retirement in order to
• Practice Profile: how many active patients, apply for a GMS assistant.6
what is the consulting profile? What
administrative supports are in place to
support clinical work, and what systems, e.g. 2.4 GP Principal
administrative and IT, are used? A principal is generally taken to be one of the
• Practice Income: access to and accuracy of main stakeholders in the practice. They are usually
analysis of practice income and expenditure partners or associates.
• What is the current status of the other doctors
working in the practice? 2.4.1 GP Partner
The legal definition is that a partnership exists if
Many of the above issues are also addressed in people are conducting business in common with
subsequent chapters. a view to making profit. A partner in a practice is
a principal who shares profits and responsibilities
For the newly qualified GP, the advantage of GP in an agreed proportion, with the other practice
Assistantship may provide the most stable option partner(s). This may be expressed in a written
from a financial point of view and also in terms agreement and it is advisable to have a formal,
of career perspective; it allows for a sense of legally robust written partnership agreement.
inclusion in the practice, provides for continuity of Partner/partnership has a specific meaning in Irish
care and allows one to integrate with patients and law, and in the absence of a written agreement,
the wider community. It can also offer one a more the Partnership Act 1890 informs the rights and
detailed exposure to practice management: staff, obligations of the partners7.
finance, systems, and IT, all of which expands the
establishing GP’s skills and knowledge. In the context of ‘Assistantship with a view to
partnership in the GMS’ a written partnership
Of course, assistantship with a view to partnership agreement is a pre requisite to obtaining a GMS
may not suit everyone. There are disadvantages, number.
particularly immediately post-training, when a
short term (6 - 12 month) agreement may be more 2.4.2 GP Associate
preferable. Attempting to obtain a clear picture This is a term used to describe a relationship
of the practice and how it operates is essential in between GPs who share expenses and operating
making a decision to join a practice, in whatever costs but who keep their income (and possibly
capacity: their patients) separate. Such arrangements
require careful consideration and once again,
- GP Assistant with a view to preferably expressed in a written agreement.
Partnership in the GMS
The above term is specific and there is less
ambiguity than with other roles; a tangible state
6 See Chapter 10, ‘State Contracts’

7 http://www.bailii.org/nie/legis/num_act/pa1890154/s50.html

3:
Establishing a Practice

Introduction control systems, audits, calculation of tax liability,
and submission of tax returns. Many accountants
Establishing or setting up a practice applies to provide additional professional services including
many different scenarios. In the old fashioned business consultancy, preparation of business
sense, it can be about putting up your plate plans, investment advice, etc.
and awaiting business but the term also applies
to situations such as acquiring a GMS list, or In selecting a financial advisor such as an
modernising a long established practice. accountant, it is recommended that one initially
discusses specific requirements with a number
Chapter 1 summarised the basic requirements for of potential providers. It is important to compare
working independently as a General Practitioner the services provided and the professional fees
upon completion of training. structure, as well as any added value services.
Current and future requirements should also be
This chapter looks at the key issues which the considered. Fees are determined by the time
establishing GP will encounter in setting up a new taken, the seniority of the person doing the work,
practice. However, many of the areas addressed whether general or specialists work e.g. general
are equally relevant to doctors joining an existing accounting, specialist tax advice, the complexity
practice, where change in the operation of the of the practice/ business, standard of financial
practice is likely. Here, reference is made to these records maintained by the practice.
issues but dealt with in much greater detail in
other chapters of this publication. As with other relationships, it is a matter of
personal choice and a question of compatibility.
One should be able to easily communicate with
Basic requirements for one’s business advisor and have a comfortable
setting up a new practice relationship, as it is likely to be a long lasting one.1
At the outset the advisor should be able to explain
3.1 Select an accountant the rationale for professional fees relative to the
Before choosing an accountant, one should be services offered/provided.
fully au fait with the normal professional services
accountants provide and the additional wider
professional advice accountants may provide. A 3.2 Choosing a premises
key aspect in the selection process is to ensure The old adage of location, location, location
that the accountant chosen has a very good holds true for any business and general practice
knowledge of the day-to-day workings of a is no exception and a poor location may negate
professional medical practice, and has a practical all other considerations. This is obviously a
understanding of the characteristics unique to big decision but may not have to be made
general practice. An accountant (or accountancy immediately if joining an established practice.
firm) with a track record of working successfully Irrespective of this it is likely that moving or
for GP clients is to be recommended. The range developing a new practice building will happen
of services available from accountants is broad, at least once during one’s working life in general
including: setting up and monitoring of financial practice.
1 See Chapter 4, ‘The Business of General Practice’.

a. Budget (appointment, open access, mixed), the
A comparison of the estimated costs with available number of doctors, nurses, ancillary clinical
finance will determine the budget required for the services, administrative staff. Health and safety
structural needs (as to whether renting, leasing or regulations also mandate minimum work space
purchasing a site, a new premises). Consideration requirements. While it is obviously difficult to
also needs to be given to the fixtures and fittings make recommendations on size typically 600-700
that are needed. sq ft. area should allow good size for a reception,
waiting room, 2 consulting rooms, administration
The usual financial considerations should office, kitchen facility and toilet (s).
also be made: cost of finance, interest rates,
repayment period, variety of packages available. c. Location, Location Location!
A choice of providers exists in the market place, This is a key consideration - the practice needs
including those providers allied with professional to be as visible and accessible as possible to the
organisations. Thorough research should be patients and potential patients it seeks to serve. In
undertaken and all facts and figures need to be deciding on a location, one needs to gather key
committed to paper for effective comparison. information on building developments in the area,
population growth trends/projections, age/gender
Whether renting or purchasing a premises, one distribution, access to transport and other services
needs to educate oneself about commercial (IT, waste disposal), proximity of other general
realities. Consulting a number of commercial practices and primary care centres, location of
estate agents will provide a gauge of current ‘complimentary’ businesses, e.g. pharmacies,
property values (i.e. the price per square foot/ supermarkets. Patterns and volumes of both
metre). Ground floor premises will command pedestrian and motor traffic, parking locations,
different rates to other levels and impact on and crime levels are all factors to consider. It is
business needs to be taken into account. important to determine which tertiary care area
In order to estimate the purchase value, an old in which the practice/potential practice will be
rule of thumb is to multiply the annual rental located.
costs by 20-22. Values will obviously be location
specific and will change depending on market In most urban environments travel time and
climate. transport to work from home will be a factor for
the newly establishing GP and other practice
b. Space requirements personnel in terms of location decisions.
One needs to estimate how much space is
required and the relative breakdown of the An obvious but sometime overlooked issue
different work spaces within the premises: in planning premises and location is that of
consultation, treatment, waiting, administrative, locating treatment and consultation area on the
storage, hygiene, and the overall area (metres ground floor. For example, locating in a retail
sq.) of the premises. Requirements need to be development there may be considerable pressure
fully researched. Typically, GPs underestimate to set up on the first floor. Even with lifts , this acts
the amount of administrative space needed. as a disincentive to potential patients – particularly
Consideration needs to be given to immediate the elderly and mothers with children. The
needs and future potential - the number same principle applies in other types of practice
of patients/consultations, access systems premises. Even if there is additional costing ,

ground floor locations add greatly to the value of including fire regulations must be factored
the practice. into any decisions regarding new or renovated
premises.3 Seek professional advice in the first
Taking on a new GMS list/contract will to some instance e.g. architect.
extent limit choice on location in that the
participating doctor is required to locate the d. Planning permission and other regulations
practice within a specific geographical radius. Consider planning application if applicable
If one is taking over an existing GMS patient list and seek information from the local council/
but providing services from a new location there is corporation/planning officer on any relevant
a requirement to comply with distance restrictions. restrictions related to the premises. For example,
For example, there is a significant difference in taking over a retail premises, there needs to be
moving 3 miles within an urban area with no public change of use permission obtained, extending
transport connection from the original practice premises may require planning permission. One
and a similar move in rural area where access is needs to factor in the time required to achieve
much less affected. permissions in many cases several months.
The visual impact of any practice premises is It is also worthwhile contacting HSE in context
important. A new practice must have visibility of local and regional developments in Primary
within its immediate environment in order to Care and primary care infrastructure and also to
attract new patients. As with any other business access information on the e tenders site, which
premises the opportunity for optimum signage gives access to tender notices on government and
‘exposure’ is desirable. However this must not be public sector procurement across Ireland access
in conflict with one’s ethical obligations.2 Equally on:http://www.etenders.gov.ie/
competition law may in the future inform the
current position. When considering the purchase or lease of
premises/site it is vital to assess the planning
Parking and access are important considerations status of the property in advance and to be aware
which can strongly influence choices decisions on of the risks that permission may not be granted
location. Allowances for disabled parking must subsequent to acquisition.
also be considered.
Note: Fire regulations and health and safety
It is also important to take lighting into account, requirements can be onerous when developing
both internal (natural light in work and examination premises.
areas) and external (for visibility and safety).
Health and safety legal requirements are
considerations in setting up and operating in
practice – therefore health and safety factors,
2 Irish Medical Council 2004. A Guide to Ethical Conduct and Behaviour. 6th ed. Available from: http://www.
medicalcouncil.ie/_fileupload/standards/Ethical_Guide_6th_Edition.pdf
3 ICGP, 2007. Managing Occupational Health & Safety in General Practice. 2nd ed. Available from: http://www.
icgp.ie/library

In summary, the premises must be affordable
e. Lease agreements
for one’s initial needs, yet, match short to
If one is renting premises, then duration of the
medium term plans. Plan for at least one spare
lease and other terms and conditions will have
consulting room from the outset
to be negotiated in order to best meet practice
needs, current and future.
Due consideration should be given to a wide
range of issues when deciding on the location
• Consider an internal repair only form of lease,
and design of practice premises. One can
not an “ FRI “ type of lease - a full repairing and
access more information on these matters in the
insuring category of lease. ‘FRI’ leases are more
‘Practice Premises’ section of the ICGP website
common in long term leases, while interal repair
at: www.icgp.ie/neg
leases are more common for short term leases.
• Negotiate an extended rent free period: three 3.3 Practice Name

months is standard From a ‘branding’/ marketing point of view, the
business name of the practice is important. This
• Negotiate a break clause, having this is very needs to be decided at an early stage to allow
much a plus factor: If the practice is thriving , the ordering of stationery, registering in phone
you may want a bigger premises or consider book, trade/professional directories, websites
purchasing a building ; If the practice location and notices. As a ‘brand’, the practice name will
is poor you may want to relocate. seek to become established and the name chosen
should allow for future changes in the context of
• A formal rental/lease agreement should be taking on possible partners. One may not want the
requested and one should consider what practice/business to be named after a particular
leasing/rental period or duration will meet doctor.
future plans? Is a short term or long term lease
better for your requirements? The Medical Council’s A Guide to Ethical Conduct
and Behaviour is prescriptive as regards guidelines
• If one is awaiting a GMS panel/contract on practice names, notices, signage, etc.4
for instance, that may arise but outside the
current practice area – being committed If opening a practice and using a ‘business’ name
to a long term lease may limit choices and which differs in any way from one’s surname there
opportunities. Many leases have a ‘buy out’ is a requirement to register the business name
clause. Note a lease of over 5 years provides with Companies Registration Office (refer to:
tenants with rights and protections www.cro.ie) The registration certificate is required
to enable one to open a business bank account in
• Long term leases are usually ‘for sale-lease’ the ‘new’ name. This process can take a number
e.g. 30 years. ‘Key money’ may be sought of weeks.
and considerable sums may be asked for the
privilege of a long term base. This may not be
advisable in the current climate
4 Irish Medical Council. 2004. A Guide to Ethical Conduct and Behaviour. 6th ed. Available from:

3.4 Telephone Systems & Installation Answering call/call forward facilities should also
This can be a rate-limiting step as it is so important be investigated. In addition one should consider
in respect of making progress on all fronts. It that broadband is a ‘must have’ (despite coverage
therefore should be considered as a priority. issues nationally) and ensure an integrated system.
One also needs to plan for the best location and
Initial contact with Eircom must be made to get space for the operating system.
the line activated/switched from previous owner.
Then choices can be made about providers for the
system desired. 3.5 Practice Bank Account(s)5
A practice bank account should be set up in the
Enquires should be made about types of lines e.g. form of a business bank account, (separate from
analogue/ISDN as this will allow fax / broadband, personal account(s) which will include credit card
number of calls that can be held, messaging and laser services. This then becomes the basis
service etc. This is very important as one may for the practice accounting system – accurately
underestimate the amount of lines required when tracking and monitoring all transactions in and
setting up. out of the business/practice. On line banking
facilities allow much greater efficiency in the
It may prove useful research to contact practices regular (weekly, monthly) management of practice
of similar size to investigate matters from a finances. Setting up credit /laser card facilites has
user’s perspective and form a view on suitability, advantages. However set up can take time and
effectiveness, potential problems and costs. costs money and also requires a telephone line.
As a ‘cash business’ consideration needs to be
The telephone line is initially obtained from Eircom given to regular cash lodgements and safety
therefore this is a good starting point to research and convenience in this regard. The proper and
quotations and cross compare rates and services accurate recording of lodgements and related
from a range of providers. transactions should become a norm.
One can request an easily remembered phone

number from the telephone company which is 3.6 Financing
useful for patient and staff alike. Business loans, mortgages, overdraft, may have
to be considered e.g. overdraft facilities to cover
The Golden pages can be a useful place to short term cash flow deficits may be required in
start identifying providers. Providers should be the initial period.
requested to email information in a standardised
format to allow one to cross compare services and Writing a business plan is recommended as it
costs. One can then request a follow up from the gives structure and objectivity to planning and
sales person of the company. One can also ensure development. In general having a written business
that the practice is listed both under one’s name plan will greatly assist in negotiating optimal terms
and the practice name (if different) with directory with a finance provider. Feedback from people
enquiries. who have set-up suggests that one is in a much
better negotiating position with a well prepared
5 See Chapter 4, ‘The Business of General Practice’

business plan; one that anticipates estimates of As the practice is established, decisions need
costs, projected income (1 – 5 years), growth, to be made on practice systems, organisational
customer (patient) profiles etc. An illustration of a structure, access, size, staffing. These issues
generic business plan layout is included in chapter are further considered in Chapter 9, ‘Practice
4, ‘The Business of General Practice’. Management’.
Professional advice from an appropriate advisor Personal Drawings/remuneration:

in business planning is recommended and will In common with other ‘entrepreneurs’, GPs
also be advantageous in negotiating with financial establishing in practice may not be realistic with
institutions. regard to drawing down personal remuneration
from the business, and similarly may not plan for
Doctors including general practices are viewed adequate time off. This point is often reiterated in
as very attractive customers from the perspective retrospect by established GPs with regard to pay
of the finance providers, therefore to a certain and holidays.
extent it is a ‘buyers’ market. A thorough research
of the increasingly competitive financial services Networking and maintaining good relationships
market is indicated. All potential providers with local colleagues may give opportunities for
should be considered including those allied to cover for half-day/day off in lieu of returning the
professional medical organisations. Factors such favour, thus reducing the costs. This is perhaps
as convenience and the benefits of building up easier to arrange if other establishing GPs are
a good business relationship with the company’s located nearby.
representative over the life time of the practice
have their value. 6 Financial Records and Procedures:
From the outset financial systems and procedures
will also have to be determined. This involves
3.7 Practice Structure keeping daily/weekly/monthly financial records,
At the initial stages in starting up in practice one including a day-book/summary transaction sheets,
may have a number of aspirations with regard to while working to a set budget.
practice structures, some or all of which may be
contradictory, e.g. having small numbers of staff The working day:
that one knows and trusts, as opposed to having Other factors that need to be considered include
a large practice, which can provide flexibility in days of business, opening hours, after-hours and
terms of back-up and holidays. In addition, as holiday arrangements. In relation to the latter
one progresses over time, needs may change - if point, it is likely that one’s view may change
working with other GPs, one will need to decide considerably when as a principal, one must meet
on the business relationship that is mutually the locum fees demanded!
agreeable, whether in scenarios of partnership (the
legal definition), associateship, or independent
practices sharing premises, etc.
6 There are websites that can help you draw up your business plan, including the websites of the banks and other
providers. See more on business plans in Chapter 4 ‘Business of General Practice’

3.8 Taxation7 One’s accountant will give guidance and direction
As mentioned in other chapters, when one to the financial planning required to both meet
changes from being an employee (either NCHD/ and minimise tax liabilities.
GP trainee status or ‘employed’ GP) all the legal
requirements regarding taxation apply. It is important to be aware that in providing
GP services to the State e.g. GMS contract,
As a self employed individual one must make a Mother and Infant Scheme, Primary Childhood
return to Revenue each year indicating the tax Immunisation Scheme contracts; ‘withholding tax’
liability for the year – based on earnings and is withheld at source (currently 20%).
business expenses and make appropriate tax
payments by specific dates within the tax year. The money ‘withheld’ is offset against one’s tax
Where one becomes an employer there is the liability at the end of the year. When payments are
additional legal obligation to make returns and received from the HSE in respect of state contracts
deduct Pay as you earn (PAYE) and Pay related an F45 is also issued. It is important to maintain
social insurance (PRSI) from staff salaries as well all the F45 certificates on file as an accurate
as paying employers PRSI. All self employed record of amount of withholding tax paid as they
individuals are subject to revenue audit. This may are equivalent to ‘post dated’ cheques.
involve detailed on site inspection of your financial Amounts paid via withholding tax need to be
records in respect of tax returns and employer tax borne in mind in respect of both annual tax
obligations. liabilities-bill, cash-flow management and monthly
budgeting.7
Where returns are not made by due dates and
/or are incorrect the tax payer is subject to VAT (Value added tax)
interest and penalties related to outstanding VAT is a consumer tax. GPs are not registerable
tax payments. Interest and penalties may be for VAT; this means that they do not charge VAT
substantial. on their professional fees. However, GPs, like all
other businesses, will be charged VAT on goods
The legal powers of the Revenue are considerable, and services – e.g. stationary, utilities, IT services,
both in respect of ensuring the compliance of rent/lease payments. Given that the current
the self employed tax payer as well as powers of standard rate of VAT is 21% this increases practice
inspection and audit. costs considerably and is important to bear in
mind when reviewing quotations and in budget
As previously mentioned it is advisable to make planning.
provision each month for annual tax liabilities
– e.g. setting aside an amount in a notice deposit
account each month for example, so that there
is no shortfall at the year end and/or need for
additional funding (overdraft/loan etc).
7 Refer to Chapter 6 for a discussion on the taxation system and the tax rules and regulations relevant to General
Practitioners.

3.9 Practice Computerisation line’ and can carry out updates, address technical
It will be assumed that any modern practice will problems remotely via broadband depending on
be computerised as it would not be sustainable the problem and its complexity.
to operate otherwise. The choice of hardware and
software for the practice will be a product of one’s Depending on progress locally, with laboratories and
own personal experience and preferences, current hospitals, it may be possible to link electronically,
budget and what the various suppliers can offer. therefore compatibility issues need to be
considered.
A list of the main companies currently operating in
the Irish market is available in Appendix 7. Other Providers will organise demonstrations of their
providers may enter the market in the future. products and it is important to ask the provider
to demonstrate how the software deals with the
Potential purchasers should ensure that the typical daily routines and requirements of one’s
software they are reviewing complies with the practice during the demonstration, rather than
accreditation criteria applied by the National GPIT only covering the positive ‘selling’ points of the
Group (HSE/ICGP). These criteria are accessible system.
on the IT section of the ICGP website http://www.
icgp.ie/gpit From this section of the site there It is important to ask about the flexibility of the
is access to a number of guidelines and advisory system and ease of transfer of current / future
documents on computer use and data security. patient database to a new system
A number of other useful guidelines can also be It is also recommended to contact other users /user
found online, covering such topics as broadband, groups before making a final decision. The ICGP
data transfer, data back up and security issues (e.g. GPIT tutors/tutor network can be of assistance. See
‘No Data No business’), software and hardware the College website for more details.
issues, practice websites, and computerised
prescribing systems. Registration with the data commissioner is a legal
requirement under the Data Protection Act; email:
Initial costs can be high when software, hardware info@dataprotection.ie for further information
and maintenance costs are considered e.g. on how to register. Registration fees relate to
minimum €10,000 (approx) for two work station business/practice size, for more information
practice. A once off computer grant exists up to on current rates refer to the Data Protection
the value of €2,500 under a full GMS contract Commissioner site: http://www.dataprotection.
which can be applied for via relevant HSE office. ie/viewdoc.asp
Decisions on the choice of package will be The current minimum registration fee is €25.39 9
influenced by such factors as user experience of
packages, ease of use to new users, back-up and
quality of support, training and costs.
Many companies will offer a support system ‘on-
9 See http://www.dataprotection.ie/

3.10 Stationery This latter point is important as reception staff
Ordering practice stationary shouldn’t present must be trained and assisted to operate the
too much of a challenge and keeping the appointment system effectively and be able to
following in mind will make this more efficient: deal with inherent pressures that can arise.
order prescription pads, headed letter paper and
certificates together. Cross compare prices with
printers and assess what is on offer, including 3.12 Practice Brochure
facility for reprinting at short notice. In general This is an effective way of communicating the
larger orders are less costly but it is important to times and services on offer and provides an
ensure that the text does not require frequent opportunity to promote your practice, albeit
changes. within the confines of the practice. Business cards
can also be printed for giving to patients, thus
With some software packages the practice reinforcing the information on contact numbers,
‘header’ can be put into the settings thus allowing including out of hours service and appointment
for printing of header on blank stationary for times. The more the ‘message’ is communicated,
correspondence, prescriptions etc. the greater the level of information transfer. The
practice brochure needs to be regularly reviewed
and updated.
3.11 Appointment Systems
& Patient Access
This is a long standing challenge as one will want 3.13 Marketing the Practice
to encourage people to make planned times that and Advertising
will suit both the practice and the patient. While Standard business advertising is not available to
in the start up situation, accessibility will be a very registered medical practitioners who are subject to
important factor to encourage new patients to quite narrow restrictions required by the Medical
re-attend. Council.
One’s preferred consultation time/ length and/ One advertisement is permitted in the local
or that of other clinicians will also influence the and /or national Newspaper and the size of the
appointment system as well advertisement must be no larger than 100 mms in
any direction.10
When beginning it is prudent to space patient
appointments in order to allow for walk-in patients Equally important is ensuring that the practice
and give good quality first-time consultations. It is name and telephone numbers are listed in
important that all staff and patients are clear as to telephone directories including national, local and
the system in operation; that clinical staff apply the Golden Pages directory. If one is ‘trading’ under a
system consistently so that staff are supported in name other than your personal name ensure that
their operation of the appointment system. one’s name is also listed in ‘Directory Enquiries’.
10 Irish Medical Council. 2004. A Guide to Ethical Conduct and Behaviour. 6th ed. Available from:

On-line Directory
The ICGP provides an one line directory service Practice Staff also ‘sell’ the service
for the public ‘find a gp’ (refer to http://www. Whether on the phone or in person, the first
icgp.ie/go/find_a_gp) individual the patient will encounter is the
practice receptionist. This person is integral to
Reputation the marketing of the practice and its services,
Advertising is only one aspect of marketing a therefore encounters with patients at reception
professional service/ practice, probably the most must be appropriately managed. This requires the
important is building up a professional reputation. recruitment of a competent receptionist, trained
and operating at the required standard.12
Research shows that word of mouth is the main
reason for attendance of new patients.11 Practice staff and most importantly the practice
receptionist ‘market’ the practice by the quality of
It is helpful to visit the local businesses and their work and communication style with patients
pharmacies in the area to inform them about the and prospective patients. As GP /owner /partner
new practice and the services provided. one needs to convey a clear understanding of how
to manage patients requests. The receptionist is
It is recommended that you visit and/or notify the face and voice patients will encounter in the
other general practitioners in the area as a new practice. The staff’s response needs to be
courtesy to your professional colleagues. congruent with one’s objectives for the practice.
Instruction, training, on going review for staff
Joining the local CME groups/ICGP faculty will and awareness by the GP will ensure that this is
also foster collegiality and inter-referral should achieved.
you provide extra services. The support of local
colleagues even on an informal basis when Practice website
establishing a new practice is invaluable. Establishing a web presence is a low cost tool to
compliment others and is relatively cheap. It can
Premises as a marketing tool: supplement or replace Practice Brochures and if
Exterior updated regularly can act as a practice Newsletter.
The premises need to ‘speak for itself’ and convey
the visual impression of a doctors practice. The 3.14 Out Of Hours Cover
design, signage, external appearance all need There is no legal obligation to provide out-of
to convey messages to the patient and potential hours cover for private patients.
patients about the practice.
Interior It is essential however, to consider one’s policy
The interior of the practice needs to continue to with respect to out of hours care.
convey and communicate to the patient/potential There are specific contractual obligations with
patient messages about the service, how to access regard to out of hour services provided to GMS
and about the providers. patients13.
11 Ball, John. 2006. Extra services a plus for establishing practices. Forum, 23 (11), November: 28-9.
12 See Chapter 9, ‘Practice Management’
13 See Chapter 10, ‘State Contracts’

Co-ops and GPs rotas allow for a better work/life 3.17 Sources of income
balance while meeting clinical obligations and There are several sources of income that one
also provide the opportunity for additional work/ should explore when establishing a practice. The
income when starting off in practice. following is a brief checklist of some of these
sources.
It is extremely important to convey the correct
information to patients regarding out of hours • GMS
arrangements and to do so consistently: posters, • Private Patient Fees
telephone answer messages, practice leaflets and
• Occupational Health
reinforcement when dealing with patients directly.
One of the most common sources of complaint • Department of Social Welfare
by patients to the Medical Council relates to the • Mother and Infant Scheme
patients perception of not being able to contact • Insurance work
their GP out of hours. • Medico legal work
• Pharmaceutical trials
It is important also to regularly check the
• Drug and alcohol testing/ Dept of
messages conveyed on the telephone answering justice work
service and ensure a daily check that phones are
• Minor surgery,
switched over correctly.
• Travel vaccinations.
3.15 State Contracts (other than GMS):

Once in the position to provide GP services to Conclusion:
patients, application should be made to obtain the In conclusion, establishing a practice can be a
Mother and Infant Care Scheme and the Primary very challenging but worthwhile experience. It
Childhood Immunisation Contracts from the HSE. is important to formulate a plan well in advance
A separate application is made to the Department of commencing ‘business’ and it is hoped that
of Social and Family Affairs for registration as a the guidelines above will be of assistance in
medical certifier. (Refer to Chapter 10) addressing the key issues.
3.16 Registration with Health

Insurance companies
Once set up in practice one should register with
the health insurance companies (VHI, VIVAS,
Quinn Healthcare etc) for claims made by patients
through these insurers for services provided in
your practice e.g. cyrotherapy.

4:
The Business of
General Practice

Introduction The working relationships between GPs will, in
theory at least, be described in the following three
In Chapter 2 we described the many different main categories:
guises of work that are available to the
Establishing GP within the current General Practice A) Contract for Services
environment. However, one of the first problems B) Employee (Contract of Service)
encountered by new and establishing GPs is C) Partnership & Associate Agreements
an understanding of the intricacies of business
norms and terminology in the wider financial A. Contract for Services: Independent
environment. This confusion prompts frequent Contractor
requests from establishing GPs for advice and This is the legal equivalent of the tax term “self
guidance. It is hoped this chapter will aid the new employed”. The relationship between a practice
and establishing GP in this difficult area. and an independent contractor is described as
a contract for services. Many GP Assistants fall
Due to the complex nature of these subjects, into this category. The ‘contractor’ (i.e. sessional/
separate chapters are devoted to insurance, locum/GP Assistant) provides services to the
pension planning and taxation. practice and then bills/invoices the practice for
the services provided, and the practice pays the
This chapter can be subdivided into the following contractor the gross amount, as invoiced.
sections:
In business, it is the norm that the provider
4.1 Working relationships: Business and Legal indicates in advance the terms and conditions
definitions under which the service will be provided and both
4.2 Choosing an Accountant parties negotiate and agree final arrangements.
4.3 Banking
4.4 Raising Finance Ideally a written contract should be agreed
between the establishing GP and the practice
when one is working as an independent
4.1 Working relationships: contractor. Theoretically, this should apply to
Legal and Business Definitions even short term work, although in reality short
Accurate descriptions are important in defining term locums are often agreed verbally. It is
one’s status and working relationships with others. recommended that longer term commitments
It is likely that such definitions will be new to e.g. over 3 months are clarified in the form of a
establishing general practitioners and a certain written contract. The following issues should be
ambiguity surrounds their use among established addressed by the establishing GP in formulating
GPs. and reaching agreement with the practice. For
a more extensive list of issues to be addressed
It is equally important to understand how those in contract negotiations, refer to Chapter 7,
outside general practice – Revenue, creditors, ‘Negotiation’.
banks, suppliers, planners, advisors, the courts,
and regulatory bodies – engage with general
practitioners as legal and business entities.

(i) Hours of Work (iv) Clinical Protocols
The working hours/duration and number of Ideally, agreement on the clinical protocols
sessions needs to be specified. Consideration operating in the practice should be referred to
should be given to administration time as well as in the contract e.g. practice formulary, referral
direct patient contact time when agreeing duration procedures, nursing protocols, use of equipment,
of sessions. All contractor hours of work should clinical roles of different staff members.
be agreed and pre-approved by the Practice.
Commencement and finishing time should be (v) Indemnity, Insurance & Accreditation, Work
specified. The times and dates on which these are Permit/Visa
to be provided should be specified in the contract. The practice should obtain/be provided by the
The interpretation of what is a session varies, contractor with the following documentation:
but tends to be considered as three hours work
approximately. • Confirmation of current medical indemnity
status
(ii) Services/Duties • Current Certificate of Medical Council
The contract should detail the services to be Registration (including evidence of
provided, e.g. house calls, paper work, minor Competence Assurance where applicable)2
surgery, out-of-hours commitment, phlebotomy, • Work permit if required3
repeat prescriptions, etc.
(vi) Notice/Availability/Absence
(iii) Practice Policies Availability and notice of availability/non-
The contractor and the practice should address availability of contractor should be agreed.
practice policies, both administrative and clinical, In other sectors a contractor would not expect
that will impact on the contractor while working in to be paid for periods when services are
the practice. It is recommended that the practice not provided, therefore it is important that
provides a ‘locum’ pack to enable any new doctor expectations regarding absence and payments are
to quickly and easily familiarise themselves with addressed e.g. contractors/self employed are not
the practice and ideally provide this in advance covered under Maternity legislation
of commencement. This is particularly important
for the contractor during any absence of the (vii) Lay-Off/Short-time/Termination
principal(s) - holiday leave, sick leave, OOHs, etc. The practice may reserve the right to reduce
Policies include health and safety, patient and staff contracted hours in accordance with the needs of
confidentiality, complaints procedures, billing and the practice. As with other contracts a termination
claims procedures, data protection, and use of clause should be included. It is important that
IT/GP management systems, including email and both parties are clear that if the relationship is one
internet access. of contract for services then it is not a contract
of employment – the relationship is not one
of employee and employer and therefore not
covered under the terms of the Unfair Dismissals
Act, 1977 - 2005.
2 Refer to Registration at www.medicalcouncil.ie

3 Further information is available from the Department of Trade, Enterprise and Employment at www.entemp.ie

(viii) Future Relations The contract may specify terms regarding the
The contract should address the issue of future use and ownership of practice property e.g. all
work with the practice and/or potential for the books, documents and data including patient
working relationship to change. The practice files prepared in the course of providing services
may require the following clause or similar to remain the ownership of the practice.
be inserted in the contract: e.g. ‘nothing in this
contract binds either party to negotiate or enter (xii) Revenue/Tax Liability
into any further agreement’. As the contractor is considered as a self employed
individual, and to ensure that there is no potential
(ix) Contractor Fees for the practice to be burdened with employers
A clause detailing the specific fees/payments as tax liability (PAYE/Employers PRSI), the contractor
agreed should be included in the contract. It is may be required to provide independent
good business practice that the contracting doctor confirmation of self-employment status.
bill/invoice the practice for his/her services and
the agreed interval for the issue of invoices should Note: The practice is legally obliged to complete
be indicated. The method by which contractor and send a Return of Third Party Information
fees are to be paid should also be specified. (Form 46G) to Revenue annually, in respect of all
payments made to contractors over €6,000.
(x) Patient Fees
Where patients pay consultation fees directly B. Contracts of Service
to the contractor doctor, agreement should Doctors may also work in the practice as
be reached in respect of this matter including employees. The relationship is then one described
financial recording procedures. Out of hours as a contract of service. Some GP Assistants fall
arrangements should also be addressed in this into this category. The rights and obligations of
context. both parties are defined by statutory regulations,
the terms provided in the employment contract
(xi) Restrictive Clauses and by decision of the courts. In this situation the
Reference may be made to restrictions which doctor is ‘employed’ under a contract of service.
apply to the contractor including confidentiality, in The status is then one of employer and employee.
relation to all clinical and business aspects of the As an employee of the practice the doctor is
practice. The practice may also require restraint entitled to all the legal rights and entitlements
of trade type clauses which attempt to restrict or provided to all employees including minimum
influence, e.g. the contractor setting up in practice statutory rights to annual leave, maternity leave,
locally in the future. Note: It is a matter for the etc. The following issues need to be addressed in
contractor to assess the reasonableness and formulating the contract of employment with the
enforceability of such clauses.4 employed GP.
4 Refer to The Competition Authority at www.tca.ie. Search under the term ‘General Practitioners’.

(i) The Employment Contract (ii) Duration of the Contract
As with other legal contracts, a legal relationship Employment contracts may take different forms,
exists once one party makes a job offer, the such as:
person accepts the offer and that consideration
(remuneration) is involved. This relationship places • a fixed term contract, which will cease at a
legal obligations and provides legal rights to both specific stated date in the future.
parties. • a contract of specific purpose, e.g. in order to
cover sick leave.
The relationship must be expressed in writing • a permanent contract, i.e. one that ends upon
in that it is the duty of the practice/ employer retirement
to provide all the employees; (both clinical and
administrative staff), with the terms and conditions ‘Fixed term’ contracts, and those for a ‘specific
of employment in writing. This will include: purpose’, should be expressed in writing and
signed by both parties, employer and employee.
• The full names of the employer and employee The duration/specific purpose of the contract must
• The full address of the employer, where there be clearly stated. It is common for employers
is more than one location of practice to insert a clause such as the following in such
• The job title or nature of the work contracts:
• Date of commencement
“This contract is a fixed term/specific purpose
• Expected duration (if the contract is contract, the provisions of the Unfair Dismissal
temporary or, where the contract is for a
fixed term, the date on which the contract Acts 1977 to 2005 shall not apply where dismissal
expires) consists solely due to the expiry of the contract/
• The rate of remuneration or method of cessation of the purpose of the contract”.
calculating remuneration and whether it is to
be paid weekly, monthly or otherwise
• Terms or conditions relating to hours of work (iii) Renewal of Fixed Term Contracts
(including overtime) A fixed term contract which is continually renewed
• Terms and conditions relating to paid leave5 will be viewed as a contract of indefinite duration,
• Terms and conditions relating to sickness/ in which case the provisions of the Unfair Dismissal
injury and paid sick leave, pensions and legislation apply and cannot be excluded from
pension schemes such contracts.
• Periods of notice to be given to and by
employees Where an employee has three years continuous
service with an employer (prior to 2003)6 the
Any changes in the particulars given in the employer may renew the employee’s contract on
statement must be notified to the employee within only one more occasion. Any such renewal shall
one month of such change. The employer is also be for a fixed term of no more than one year, after
obliged to set out the practice procedures in which the employee is deemed to have a contract
relation to dismissal (under the Unfair Dismissals of indefinite duration, i.e. a permanent contract.
Acts 1977 to 2005). If an employee who commenced employment on
5 See ‘GP as employer’ in the Management in Practice section of www.icgp.ie/mip

6 As indicated in the Protection of Employees (Fixed Term Work) Act 2003.

a fixed-term basis on or after 14 July 2003 has had Why is the distinction between an employment
two or more fixed term contracts, the combined contract (Contract of service) and a contract
duration of the contracts shall not exceed four (Contractor) for services relevant?
years. After this, if the employer wishes the The distinction is important in many respects, e.g.
employee to continue, it must be with a contract a doctor ‘contractor’ is responsible for meeting
of indefinite duration. his/her own professional obligation such as:
• Medical Council Registration
(iv) Contract of Specific Purpose • Professional Indemnity insurance
A contract of specific purpose may arise where • Taxation obligations
the work involves a task(s) or assigned objective, • Pension contributions
for which the end date is not immediately • Cost of equipment and ‘tools of the trade’
determinable. A clause in the contract expressly
stating that the contract will cease on completion A contractor/self employed GP is able to claim
of the work specified is recommended, e.g. when against tax, all legitimate expenses incurred in
replacing a GP of the practice who is on sick providing services. This is not available to a PAYE
leave, and for whom the return to work date is not worker.
currently definable.
The employed GP, as with other employees is
(v) Changing the contract not responsible for calculating PAYE tax, may
An employment contract does not need to be not be responsible for the costs of professional
a ‘fixed’ agreement. It can be anticipated that indemnity insurance, and other professional
changes will occur over the duration of the requirements which may be deemed/agreed are
contract, initiated either by the employer or the his/her employer’s responsibility. Furthermore, an
employee or both. Changes however are subject employee has an entitlement to all rights provided
to negotiation and agreement between the for by law e.g. minimum statutory leave, holiday
employer and employee. and other leave entitlements which does not apply
in the case of a ‘contractor’.
As stated above the employment contract
provides for the terms of employment as agreed An employee owes an employer the obligations
between the parties while legislation and contract of fidelity and loyalty. This does to some degree
law provides the wider legal framework to the (competition law not withstanding) prevent
employment relationship. a doctor from enticing away their employer’s
patients during the course of the employment.
The main headings of an employment contract are
given in Table 4a at the end of this chapter. Generally where an employee is subject to a high
degree of control by the employer (“control test”),
it is more likely that that the contract is one of
employment.
For more detailed consideration of the tax

regulations in this context, refer to Chapter 6.

C. Partnership & Associate/Agreements provision of financial planning advice etc. In
Where two or more people go into business selecting a firm of advisors the GP should:
with a view to making a profit from the
business, then this is a partnership unless (i) Speak with colleagues and get information
there is an agreement to the contrary.7 If one about the professional advisors that
is contemplating establishing a practice with they use and ask whether they would
another person or entering into any form of profit recommend that practice.
sharing arrangement, it is important to seek
appropriate legal advice before committing to the (ii) Use the facilities offered by the ICGP
arrangement. to identify professional practices that
work with GPs. A list of accountants in
Frequently GPs operate within the one building, Ireland who profess to have a special
share some or all expenses and overheads but do interest in General Practice (along with a
not share profits; essentially they are operating list of suggested criteria for choosing an
as separate entities. This may be considered an accountant) is available on the college
associate agreement and this situation pertains in website.8
many practices
(iii) Although it is not a prerequisite that
The main headings and clauses for a typical the firm of advisors be a member of a
partnership agreement are given in Table 4b at the regulatory body it is preferable. As with all
end of this chapter. professions where there is regulation one
can expect a high level of professionalism
For further information on GP Assistantship, and thoroughness. The relevant recognised
see the ‘Practice Formation’ section at accountancy bodies are the Institute of
www.icgp.ie/neg Chartered Accountants in Ireland (ACA or
FCA), the Association of Chartered Certified
Accountants (ACCA or FCCA) and the
4.2 Choosing an Accountant Institute of Certified Public Accountants in
The key criterion in selecting a firm of professional Ireland (CPA or FCPA).
advisors is that they should have a very good
knowledge of the day to day workings of a (iv) Generate a short list of professional
professional medical practice and have a practical advisors and request a meeting with each
understanding of the characteristics unique to firm to discuss the GP’s requirements. The
general practice. Ideally a GP should engage GP should where possible arrange to meet
a multi-faceted firm of professional advisors the various advisors within each firm that
who will have the skills to advise on all financial specialise in different aspects of advice such
matters including set up and monitoring of as accounting, tax and financial planning.
financial control systems, preparation of business
plans, preparation of accounts, preparation of
tax returns, provision of tax consultancy advice,
7 Partnership Act 1890

8 See www.icgp.ie/go/in_the_practice/practice_management/finance. (Members section, ID and PIN required).

Fees should not be the determining factor in • Financial statements for the practice detailing
choosing an accountant. However it is important the income and expenditure and the resultant
that the GP is advised of the cost of the services net profit and a balance sheet detailing assets
in advance of engaging the professional owned, monies in hand, monies receivable and
advisors. The fees are determined by the time payable.
spent working on the client’s affairs, at rates that • Computation of the GP’s tax liability for the
vary depending on the seniority of the person year.
undertaking the work. • Preparation of the GP’s annual return of
income.
The role of the accountant • Summary review of the financial performance
Once a firm of professional advisors has been of the practice. Comparing actual & budgeted
identified, it is necessary to agree the terms of financial performance and the practice
the engagement. It is normal practice for a firm business plan.9
of professional advisors to issue an engagement • The accountant should also prepare a note
letter detailing their understanding of the services on any recommendations regarding the
required, the cost of the services and the manner maintenance of the accounting records that
in which the agreement can be terminated etc. would assist in the preparation of the financial
The GP will be required to sign the letter of statements in the future.
engagement as acceptance of the terms.
Note: Professional Accounting fees are allowable
A comprehensive list of functions should be for tax purposes.
prepared detailing the work that needs to be
performed on a daily, weekly, monthly and annual 4.3 Banking
basis. This list should then be separated into the The GP should operate distinct business and
services to be provided by professional advisors personal bank accounts. All monies generated
and those that will be performed by the GP and /or in the practice should be lodged to the business
practice staff. This list should cover the following: bank account and all practice related expenses
should be paid from the business bank account.
• Maintenance of daily accounting records. A monthly standing order should be set up to
• Preparation of regular reconciliations. transfer funds, referred to as drawings, from the
• Preparation of PAYE/ PRSI returns. business bank account to a personal bank account.
• Preparation of budgets and cash flow All personal expenditure should be paid from the
forecasts. GP’s personal account. Where pension payments
• Preparation of annual (or other periodic) are being funded monthly then these can be
financial statements. withdrawn from the practice bank account.
• Preparation of annual tax return.
Given the significant level of cash transacted
Outside of ad hoc consultancy assignments the within a general practice it is necessary to
accountant should provide the following services safeguard against loss and/or theft. Making
on an annual basis: regular lodgements will act as a safeguard.
9 Where the accountant has a number of GP clients and is therefore better informed to assess the financial
performance across practices

The installation of a fireproof safe will allow for 4.4 Raising Finance
the safekeeping of monies received after banking There will undoubtedly be a stage in the
hours. Care should be taken with regard to development of the practice where the GP will
personal safety of the GP and practice staff when need to approach a financial institution for some
making lodgements. form of short or long term finance. The GP
should discuss the finance requirement with the
It is good practice to provide for income tax professional advisor who will be able to advise on
payments on a monthly basis. This ensures that what type of finance best suits the GP’s needs.
sufficient funds are available to meet the tax The objective of all financial institutions is to ‘sell’
liability. One option is to set up a bank account financial products. The establishing GP needs to
and transfer a monthly amount of practice income choose the right form of borrowings to suit his/her
into the account. Typically the rule of thumb requirements.
is that 30% of total monthly income should be
lodged to the ‘tax’ account. However, where Typically the banks will require the following
there is a significant amount of money being information before providing funds:
earned through the GMS scheme then this
percentage could be reduced to closer to 20% as • Up to date financial statements for the
the professional services withholding tax (PSWT) practice.
deducted from the payments can also be used • Detailed business plan.
to discharge the income tax liabilities. (Refer to • Financial projections for a period of up to 3
Chapter 6 for more detailed consideration of years, these include projected income and
provision of tax liabilities) expenditure statements and a cash flow
statement.
Consulting Fees by Credit/Laser Card • A statement of the GP’s net worth.
Where credit/laser machine is to be installed
to facilitate payment of fees by patients, it is The main source of finance will typically be
important to ensure that all associated bank provided by the banks. However, it is appropriate
charges are highlighted before the machine is to evaluate what other providers can offer,
installed. Ensure that the telephone facilities in the including building societies and credit unions
premises can dedicate a line to the machine. before making final decisions.
Online Banking As with the practice accountant, building a

Gaining access to online banking allows the relationship with a bank manager is important. If
practitioner access to view and make account a relationship already exists with a bank then it is
transfers from the computer. It should be good practice to allow the bank quote for finance,
remembered that the bank balance on the screen however bear in mind that the bank still needs
may not be the real bank balance as it may not to be offering competitive products. The GP
account for cheques or lodgements not yet together with the accountant should compare and
cleared. It is more accurate to review the bank assess the offers received.
reconciliation prepared by the bookkeeper.
On line banking can offer other facilities including
e.g. salary payments to practice staff.

4.4.1 Types of Finance (ii) Short Term Loan
A short term loan is a loan for a short period of
(i) Overdraft usually between 1 and 7 years. A short term facility
An overdraft is a flexible source of short-term should be used to finance asset purchases which
working capital finance. It is used where there are will benefit the practice over a similar period as
shortages in cash flow. These typically arise when the loan. For instance short term finance might
there are significant non regular cash outflows. be used to finance the capital equipment e.g.
furnishings, computers, medical equipment etc
If an overdraft is operated effectively it can needed to set up the practice.
depending on circumstances, be one of the
cheapest forms of borrowing as interest is only Interest will be charged at a fixed or variable rate
charged on the overdraft amount daily. on the short term loan. A fixed rate of interest
gives the GP the security of knowing how much
If an overdraft is used to build up debt then this the finance will cost over the duration and the
becomes an expensive form of finance both in amount of the regular repayments. However, fixed
terms of interest and charges. A bank will charge rate loans can be more inflexible if the practitioner
a ‘referral’ fee for every amount presented on a has the means to repay the loan earlier than its
bank account when an overdraft is exceeded. term. There is usually a penalty for settling a fixed
interest loan early. A variable interest rate loan is
To enable a practice to determine where the cash more flexible but does not provide the GP with
shortages are likely to occur and arrange for the the security of knowing how much the loan will
provision of an overdraft facility for these occasions cost from the outset. If interest rates rise the cost
the practitioner will have to prepare, with the of the loan rises accordingly, however if the rates
assistance of the accountant, cash flow forecasts decrease the practitioner gets the benefit in a
on a monthly basis. A cash flow forecast details the reduced cost of the loan.
projected income and outgoings for the practice,
highlighting the periods where the outgoings are The loan repayments should be factored into the
increased. cash outgoings of the practice, and form part of
the cash flow forecast that is used to identify cash
When the practice is making use of the overdraft shortages to be funded by an overdraft facility.
facility it will be necessary to monitor the bank
account, using bank reconciliations, on a weekly (iii) Leasing
basis. This will allow the practitioner to monitor Leasing is similar to short term loan finance. It is
the expenditure within the practice so that there is designed to fund purchases over a typically 3 to 5
less likelihood of the overdraft being exceeded. year term. Capital equipment or vehicle purchases
are the assets financed by leasing as the asset is
usually held as security for the lease, and in many
instances the ownership of the asset does not pass
until such time as all the lease payments are made.

It is normal with lease finance that the capital 4.5 Drafting a Business Plan for
injection required by the practitioner would be Your Practice
minimal and therefore the asset is 100% financed. A business plan is a management tool to assist in
the management and development of a business.
(iv) Long Term Loan It may also be adapted and used in making a
Long term loans are used to finance the purchase submission to potential financial providers.10
of assets that will benefit the practice over a In drafting a business plan the following headings
period of longer than 10 years. Repayment is should be considered:
usually over a period of between 10 and 20 years,
but this is somewhat determined by the age of the 1. Presentation
practitioner. Interest rates can be fixed or variable Include concise executive summary – what the
with the same issues attaching to long term plan is trying to achieve and how the plan holds
borrowings as to short term borrowings. together. Overall layout is important: spaces,
headings, subheadings, graphs. Focus on key
When borrowing over a longer period the financial messages.
institutions will only finance approximately 85%
of the asset value. As the asset purchase being 2. Figures
financed is of a higher value the practitioner At every point possible, illustrate with actual or
must provide alternative funds to meet the 15% projected figures to support assumptions.
shortfall.
3. The Business/Practice
When borrowing over a longer term there is the Overview of how the ‘business’ works/how you
option to postpone the capital repayments for a plan it to work; how the functional areas interact
period of the loan. This interest-only period can and support overall practice (e.g. GP, Nursing,
be negotiated with the financial institution. This Management, Administrative).
could assist the establishing GP with cash flow at
the commencement of the practice. 4. ‘Product’/Services
This refers to the services provided to patients by
(v) Restructuring Loans the practice. Clearly define services provided/to
Quite often it pays to consolidate a number of be provided, highlighting the unique aspects and
smaller loans into one larger loan. There is usually potential for new/additional services, volume and
a cost saving in doing this. The cost saving can level of usage/demand and where demand will
be achieved by negotiating a more competitive come from ; modes of delivery (e.g. out of hours
interest rate or extending the term of the new care); pricing structures. Need to highlight what is
loan. unique about the services and service providers.
10 Financial institutions may provide further information and templates on business plan presentation for finance
application and may be downloadable from relevant institution’s website

5. Market Information 1 year minimum: projected income (or actual if
Must be included to demonstrate growth available) by patient sub category e.g. GMS,
potential. Market profile includes: population private, occupational health, etc.. Details on
profile (age, gender, socio economic grouping), expenditure, margins, profitability, volume of
distribution, access (transport), competition, delivery of services. Ideally, figures presented in
access to other medical services (e.g. hospital, spread sheet format - monthly, quarterly, bi-annual
pharmacies, community services), planning and and yearly quantifying - with relevant inputs and
development in the area, existing and potential outputs.
sources of employment.
8. People
6. Sector Overview One’s qualifications, skills, competencies and that
Describe the sector in which practice operates: of others working in the practice/business.
primary care, wider health care sector with
illustrative figures e.g. number of GPs graduating One’s Track Record
each year relative to demand etc. Developments History to date of practice and/or practitioner(s);
in sector and how practice is aligned to take work experience in variety of environments;
advantage of this potential. evidence that propositions are valid and that
strategic links will work (e.g. contracts with HSE,
7. Money industry etc); case studies; illustrate points.
Clearly describe how the practice/business
generates money and profitability.
There is a need to define the services also in terms
of quantity and price/fees e.g. average consulting
rates, details on fees charged /proposed. As well
as fees charged to private patients, this may also
include a schedule of fees applicable to public
practice (i.e. GMS,other state contract work),
and other services, occupational health etc.
Financial projections may be conveyed in actual or
projected income and expenditure/figures.

Table 4a
The Employment Contract – Heads of
Agreement
The following terms should be addressed in any
employment contract and should be of assistance
when drafting a contract of employment.11
1. Position (Job Title) 16. Absence/ Leave Practice Policies

2. Commencement Date 17. Training
3. Type of Contract 18. Capability & Competence
4. Place of Work 19. Employee Handbook
5. Probation 20. Health & Safety
6. Duties 21. Bullying & Harassment
7. Remuneration 22. Confidentiality
8. Hours of Work 23. Competition
9. Retirement 24. Lay-Off/Short-Time
10. Lateness/Absence from Work 25. Redundancy
11. Medical Examinations 26. Indemnification, Insurance & Accreditation
12. Grievance Procedure 27. General
13. Discipline/Dismissal Procedure 28. Data Protection
14. Notice of Termination 29. Implied Terms – Employee
15. Annual Leave & Other Statutory Leave 30. Changes in the Contract
Entitlements 31. Signatures
11 For an extended version of this table, with additional commentary on each term, see ‘GP as Employer’ section of
the Practice Management page at www.icgp.ie/mip

Table 4b
Partnership Agreement - Typical Headings/
Clauses
• Date of document • Practice expenses

• Name, title and address of the practice • Practice premises
• Names of the parties • Items to be provided by partners (e.g.
• Date of commencement clinical instruments, car etc.)
• Nature of practice business:(e.g. • Taxation issues

conventional v complimentary medicine). • Management of the practice
• Duration of assistantship • Management of practice staff (including
• Partnership income (private fees, GMS, hiring and dismissal process and
professional appointments) responsibilities)
• Profit sharing • Locum provision
• Gifts • Power to make decisions
• Hours of work • Acts requiring consent of all partners
• Leave (holidays, sick leave, maternity • Restrictive covenants

parental/adoptive leave, study leave, • Professional medical indemnity
sabbatical) • Banking arrangements (including signing of
• Absence (rules applicable in all cases and cheques etc)
specifically in relation to incapacity), • Drawings
• Retirement (payments applicable and • Accounts
acquisition of outgoing partner’s share)
• Partnership capital
• Goodwill (value placed if any and rules
applicable) • Review arrangements
• Grounds for termination and notice of • Allocation of patients (GMS and private)
termination of contract • Confidentiality
• Dispute resolution procedures (specific • Expulsion (and manner of winding up
mediation, arbitration mechanisms and
avenues that will be followed, etc.) partnership)

5:
Providing for the
Future

Introduction 5.1 Insuring the assets of the practice
The general practitioner should check that all
Due to the length of time spent in university the fixed assets of the practice (fixtures, fittings,
and in training, general practitioners tend to be equipment and premises) are insured adequately
much older than the average professional when against loss, damage and theft. The cover should
they begin to earn significant income. Making be reviewed regularly. Cover should definitely
adequate provision for the future should therefore be reviewed when significant changes are made
be of paramount concern to any newly qualified to the practice, e.g. after the purchase of new
practitioner as he or she has a significant amount medical equipment or any structural alterations
of catching up to do. made to the premises such as an extension, etc.
Provision for the future will be made from the Individual items may be insured separately
profits which the practice achieves. It is easy but it is perhaps more convenient to take out
in the busy day to day routine of the practice a comprehensive policy. If the practice has
to ignore or postpone planning for the future any expensive medical equipment then the
however. Because of this it is wise to provide for practitioner should ensure that they are covered
the future in the context of an overall financial by the comprehensive policy.
plan. This will take into account your expected
income and likely outgoings over the next few Eventualities such as fire and theft must obviously
years. be covered and most policies will include standard
cover of this nature. It is advisable however to
Sometimes general practitioners tend to check that there is specific cover in the policy and
assume that their practice, once established, will that it is up to date. The primary consideration
continue at the same level of activity and that when assessing the level of insurance coverage
they themselves will continue to work up to the required should be the cost of replacing any
point of retirement. At that stage, they hope damaged or stolen equipment or fixtures.
to live in retirement funded on the proceeds of
capital accumulated in the intervening years.
Unfortunately, such assumptions are rarely valid
and without provision for ill health, retirement and
death the practitioner may carry an inordinate
level of personal risk.
This chapter deals with:

• Insurance: various types of insurance cover
that need to be considered in the context of
one’s risk profile
• Pension: necessity of pension provision for
both private and state income.
• Drafting of a will: some issues to be
considered

Insurance of premises and residence All the details of a policy should be noted, in
Points to remember: particular the exclusion clauses.
i. Any property is not fully covered for loss or
damage unless it is insured for the full value. Note: Some insurers provide specific medical
Cover should be reassessed at each renewal surgery cover.
and increased appropriately, if there is no
automatic adjustment. It is the responsibility When Reviewing Insurance Cover
of the policy holder to check this matter. Insure premises, equipment, fixtures and fittings
Have adequate cover
ii. The cost of house insurance varies and it is
Regular review
worthwhile shopping around as the policies
provided by a finance house will usually not be Important to review cover after major practice
changes/investment
the most competitive. It is advisable to seek
the advice of a broker. ‘Shop’ around
Seek independent advice
iii. In most policies an Average Clause exists. This Some insurers provide specific medical /
means that the insurance company will only pay surgery cover
out on a claim an amount in proportion to which
the sum insured relates to the value at risk.
5.2 Life insurance
The easiest way to illustrate this is with an The provision of financial protection for family
example. In this example the practice suffers and other dependents is the primary role of life
damage amounting to €50,000. The premises insurance. In taking out life cover your aim will
are insured for €200,000 and the value at risk be to make enough money available to provide
is €300,000. adequately for your dependents in the event of
your death.
Sum insured = €200,000
Value at risk = €300,000 In selecting a suitable life insurance policy it is
Total loss = €50,000 important to keep in mind the distinction between
protection and saving/investment. The reason
Because the sum insured is 2/3rds of the value for this is that in addition to simply providing
at risk one is insured for two thirds of the low cost insurance products most life insurance
actual loss, i.e. two thirds of €50,000. offices also offer more expensive policies that
combine insurance with a savings plan. Before
Actual compensation will be €33,333 one decides on the type of insurance product
required it is important to examine the differences
For full cover on house property it is best to between the various types of policies offered.
opt for an index linked policy. The choice of policy will depend on the type of
cover you require and the finance available to you.
iv. It should be remembered that when a finance Availability of finance may be the deciding factor
house arranges the house insurance this policy for the establishing GP. Level term insurance is
will usually only cover the initial purchase price likely to be chosen by the establishing GP as it is
and not the contents. the most cost-effective option.

Because there can be quite considerable Types of life cover available
differences in quotations for life assurance There are many different types of life insurance
products it is advisable to use the services of an policies but they can all be divided into two
independent broker. Usually the cost of arranging basic types: death policies (also known as term
cover will be the same whether dealing directly insurance) and investment policies. The main
with the insurance company or using a broker. categories are:
The differences between various policies are i. Term insurance: This gives the policyholder
discussed on the next page. the assurance of a specific sum should he/she
die within a specific period, e.g. a sum of
How much cover? €1,000,000 in the event of death at any time
The level of cover required should be determined within a period of 20 years. If the insured
by the minimum income needs of your survivors. person dies during the term of the policy, the
A rough guide is that €500,000 worth of cover sum insured becomes payable; if he survives
will provide a dependent with a tax-free income of the policy will have no encashment value. Term
around €21,760 per annum at 2007 rates of return. insurance is the cheapest way of providing
If inflation is accounted for the dependent’s income protection and at a minimum every individual
will fall even further. with dependents should have this type of cover.
General industry guidelines would suggest that ii. Convertible term: This type of policy is similar
a person with dependents should have cover of to term assurance but by paying an additional
between 10 and 15 times their gross income. premium the policyholder receives the right
It should be remembered that any outstanding to convert the policy to either a whole-of-life
debts, loans and other liabilities will need to be contract or an endowment plan1, irrespective
paid on death and this amount should be added to of his state of health. One limiting factor is
the multiple of income you compute. that the sum assured on the new policy cannot
exceed the sum assured under the original
Naturally higher levels of cover have stricter policy.
underwriting requirements. These requirements
vary with age. iii. Whole-of-life: This category provides an
individual with life assurance for life provided
Life cover arranged with loans tends to be that he continues to pay the premiums required
extremely expensive. Normally this type of life by the policy. A whole-of-life policy normally
cover should be avoided and all such debts should includes an investment component with the
be covered by a separate life insurance policy. result that the policy acquires an encashment
Normally only a mortgage on the principal primary value. However because the rates of return on
residence will require life cover. Other loans should the investment portion of this policy tend to be
be covered by a separate life insurance policy. much lower than those available from other life-
office investment products this kind of policy
rarely makes economic sense.
1 An endowment plan is a long-term regular savings plan with included life cover. At the end of the plan the
policyholder receives a lump sum equivalent to the sum assured plus any bonuses which have been added over
the years. Unlike simple term insurance the policy also carries a encashment value. It is likely that this encashment
value will be less than the total premiums paid during the early years of the policy.

iv. Critical/Specified illness cover: This is a form PHI will be more appropriate in providing long
of insurance where a lump-sum benefit is term cover against loss of earnings as a result
paid to the policyholder on the diagnosis of of medical illness or accident while specified
a specified medical condition. Critical illness illness cover might be appropriate where a
cover can be an additional benefit to a life lump sum benefit would be more appropriate
insurance policy or on a stand alone basis. e.g. in connection with mortgage protection.
The medical conditions can include forms of
cancer, heart attack, stroke and so on. The
medical conditions covered vary from one life 5.3 Permanent Health Insurance (PHI)
office to the other and should be studied in Being ill and unable to work for an extended
detail before a policy is taken out. The policy period is an experience that becomes even more
could also cover permanent total disability worrying if financial difficulties arise as a result.
as a result of an accident.In fact it is more
common today for these policies to be called Permanent Health Insurance (PHI) guards against
specified illness cover rather than critical illness such an eventuality by providing a policyholder
as they only cover certain medical conditions with a maximum of 75% of the salary or profit-
determined by the life office. The cover share earned prior to illness. The benefit from
and premiums can be indexed-linked. The the policy will not become payable immediately.
premiums for this policy are higher than for Normally the period of delay will vary from
other policies and so you should take care to between 13, 26, or 52 weeks.
familiarize yourself with the circumstances in
which the critical illness cover will apply. The continued payment of pension premiums
should also be considered when examining PHI
PHI and Critical Illness are entirely different coverage. Waiver of premium benefit can be
types of insurance policies: arranged which will mean that after a period of
PHI (Permanent Health Insurance) provides 26 weeks of illness the insurance company will
cover from any medical condition which continue to pay the premium to your pension plan
prevents the policyholder from working. It until retirement age. This provides the benefit of
does not specify particular medical conditions a pension income after PHI benefit ceases. PHI
which must be diagnosed before the benefit usually ceases at retirement age, normally 65.
becomes payable. Many common illnesses
such as prostate cancer (at the early stage of PHI premiums are allowed as deductions for
diagnosis) or skin cancers are excluded from income tax purposes. The deductible premium
critical/specified illness policies by various cannot exceed 10% of your total income for the
life offices. Given the fact that PHI covers tax year in question. Any pay-out that you receive
any medical condition the underwriting from a PHI policy is charged to tax under PAYE.
requirements tend to be much stricter than
critical/specified illness policies. PHI and The cost of PHI varies depending on the amount
specified illness policies differ dramatically of cover agreed, the period from when the
in their structure and tax treatment and both policy will take effect and the age of the general
options should be thoroughly examined before practitioner when taking out the policy.
a decision is made on what type of cover is
appropriate for a given situation. It is likely that

PHI cover is particularly important for the self- A choice then exists. The sum may be used to
employed as it provides a replacement income provide either:
should the policyholder be unable to work for
an extended period of time. Given the fact that i. An immediate lump sum plus a pension and
the benefit is “permanent” this benefit could dependants pensions or
continue to be paid until retirement age in the
event of a disability or other severe accident which ii. A deferred lump sum pension and dependants
prevented the practitioner from ever returning to pension
work. The underwriting requirements are much
stricter than for other protection policies and During the period of deferment, the fund will
the policy structures can vary dramatically from continue to accumulate – this option may be
provider to provider, some offer “guaranteed” preferred if the general practitioner has adequate
cover while others will only offer “reviewable” PHI cover.
cover. Expert advice should always be sought In reviewing permanent health insurance the
before a PHI policy is taken out. practitioner should pay particular attention to the
following:
GPs with dependants and significant monthly
outgoings should ensure PHI is a central part of i. The proportions of GMS and private practice
their protection planning. earnings.
Permanent health and GMS income ii. The fact that GMS capitation fees continue for
Where practice income is derived from both a year while private earnings will reduce within
private fees and GMS payments, it may be a short period after incapacity.
necessary to arrange separate PHI policies.
iii. The need to provide for an income in
Under the contract at present, if unable to work retirement after the PHI benefit ceases.
due to ill health, general practitioners with 100
or more GMS patients continue to receive full • It is recommended that in respect of GMS
capitation fees plus an allowance to offset the cost income, general practitioners should
of a locum for a period of one year. have permanent health insurance which
commences after 52 weeks and is payable
Under the GMS Superannuation Scheme a general to age 65, so that when the capitation
practitioner who is aged under 55, and who suffers income ceases after one year, the permanent
permanent and serious ill health and is retiring for insurance payment will commence.
this reason will be provided with a sum of twice It may be advisable to arrange a separate
the average annual GMS capitation fees, plus a policy with a short deferred period and
refund of his own adjusted 5% contributions with payable to age 65, in respect of private
interest. earnings.

iv. Many insurers impose HIV/AIDS exclusions Separate Life & Savings Cover
on new policies. General Practitioners should • In general it is more efficient to make
be wary of discontinuing existing PHI policies separate arrangements for life cover and
before being sure that replacement policies savings cover rather than opt for a policy
offer at least equivalent cover. which contains both. Quite often the cost
of providing protective cover (such as life
insurance) will dramatically diminish any
Note: Fluctuations in practice income may be potential investment return from a savings
queried by Revenue and must be accounted for; policy. For this reason it is better to keep
therefore it is important to record all days not savings needs and protection needs in
worked due to illness and to keep all supporting separate policies.
documentation.
In deciding on an investment policy you need to

5.4 Spousal cover examine what the policy is invested in. Investment
Quite often the contribution of a spouse to the policies can invest in a variety of assets from
running of a practice goes unnoticed. If the stocks to government bonds to property. How a
spouse died the impact on the smooth running of policy is invested is known as its asset allocation
the practice could be very significant indeed. policy. Investment assets can vary from high risk
e.g. emerging market equities such as Chinese or
Taking out a policy on the life of a spouse is Indian stocks or volatile commodity assets such
worth considering even if the spouse has an as oil, silver or corn to low-risk e.g. government
independent income. This is because a spouse’s guaranteed bonds. Life offices offer policies which
contribution to the financial performance of a vary according to the risk profile of the investor. A
practice is very often not realised until it is absent. policy which is 100% invested in emerging market
equities will be much higher risk than a policy
By arranging adequate cover the surviving spouse which is 100% invested in Euro denominated
would be in a position to pay for services such as government bonds.
administration and secretarial that the deceased
spouse had been contributing. The tax treatment The range of charges can also vary dramatically
of such payments of these premia require expert from one type of policy to the other. A unit-linked
advice. guaranteed policy with a protection mechanism
which invests in a managed fund will be more
expensive than an index tracking policy which
5.5 Investment policies simply follows the performance of a stock market
In addition to pensions and term insurance life index e.g. FTSE-100. The increased charges are
offices and banks offer a range of investment used to pay for the additional features such as a
policies. These policies are designed to provide guarantee and a protection mechanism in the case
the policyholder with a future lump sum. Usually, of the first policy.
but not always, an element of life cover is built
into these policies.

In choosing a policy one of the most important 5.6 Insuring practice partners
factors to consider is the policy’s net-of-cost (Key Person Insurance)
investment performance. The performance The consequences of the death (or disability) of
figures published by the life offices generally do a practice partner should be considered in any
not include any annual management charges or review of the insurance cover of the practice.
policy fees. These performance figures illustrate The point being that in the event of a partner
how the funds have performed over the past being unable to contribute to the practice, funds
number of years. While past performance is not a will be required to ensure the continued smooth
predictor of future performance a life office which operation of the practice and to compensate
has consistently performed well inspires more for the loss of the partner’s contribution towards
confidence than one with a very erratic investment costs.
performance.
Various forms of life policies can be utilized,
It is advisable to seek independent financial ranging from pure term assurance and whole-of-
advice before purchasing an investment policy life cover, to critical illness cover.
from a vendor such as a life office or bank. The
range of investment policies currently available Own life in trust: The most flexible approach
is quite extensive and can vary from with-profits to this form of protection is an ‘own life in trust’
to unit-linked with guarantees and/or protection. policy, i.e. the general practitioner takes out a
These can be quite bewildering to the novice policy on his own life in trust for his partner. If the
investor. A competent independent adviser will be general practitioner survives until retirement age,
able to examine your tolerance to risk and your or the partnership is dissolved, the trust can be
expectation of future returns. He or she will also revoked and the policy will then revert back to the
discuss whether these investment funds are likely practitioner, who may then put it in trust for a new
to meet your needs. partner or spouse.
Unlike pension premiums, premiums on life Critical iIlness & Disability Cover
insurance policies are not tax-deductible. • It is important to include critical illness
cover and total permanent disability when
Surrendering a Policy arranging cover, e.g. if a partner suffers a
While most investment policies provide for early stroke and cannot work again, the other
encashment, every investor should be aware that partner may wish to buy his/her share of the
early encashment usually gives rise to a penalty. practice.
This can be quite severe. For example if you
encash some policies within the first year you can
lose around 5% of your capital.
A further point to be remembered in dealing
Protection policies such as term life policies, with partnership insurance is that problems can
mortgage protection and convertible term do not arise for a younger partner when an older partner
have a surrender value as the policies have no survives to retirement. For example, the older
investment content. partner’s share may have to be purchased yet
no insurance policy has paid out to the younger
partner to fund the purchase of this share.

It may well be that the younger partner will have this legislation and receive the benefit free from
to borrow money to purchase the older partners tax the policy must be designated in advance
share unless he/she has made prior arrangements. that the proceeds will be used to pay a projected
CAT liability. The projected CAT liability is known
If this problem is anticipated the younger partner before the policy is taken out and the policy
should be able to invest in a savings plan so that a document is stamped to indicate that the benefit
lump sum will be built over the years. will be used to pay CAT. If the CAT liability turns
out to be less than the benefit received upon
Note: Professional advice should be sought in maturation of the policy the excess becomes
order to ensure that the sum assured is adequate taxable and subject to CAT in the normal manner.
and the buy-out of the retiring partner’s share is Also, if the benefit received is not used for the
structured tax efficiently. payment of a CAT liability the benefit becomes
subject to CAT in the normal manner. If proper
Note: Where the general practitioner already has estate planning is undertaken with a competent
an existing life insurance policy for partnership tax adviser it should be possible to minimize the
purposes he should arrange critical illness cover inheritance tax liability.
separately.
5.8 Pensions: planning for retirement
The basic concept of pension planning is to defer
5.7 Insuring against tax liability part of your current income in order to provide an
Capital Acquisitions Tax: The first point to note income after retirement. This form of investment
about Capital Acquisitions Tax on inheritances and enjoys an important tax advantage in that, within
gifts is that the tax is ‘beneficiary-based’. In other limits, your pension contributions will attract tax
words the recipient (as opposed to the deceased relief. If you fail to take advantage of this tax relief
or the donor) is liable to pay any tax that falls due. you will end up contributing additional funds to
No tax arises where a spouse inherits or is gifted the Revenue in preference to saving for your own
property by his or her spouse. retirement.
It is prudent to make advance provision if your After retirement a general practitioner and spouse
successors are likely to incur a tax liability on an will usually have three main sources of income:
inheritance from you. Tax is normally payable
within four months of receiving an inheritance • General Medical Services pension
and if no provision is made the beneficiary may • State pension
be forced to borrow to meet the liability. Note: • Private pension policies
however that CAT is not charged on gifts or
inheritances taken from a spouse. It is highly unlikely that pensions alone will be
sufficient to provide a comfortable living in
The CAT legislation enables advance provision to retirement so that other investments such as
be made for the payment of CAT. It does this by equity (stock-market) investments and/or property
providing that the benefit of certain life assurance investments will be needed to supplement
policies is not taxable where the proceeds from pension income.
the maturation of the policies are used to pay a
successor’s CAT liability. In order to comply with

5.8.1 The GMS pension scheme The amount of money which general practitioners
GPs with GMS income participate in the GMS can invest in a pension and receive full tax relief
Superannuation Plan in respect of the capitation on their relevant earnings (i.e. non GMS practice
payments made to them. The GMS Payments fees net of allocated expenses) is as follows:
Board contributes at the rate of 10% of such
amounts to the scheme and each GP contributes Highest age at any time % of relevant
at the rate of 5%. The contribution by the GMS during tax year earnings
Payments Board is not treated as part of the Under 30 15
general practitioner’s taxable income while 30-39 20
the general practitioner’s contribution is tax
40-49 25
deductible. GPs are not entitled to make any
further pension contributions in respect of GMS 50-54 30
payments. 55-59 35
60 and over 40
For most practitioners the GMS pension will
not provide sufficient retirement income with The pension contribution is deducted from total
the result that they will need to contribute to a income with the result that tax relief is given at the
private pension. Almost all insurance companies contributor’s marginal rate of tax (up to 41%). It is
market private personal pension plans. There are, this generous tax relief which makes pensions an
however, private group plans available for general essential part of retirement planning.
practitioners
The earlier a private pension plan is started the
GMS pensions and Partnership formation: better off the contributor will be. This is primarily
When negotiating entry to GMS practice the due to the effect of compounding. A stark
parties will obviously have to address the illustration of this is the difference in the size
treatment of partners GMS pensions and of the final pension fund of an individual who
related issues including years of service, private started a pension at age 25 contributing €1,000
pensioning arrangements, profit share etc. a month compared to an individual who started a
pension at 35 also contributing €1,000 a month.
Assuming that both retire at age 60 the individual
5.8.2 Private Pension Plans who started the pension at age 25 would have a
GPs in receipt of GMS income can make pension final pension fund of €2.2 million (assuming fund
contributions in respect of their non GMS practice growth of 8% p.a.) compared to his colleague’s
income. Professional advisors will be aware of the fund of €865k! By starting 10 years earlier one
method of computing the income in respect of retiree would have a fund over 2 ½ times as large
which pension contributions can be made. GPs as the other who started his/her pension at 35.
will be entitled to make pension contributions (at
15% to 40% depending on the GP’s age in the tax
year for which the payment is made) based on the
private practice fees net of the expenses allocated
against those fees.

5.8.3 Pension Review Transfer to an Approved Retirement Fund is
There is one major caveat to pension saving. This currently more attractive than the purchase of an
is that success will only come to an investor who annuity. Annuity rates are primarily determined
is vigilant. Most individuals make contributions by medium to long-term interest rates and these
to a pension policy which is sold to them by rates are currently very low compared to historical
a broker or a bank and rarely examine the norms. For example, €100,000 used to purchase
investment performance of the pension itself. a dual-life, 5-year indexed guaranteed annuity
The generosity of the tax relief sometimes would provide an income of €4,058 per year and
overshadows what might be an extremely poorly current annuity rates, i.e. 4.05%. This does not
performing investment. Research has shown that compare at all favourably with a deposit account
the difference between the best performing and where one could expect to receive approximately
worst performing pension fund over a 25 year 5% and you still retain ownership of the
period for an annual contribution of €10,000 can investment capital. You still own the investment
be as much as €526,000! Professional advice from capital with a deposit account but you give up
a competent financial adviser should be sought the investment capital when you purchase an
prior to starting a pension policy. annuity. This low annuity rate currently available
when combined with the fact that you give up
Such advice will involve a pension funding ownership of the investment capital make ARFs
analysis. This will help quantify the contributions more attractive than annuities at present.
required to provide an adequate income in
retirement. Another attractive feature of an ARF is that it is
inheritable whereas an annuity is not. In order
In general it is not advisable to contribute any to illustrate this lets assume the trustees of your
sum to a pension plan that does not attract relief. pension fund purchase a single life annuity for
There are more efficient forms of saving than non- €1,000,000 which produces an annual income of
deductible pension investment. These investments €45,000 and you die after 6 years. In return for
are important since they will generate returns that your €1,000,000 you will have received €270,000
will be subject to capital gains tax (CGT), currently in income and the life-office will have kept the
taxed at 20% whereas pension income is taxed at remainder. Essentially therefore by purchasing an
normal income tax rates. annuity you are betting on your life expectancy. If
this is longer than average you come out trumps.
At retirement age the individual has the option If it is shorter, the life office will win the bet.
of taking a tax free lump sum of 25% of his/her
accumulated pension fund. The balance is either This should not blind you to the fact that annuities
used to provide a pension for life through the at times can be useful. One of the most attractive
purchase of an annuity or is transferred into an features of an annuity is that the income is
Approved Retirement Fund (ARF). It is likely that guaranteed until the retiree dies. In the case of
most practitioners will transfer the majority of their an ARF a retiree is taxed on withdrawals from the
pension fund into an ARF as this fund can continue ARF at income tax rates and there is always the
to grow capital-gains tax free and may be passed possibility that he/she could exhaust the fund
on to beneficiaries as part of the practitioner’s before death. Pension-based annuities are also
estate. taxed as ordinary income.

Cost of cover for Dr. Average
This example illustrates the cost of providing various types of cover for Dr. Average, aged 40, with a
net practice income of €300,000 and married. For the purposes of the example, it is assumed that the
general practitioner is male and a non smoker and that his GMS/private income is in the ratio of 2:1.
Monthly Monthly*
Gross Net
Life cover
€1,000,000 Pension death to age 65 €158.47 €93.50
€1,000,000 Convertible term 15 yrs €120.10 €120.10
€1,000,000 Unit linked whole-of-life (inc. Cll)
€ 500,000 CI (10 times income) €1285.79 €1285.79
Permanent health insurance

€XX,XXXpa GMS cover deferred €XX.XX €XX.XX
52 weeks (to age 65)
€75,000pa private cover deferred €260.71 €153.81
13 weeks
Note: Maximum cover restricted to 75% of income
Personal pension
15% of private income, i.e. €15,000 €1,250.00 €737.50
(€15,000 gross per annum
€8,850 net per annum)
*The monthly net figure only accounts for tax relief at 41% additional relief from PRSI will also be
available.
5.8.4 Death Benefit 5.8.5 State pension

If the practitioner dies while contributing to a A general practitioner will be entitled to an old
private pension the accumulated private pension age pension where 10 years contributions have
fund forms part of the practitioner’s estate. This been made. This means contributions must have
is different from an occupational pension scheme been made before the age of 56.
where Revenue limits the death benefit payable to
4 times annual earnings.

In the event of death the surviving spouse will 5.9 Will
remain in receipt of an income from this source. If a will has not been made already, the necessity
It is necessary that a minimum of three years of doing so cannot be over stressed. The
contributions are paid. The State pension is consequences of dying intestate are particularly
funded from the PRSI contributions paid by the stark if the practitioner is married with young
general practitioner. This pension is not means- children or is unmarried with a long-term partner.
tested. If the practitioner dies without a will his/her estate
will be dealt with by a prescribed set of rules in
While the practitioner will be entitled to the State the Succession Act 1965.
pension its contribution to overall retirement
provision is quite small, currently €223.30 per Some rules of the Succession Act could provide
week or €11,834.90 (including bonus week) per difficulties for those who are unmarried but are in
annum. It is also likely that the GMS pension will long-term relationships. If the practitioner were
not provide a significant amount of retirement to die, his/her partner would receive nothing and
income. It is therefore essential for the practitioner his/her parents and family members would benefit
to check whether he or she needs to contribute to from the deceased’s estate.
a private pension in order to ensure that sufficient
income is available to enjoy a comfortable If the practitioner is married and has children, the
retirement. The performance level of contributions estate will be divided between his/her spouse and
to this private pension should be reviewed on an his/her children. If the children are under 18 this
annual basis in order to avoid any nasty surprises may cause difficulties for the spouse as one-third
as one nears retirement. of each of the estate’s assets will be held in trust
for the children until they are 18. This can cause
difficulties for the spouse to deal freely with the
estate.

If the practitioner and his/her spouse were to Public liability policies should provide cover of up
die at the same time, in the absence of a will the to €X million against claims arising from accidents
courts will decide who looks after his/her children. to third parties in the premises. Care should be
A will can be used to appoint guardians for the taken in the structure and design of the surgery
practitioner’s children. premises and fittings in order to decrease the risk.
These are just some of the examples of difficulties Employers’ liability insurance: The purpose
that can arise if a will has not been made. It is of this type of cover is to protect the general
therefore extremely important for the practitioner practitioner against claims for damages brought
to draft a will. by an employee.
Such action may arise through the negligence

5.10 Cash insurance of the general practitioner or through failure to
Cash insurance covers loss of money by robbery, provide a safe place of work, a safe system of
theft or other causes while at the business work, or failure to engage suitable and competent
premises, in transit or while in the general employees.
practitioner’s home.
• The practice Health and Safety Statement
Insurance for cash will normally be covered in a will be of assistance in lessening the risk with
comprehensive combined policy but one should regard to the above.
be aware of the limitations in the policy.
Medical indemnity: It is compulsory to have
medical indemnity cover under the GMS. If
5.11 Insuring against legal action a general practitioner is in private practice
Public liability: It is essential that a public liability exclusively, it is foolhardy in the extreme not
policy should be taken out at the commencement to have protection against claims alleging
of practice and that is maintained. (It is medical negligence. Furthermore, it is an ethical
compulsory if using Health Board premises). requirement to hold medical indemnity.3
A public liability policy covers legal ability of the This chapter has been compiled with the
insured in respect of injury to persons, or damage assistance of Mr Laurence Daly, Director of
to their property arising through negligence of the Financial Planning at McAvoy and Associates,
general practitioner or that of his employees or www.mcavoy.ie
through any defect in the property of the insured.
3 ‘Doctors must ensure that they have adequate professional indemnity for the work they perform, Page 18, 4.15,
Irish Medical Council, 2004. A Guide to Ethical Behaviour and Conduct. 6th edition.
Available from: http://www.medicalcouncil.ie/_fileupload/standards/Ethical_Guide_6th_Edition.pdf .

6:
Taxation

Introduction • Description of employers’ PRSI and PAYE
obligations
The establishing GP’s knowledge of taxation
• Basics of cash flow management and making
is likely to be limited because, as trainees provisions for tax payments
they are PAYE workers and may not have had
• The approach taken by the Revenue on
exposure to the tax regulations governing self compliance, including Revenue Audit
employment. However, it is necessary to gain a
• From a financial management perspective,
clear understanding of the tax system as it applies the reader will gain a greater understanding
to both employees and the self-employed. of the role and contribution of financial/tax
advisors, which will include selecting and
Most financial decisions taken by a GP have tax communicating effectively with a financial
advisor
implications, though tax considerations alone
should never be the only basis for making financial
decisions. Equally, the change to self employed
status post training (and/or a combination of self 6.1The Irish Tax System
employed/employee) requires an understanding The tax year runs from 1 January to 31 December.
of taxation, including the specific legal obligations The self assessment system applies to any person
for making returns and payments to Revenue. who has income that is not taxed under the PAYE
Competency on the part of GP/Practice Manager system.
in dealing with financial/taxation advisors is also a
requirement for successful financial management Under the self assessment system, the taxpayer is
of the practice. The taxation implications and obliged to:
regulations imposed on GPs as employers also (i) Pay preliminary tax on account of the tax year
need to be fully understood. by 31 October in that year
(ii) Complete and file a tax return for each tax
Tax is a complex area requiring the specialist year by 31 October in the following year, and
expertise of a professional advisor. (iii) Pay the balance of any tax due for the year (i.e.
net of preliminary tax paid for that year) by 31
This chapter attempts to provide the reader with October following the tax year
an understanding of the taxation system, how its
regulations and procedures impact on the financial Each of these stages in the self assessment system
performance of the practice and by implication, is examined further below.
the financial status of the GP. It encompasses:
(i) Registering for Income Tax
• The key dates and actions required in the To register for income tax a GP with the help of
tax year cycle his/her advisor will complete a Revenue Form T1
• Registration as self employed tax payer and submit this form to the registration section of
• Explanation of how tax liabilities are his/her local tax office. A GP should register well
calculated in advance of the due date for filing the return.
• Filing tax returns
• Explanation of how withholding tax operates
and implications for GP state contract work

(ii) Preliminary Tax (iii) File a Tax Return
Preliminary Tax is an estimate of the income tax The taxpayer is required to complete and file a
payable for the year. The payment of preliminary tax return for each year not later than 31 October
tax is due on 31 October, for example preliminary in the following tax year. For example the tax
tax for 2007 is payable by 31 October 2007. The return for the tax year ending 31 December 2007
taxpayer must ensure that the preliminary tax must be submitted to the Collector General by
payment for any year is not less than the lower of: 31.10.08. Failure to submit a tax return by the due
date will result in a surcharge of 10% of the tax
• 90% of the final income tax liability for the liability (or a reduced charge of 5% if the return
current year, or is submitted within 2 months following the due
• 100% of the prior year’s income tax liability, or date).
• 105% of the final liability for the pre-preceding
year where the preliminary tax is paid by direct Revenue operates a secure online service (ROS)
debit. that enables taxpayers and practitioners to file tax
returns and pay tax liabilities online.
If preliminary tax is not paid by the due date or if
the amount of preliminary tax paid is too low then (iv) Pay the Balance of Tax Due
Revenue can charge interest. Interest is charged The taxpayer is required to pay the balance of tax
at .0273% per day. due for the year by 31 October in the following
year. For example, the balance of any tax for 2007
Example in excess of preliminary tax paid on account of
Dr. Good’s tax liabilities for 2005 and 2006 and his 2007 must be paid by 31 October 2008.
estimated liability for 2007 are as follows:
In addition to the obligations under the self
Year Liability assessment system the (self employed) GP is
€ required to:
2005 20,000
2006 30,000 1. Advise the local Revenue office of the date
of commencement of the practice and notify
2007 40,000 (estimate)
Revenue of any change in the nature of the
practice e.g. change from a sole trader to a
By 31 October 2007 Dr. Good is required to pay partnership.
preliminary tax for 2007 of the lower of:
2. Keep accurate records of all the business /
• 90% of €40,000 = €36,000, or financial transactions of the practice so that
• 100% of €30,000 = €30,000, or the full amount of profits or gains assessable
• 105% of €20,000 = €21,000 if tax is paid by 8 for tax purposes may be calculated. A
equal monthly direct debits in the months of professional advisor should assist with the
May-Dec 2007 installation and operation of an effective
accounting system.
Generally taxpayers pay the lowest amount of
preliminary tax that will satisfy their payment
obligations for the year.

3. If the GP is an employer he / she is obliged to (ii) Allowable Expenditure
register as an employer with the local Revenue In general, for expenditure to be allowable it must
office and operate PAYE / PRSI on payments be:
made to employees of the practice. The
PAYE system applies to all employees who 1. Revenue expenditure (e.g. wages, consumable
earn more than €33 per month or €5.71 per medical supplies) as opposed to capital
month if the employee has more than one expenditure (e.g. construction cost of a new
employment and includes family members surgery).
who work in the practice. A professional 2. Incurred wholly and exclusively for the
advisor should be contacted to assist with the purposes of the practice
operation of an effective payroll system.1 3. Not be specifically disallowed by tax
legislation
(v) Tax Clearance Certificates
A tax clearance certificate is a written confirmation The following are examples of expenditure that
from Revenue that a person’s tax affairs are in should be allowable for a GP’s practice:
order at the date of issue of the Certificate. A
tax clearance certificate may be applied for • Motor expenses incurred for the purpose of
online on www.revenue.ie. The requirement to the profession are allowable. The GP should
produce a tax clearance certificate usually arises keep records of all expenditure incurred on
in the context of a GP seeking payment under running the vehicle (e.g. insurance, repairs,
the primary care re-imbursement service (GMS servicing (including NCT), fuel costs, etc).
payments services). Records should also be kept of the usage of
the car for business and private purposes.
The allowable expenses would comprise the
6.2 Taxable Profits portion of the overall expenses that relate to
Income tax is charged for each tax year on the business use, e.g. travel to and from work is
profits of the profession carried on by the GP in not allowable, while travel involved in making
that year. The starting point for calculating the house calls is allowable.
amount charged is to compute the taxable profits.
This is done by reviewing the accounts for the • Interest on borrowings is allowable if the
relevant period. borrowed money is used for the purpose of
the practice, e.g. interest on borrowings used
(i) Accounting Profit to build/purchase a surgery.
The GP’s professional advisor will prepare the
practice accounts in accordance with general • Staff costs are allowable. These include
accounting principles. The profit or loss as shown salaries, bonuses, training, staff entertainment
by these accounts is then adjusted in accordance and mileage payments within civil service
with tax legislation. guidelines. If a GP employs his/her spouse
the cost is deductible provided the spouse is
a bona-fide employee. Where payments are
1 There are a number of payroll software packages available for this purpose.

made to employees both full and part time, • Dual expenses are allowable on a proportional
including spouses, it is essential that the GP basis. For example the part use of a residence
registers as an employer and deducts PAYE is allowable if part of a house is used as a
and PRSI. The GP should contact his/her surgery. The amount allowed would be based
professional advisor regarding the correct on a proportional share of the running costs
implementation. (e.g. rent, rate, light and heat) of the house.
To justify such a claim it is recommended that
• Payments to locums (contractors) are there is evidence that the house is used for
allowable. A GP should in conjunction with his business purposes on a regular basis.
professional advisor take care when drafting a
contract to ensure that the locum is providing • Accountancy fees
services in a self-employed capacity and not
as an employee as the GP would be liable for (iii) Disallowed Expenditure
uncollected PAYE / PRSI if it was held that a Expenses which are not allowable include:
locum was providing services as an employee.
• Personal drawings together with private
• Education/Training costs are allowable. This element of expenses which may be included in
includes the cost of CME activities, courses, the practice accounts, e.g. the private element
conferences, seminars, exam fees, books of heat, light, telephone, repairs (this includes
and professional journals incurred wholly and personal expenses charged to credit cards).
exclusively for the purpose of the profession.
Education and training costs for practice staff • Capital expenditure.2 Expenditure is
are also a business expense and are allowable. generally capital in nature if the effect of the
expenditure is to provide a long term benefit
• Subscriptions are allowable if they can be to the practice, e.g. new air-conditioning unit
shown to be incurred wholly and exclusively installed in a surgery, new examination couch,
for the purpose of the practice e.g. MICGP extension to building, cryotherapy unit etc.
subscriptions, MRCPI, Medical Council This type of expenditure is not allowable in
registration, IMO. arriving at taxable profits. However it may
qualify for capital allowances (refer to 6.4).
• Medical indemnity subscriptions
(Net of any subsidy) • Depreciation.3 Depreciation is an accounting
concept and represents the decrease in the
• Telephone expenses, including mobile value of capital assets through wear and tear
phones, are allowable. If such expenses and the passage of time.
include a personal element usage, these
must be proportioned between personal and • Entertainment Expenses (other than the
business use, with the personal element not entertainment of staff) are specifically
allowable. disallowed.
2 Capital expenditure occurs when a business spends money either to buy fixed assets or to add to the value of an
existing fixed asset with a useful life that extends beyond the taxable year.
3 Depreciation is a term to describe any method of attributing the purchase cost of an asset across its useful life,
roughly corresponding to normal wear and tear.

• Interest paid on overdue tax liabilities is also were lower than the profits earned in that calendar
specifically disallowed. year then an additional assessment will be made
in respect of that year.
6.3 Basis of Assessment

Once the taxable profits for the accounting period 6.4 Capital allowances
are computed they are allocated to a year of Expenditure on capital items is not deductible
assessment. There are special rules for assessing for income tax purposes. The tax legislation
profits in the first three years of trading. In year provides for a specific deduction for certain types
4, profits are assessed under the normal basis of of capital expenditure. This type of deduction
assessment. is known as capital allowances. Presently a
wear and tear allowance of 12.5% (per annum)
(i) Commencement for years 1 – 6 and 10% for year 7 is allowed
The profits assessable in the first year of carrying on most items of equipment or plant insert (eg.
on the profession are those profits arising from Cryotherapy, examination couch, computer
the date of commencement of the practice to the hardware, air conditioning unit installation, etc). In
following 31 December. order to qualify for a wear and tear allowance the
equipment or plant must be used for the purposes
Example of the profession.
Dr. Good transfers from salaried employment with
the HSE to self-employed status on 30/06/2007. Your tax advisor will be in a position to advise on
Dr. Good will need to register for Income Tax and the capital items that will qualify for a deduction.
file a tax return for the period from 01.01.2007 Many GPs fail to claim wear and tear allowances
to 31.12.2007 - by the 31.10.2008. The tax on plant and equipment in use for the purpose of
payment that Dr. Good will make for 2007 and their profession. This is especially true in cases
the preliminary tax payment for 2008 which is where a GP has a purpose built surgery and the
due by 31.10.2008, will depend on the amount amount of the total expenditure on the surgery
of profits generated by the practice in the period that can qualify for allowances can be quite
from commencement (01.07.2007) to the following significant. The capital allowances for a tax year
31st. December (31.12.2007). are allowed as a deduction from the taxable profits
allocated to that year.
(ii) Normal Basis of Assessment
The normal basis of assessment for a continuing
practice is the accounting period for 12 months 6.5 Leasing
ending in the tax year. For example the taxable There are various ways in which a GP can obtain
profits for the year ended 30.04.07 will be plant for use in his / her practice. He / she
assessable in the tax year 2007. may lease an asset, acquire an asset under hire
purchase or buy an asset outright. Because
(iii) Cessation leasing rates and bank interest rates are constantly
On cessation of a practice the GP is liable to tax changing it is necessary to make a lease /
on the profits from the first day of the tax year (1 purchase evaluation each time a GP plans to
January in the year of cessation) to the date of acquire an asset. When plant is let by a GP and
cessation. If the profits assessed in the prior year the burden of wear and tear falls on that GP, it

is the GP who is deemed to have incurred the In addition to his practice income the GP has the
expenditure and he / she is entitled to claim the following investment income:
wear and tear allowance. When assets are leased
the full lease rental or hire charge is generally Bank Interest 1,500
deductible in calculating taxable profits. Rental Income 10,000
The general practitioner’s tax liability is computed

6.6 Calculation of Tax Liability as follows:
Once the taxable profits are computed and
allocated to the relevant year of assessment the Income Tax Computation for the year ended
professional income can be aggregated with the 31.12.2007
GP’s other income (if any) and his/her tax liability € €
can be computed. The following is an example INCOME
of a GP’s income statement as shown in the
Profits from Practice 160,000
accounts of his practice:
Add back Depreciation 7,500
€ € 167,500
Fees 230,000 Interest Income 1,500
Expenses: Rental Income 10,000
Locum 21,000 Employment Income 2,500
Wages and Salaries 21,000 181,500
Telephone 3,000 CAPITAL ALLOWANCES
Insurance 1,500 Rental Losses ( 8,500)
Motor Expenses 5,000 Capital Allowances ( 1,000)
Light and Heat 1,500 (9,500)
Accountancy and consultancy 4,500 ALLOWANCES & RELIEFS
Repairs and maintenance 2,000 Permanent Health ( 1,000)
Insurance
Interest 2,000
Health Expenses ( 1,500)
Rates 1,000
Retirement Annuity (24,000)
Depreciation 7,500 (pension contribution)
(70,000) (26,500)
Profit 160,000 TAXABLE INCOME 145,500
Charged to 36,900 @ 20%
tax as follows: = 7,380
108,600 @ 41%
= 44,526

TOTAL INCOME TAX 51,906
6.7 Tax Credits and Reliefs
CREDITS / RELIEFS i. In order to minimise the income tax
Personal Tax Credit (1,830) liability the tax payer should ensure that all
PAYE Credit ( 500) available tax credit and reliefs are claimed.
Services Charges Credit ( 88)
ii. Depending on a GPs particular circumstances
(2,418)
the following are an example of the tax credits
PRSI / HEALTH LEVY
/relief’s which may be claimed in the tax year
PRSI Self 178,000 @ 3% 2007:
= 5,340
Health Levy Self 100,100 @ 2% • Personal tax credit. This amounts to
= 2,002
€3,520 for a married couple who are jointly
Health Levy Self 77,900 @ 2.5% assessed and €1,760 for a single person.
= 1,948 • One-parent family tax credit of €1,760.
9,290 • Incapacitated child tax credit of €3,000.
OTHER CREDITS / RELIEFS • Home carer’s tax credit of €770.
• Health expenses. Relief is available for
Paid PAYE ( 500)
health expenses incurred (medical, dental,
DIRT Credit ( 300)
drugs, Health insurance cover e.g. VHI)
Withholding Tax on Fees (30,000) • Permanent health benefit schemes. Relief
(30,800) is available for premiums paid under a
Total Liability 27,978 permanent health benefit scheme approved
Less Preliminary Tax (17,500) by Revenue. The amount of the premium
Paid in 2007 allowable is limited to 10% of a GPs total
Balance of Tax Due 10,478 income.
• Donations to eligible charities. Relief is
available for donations of €250 or more to
* Brackets signify a negative figure approved charities and approved bodies.
• Employed person taking care of an
** The tax liability is calculated on the normal incapacitated individual. Relief is available
basis of assessment for a continuing practice to a GP whose family members or relatives
are totally incapacitated and a carer is
employed. The amount of the allowance is
the lower of the expense actually borne by
the GP or €50,000.
• Relief for fees paid for third-level education.
Relief is available in respect of qualifying
fees paid by a GP on his/her own behalf
or on behalf of his/her dependants. The
maximum amount is €5,000.
• Relief for service charges (e.g. domestic
refuse collection). Relief is available for
service charges paid in the previous tax
year.

• Pension contributions made to Revenue • the tax liability for the previous tax year must
approved schemes are an allowable have been agreed and paid, and
deduction for tax purposes. Please refer to • the GP must supply Revenue with the relevant
the pensions and investment section of this Forms F45.
chapter for further information.
The interim refund is an amount equal to the
excess of the amount of tax withheld over the tax
6.8 Professional Services Withholding liability for the previous year less any outstanding
Tax (PSWT) amounts of VAT, PAYE and PRSI.
i. The Primary Care Re-imbursement Service
(GMS payments services) other government As one of the requirements of claiming an interim
and Semi-State bodies deduct withholding refund is that the tax of the previous year is
tax at source at the standard rate of tax (20%) agreed and paid it is advisable for GPs to get their
when making payments for professional tax affairs up to date as soon as possible after the
services. end of a tax year.
ii On making a payment the payer issues Form Example

F45 which outlines the gross amount due and In the year 31 December 2007 a GP has
the PSWT deducted. Form F45 is a valuable withholding tax deducted of €20,000. Her
document and should be retained carefully accounts to 31 December 2006 have been
and given to your professional advisor when submitted to Revenue and the liability agreed for
the accounts and the tax return are being 2006 is €12,000. This tax has been paid. The GP
prepared. owes PAYE / PRSI of €2,000.
iii In computing the tax payable for a tax year In order for the GP to qualify for an interim refund
credit is given for PSWT that was deducted her 2006 return must be submitted to Revenue.
from payments for services provided in the Her tax liability must also be agreed and paid for
relevant accounting period. that year.
iv. Provision is made for interim refunds of PSWT Amount of Interim Refund:
under three categories. €
Withholding tax deducted 20,000
Tax Liability for 2006 (12,000)
(a) Ongoing business.
In order for a refund to be made in the case of an Excess 8,000
ongoing business: Less PAYE / PRSI due ( 2,000)
Interim Refund 6,000
• the profits of the basis period immediately
preceding the basis period for the tax year
in question must have been agreed with
Revenue,

(b) Commencing business. 6.10 The tax status of Locums, Sessional
A formula is used by Revenue to calculate the GPs and GP Assistants
interim refund of PSWT where a GP has recently The question of whether a locum, etc. is employed
commenced business. or self-employed is important for tax reasons. A
locum who is an employee will have PAYE and
(c) Cases of particular hardship. PRSI deducted from his or her remuneration. In
In a case of particular hardship and where any of contrast a locum who is self-employed will be paid
the conditions in either an ongoing business or gross of tax but will have the obligation to pay
in a commencement situation cannot be fulfilled, to Revenue the tax on the income received. Tax
Revenue may waive one or more of the conditions. difficulties arise if a locum who is an employee
In these circumstances the amount of the refund is is wrongly treated as self employed. In these
at the discretion of Revenue. circumstances Revenue will look for the tax and
PRSI that should have been deducted by the payer
to be paid to them together with interest and
6.9 GP Partnerships and Income Tax penalties. To avoid such painful consequences it is
(i) While there is no legal requirement for a necessary to be clear on the distinction between
partnership agreement to be in writing it is an employee and a self-employed person. This
recommended that where the intention is to distinction is not one that is specific to the medical
form and work in partnership, that there is a profession however. It is relevant to any case in
formal written partnership agreement. Failure which an individual is engaged by a business
to do this gives rise to difficulties. (Refer to and as a result is important for all categories of
Chapter 4 page 46 for heads of agreement business.
example)
The basic distinction between an employee and
(ii) The partnership accounts will be prepared a self-employed person is that an employee
and adjusted to arrive at the taxable profits. provides services under a contract of service
The partnership is required to file an annual whereas a self-employed person will provide
tax return. The partnership does not have services under a contract for services. For this
a tax liability in its own right. Instead the reason it is necessary to look to the terms of the
partnership’s income and gains are allocated contract under which the GP provides services
to the individual partners and these amounts to the engagor. These can be written or oral or
are included in the individual partner’s returns a mixture of both. For example, a court will not
of income. necessarily accept that it should be bound by
written terms agreed by both parties if these are
not in keeping with the reality of their business
relationship.

Because the terms of the contract will differ from 6.11 Revenue Audit
case to case, each case must be considered on its (i) A Revenue Audit is essentially a partial or total
own facts in the light of the principles laid down review by Revenue officials of a GPs return of
by employment law. These principles are relatively income, books and records over one or more
broad. The main ones (as applied to the medical years. It is normally concerned with the review
profession) include: of a GPs return of income for one year but
Revenue may extend the audit to other years
• The business on own account principle: A where significant doubtful or unexplained
locum who provides services to a GP in the issues arise in the course of an audit.
context of carrying on a business of his own
is more likely to do this under a contract for (a) The taxpayer will normally receive at least
services (and thus be acting as a self-employed 21 days notice of an impending audit. An
GP) than under a contract of service. A locum audit usually involves the attendance of a
who carries on a business of his own will Revenue inspector at the practice for a period
have control over the amount of income he of between one and five days. Revenue
generates and the costs that he incurs (and inspectors are entitled under law to enter the
hence will be able to determine the profit practice premises, require the production of
that he earns), will be able to employ staff of accounts and records and remove records for
his own, will have his own equipment and will further examination. They are also entitled
assume certain business risks, etc. to interview and question practice staff either
with or without the presence of the GP.
• The control principle: Although the control Revenue inspectors are not entitled to access
principle is less relevant in cases where to patient’s medical records and they may not
professional services are being supplied, it is enter (other than by invitation) any premises
nevertheless a consideration. If the engaging that is occupied wholly and exclusively as a
GP is able to control what is to be done, how it private residence except when a warrant is
is to be done and when it is to be done these issued by a District Court Judge.
factors will point to the existence of a contract
of service. (b) Upon notification of the impending audit we
recommend that the taxpayer should seek a
Where an engagement is being created for meeting with his/her professional advisor to
a locum or a sessional GP the terms of the discuss the forthcoming audit. Points to be
agreement should be committed to writing and covered at the meeting would include:
competent professional advice should be sought
before the agreement is signed. • identification of any problem areas. If
any issues come to light which have given
rise to an underpayment of tax then
the taxpayer should make a prompted
qualifying disclosure. Depending on the
nature of the error or omission it may also
be necessary to take legal advice.
• identification of likely questions and
preparation of answers,

• identifying members of staff who will (b) Risk Evaluation Analysis and Profiling (REAP)
answer questions, Taxpayers are also selected for audit by
• identifying suitable accommodation for the Revenue using REAP, a computer system
Revenue official which will cause minimum that scans information from tax returns and
disruption to the practice. registrations. The data is then compared
against a set of rules and the system assigns
(c) The benefits of making a prompted qualifying scores which determines whether the taxpayer
disclosure are reduced penalties and non- should be selected for audit.
publication in Revenue’s listing of tax
defaulters. (c) Random selection
(ii) The main methods that Revenue uses in Each year Revenue conducts a random audit
selecting businesses for audit are as follows: programme to ensure that every taxpayer runs
the risk of being selected for audit.
(a) Screening of tax returns
This involves examining the returns made by
a sample of taxpayers and reviewing their tax 6.12 Tax Relieved Pension Contributions
compliance history. The figures are analysed in Pension Contributions for GPs with GMS Income
the light of trends in a particular profession or GPs with GMS income participate in the GMS
industry to identify any potential irregularities. Superannuation Plan in respect of the capitation
payments made to them. The GMS Payments
The following may be responsible for a GP Board contributes at the rate of 10% of such
being audited: amounts to the scheme and the GPs contribute at
the rate of 5%. GPs are not entitled to make any
• late submission of tax returns or late further pension contributions in respect of GMS
payment of tax, payments.
• inadequate levels of private drawings
reflected in the practice accounts, GPs in receipt of GMS income can make pension
• fluctuating or unusual income or profit contributions in respect of their other practice
margins in the practice accounts, income. Professional advisors will be aware of
• failure to adjust for non-allowable the method of computing the income in respect
expenditure, of which pension contributions can be made.
• unexplained variances in expenses on Briefly this is computed by setting the practice
previous years, expenses against the non-capitation GMS income
• unexplained capital introduced into the in the first instance and allocating the balance of
practice accounts, the expenses on a pro-rata basis over the GMS
• unexplained items in the practice accounts. capitation income and the private practice fees.
GPs will be entitled to make pension contributions
(at 15% to 40% depending on the GPs age in the
tax year for which the payment is made) based
on the private practice fees net of the expenses
allocated against those fees.

Tax Deductibility of Contributions 6.13 Taxation of Investment Assets
The pension contributions that can be made in This section deals briefly with the taxation of
respect of relevant earnings (non- GMS practice investment income such as interest income,
fees net of allocated expenses) are as follows: dividend income and rental income and
investment gains.
Age % of Net Relevant
Earnings Interest income earned from funds held on deposit
Under 30 15% account with Irish Banks is subject to tax at source
30 - 39 20% (Deposit Interest Retention Tax (DIRT)). At present
DIRT is levied at 20%. Taxpayers are required to
40 - 49 25%
include the deposit interest income in their return
50- 54 30% of income but no further income tax is payable
55 -60 35% even if the taxpayer pays tax at the high rate (41%)
Over 60 40% on other income. Levies will be charged on the
interest income.
The pension contribution is given as a deduction
against total income with the result that tax relief is Dividend income from shares is liable to income
given at the marginal rate of tax (up to 41%). tax at the GPs marginal rate of tax (46.5%
including PRSI and levies). On disposal of the
Tax Free Growth shares any gain would be subject to capital gains
The tax advantages of investing in a pension tax (CGT) which is currently charged at 20%.
fund are two-fold. Firstly as outlined above In computing taxable rental income certain
tax relief can be claimed on the contribution. expenses can be deducted. These include interest
Secondly the income and gains generated by on borrowings used to purchase, improve or repair
the fund grow free-of-tax. We regularly find that the property. In our experience taxpayer’s often
taxpayers invest in pension funds to benefit arrange their borrowings in a non-tax efficient
from these tax advantages and do not place manner. For this reason we would advise GPs
sufficient emphasis on selecting an appropriate to take professional advice to ensure that the
provider and reviewing the performance of the acquisition of property assets is structured in a tax
fund. The importance of these matters cannot be efficient manner.
underestimated. Our internal office research shows
that the difference between the best and the worst On the disposal of an investment property the
performing pension funds based on investments GP will be liable to CGT on any chargeable
over 20 years is a staggering €572k! gain generated. Acquisition and disposal costs
together with enhancement expenditure can be
deducted from the selling price to reduce the
chargeable gain.

6.14 Summary
Four key points on tax matters that a new GP
should remember:
(i) A separate business bank account should (iii) Ongoing provision should be made for tax
be opened and all business income and and pension payments which become due
expenditure should be routed through this in October / November each year. The
account. This will simplify matters greatly provision could take the form of a regular
when financial accounts for the practice are contribution to a deposit account. This will
being prepared. avoid the necessity of borrowing to pay the
tax or make a pension contribution. The
(ii) A GP should register for tax shortly after amount of the regular contribution should
setting up the practice. This will avoid be decided in consultation with the GP’s
conflict with Revenue and the imposition of professional advisor.
interest and penalties if a filing deadline is
missed because of the failure to register. (iv) Before selecting a professional advisor a GP
should interview a selection of advisors and
take advice from colleagues before deciding
on one. The GP should continually monitor
the performance of their advisor to ensure
that he/she receives value for money.
This Chapter was facilitated by:

Mr. Joe McAvoy
Director, Tax Services
McAvoy & Associates
E-mail: joe.mcavoy@mcavoy.ie
Web: www.mcavoy.ie

7:
Negotiation

Introduction Undoubtedly in many circumstances, arrangements
can be reached without difficulty. Mutual
The process of negotiation between parties is professional respect leads to agreeable working
similar whether for entry to associateship and/or conditions. This chapter is designed to assist and
partnership, negotiation of terms and conditions provide a platform to those who may initially not
of an employment contract (whether between two find it easy to formulate an agreement, whether it
GPs or indeed a GP employer and practice staff), be principal or in-coming partner/assistant.
or a contract for provision of services. This chapter
outlines the process of negotiation and provides Despite a GP’s high level communication skills
a model which allows both parties to progress these may not transfer well when dealing with
toward a successful outcome. colleagues in relation to business negotiation. It
is important to explore some of these barriers in
Negotiating a deal that is favourable to all order to become more effective as a negotiator
concerned can certainly be a challenge in general and also to understand that where it is not
practice. One may be joining an established possible to broker an agreement, one understands
practice, setting up a practice with someone else, what has occurred and can learn from this
or setting up de novo with or without a GMS experience. Frequently, it is often an incorrect
list. What is almost certain is that as a career in interpretation of the other party’s intentions that
general practice progresses, one will be required may cause progress to be impeded if not break
to become a negotiator! At the establishing down all together. It is important therefore not to
stage this may involve negotiating terms of an make assumptions, always seek to clarify the other
assistantship or potential partnership, and later on parties’ intentions.
it is likely to come into play as an employer, e.g.
negotiating salary increases with practice staff. Frequently, practical issues such as hours of work,
absence, remuneration rates, may be approached
in an ambiguous way on the misunderstanding
7.1 GPs conducting ‘business’ that such matters are too ‘delicate’ between
negotiation medical colleagues, rather than seen as normal
GPs may not be effective in using negotiation business practice. However, if approached
skills as understood in a business context. After properly it is possible to reach mutual agreement
all, the goal of the consultation is often to leave on all such issues, while maintaining professional
the patient feeling as positive as possible about values and relationships.
things, but addressing potentially confrontational
issues with colleagues may prove for many to It is hoped that this chapter can help both parties
be a challenge and a steep learning curve. For to find a successful formula, or at the very least,
example, there is no lack of respect in addressing a structure for meaningful discussion to aid their
questions of remuneration with a principal; good negotiations, thus improving negotiation skills
business practice and ethical conduct are not and increasing the opportunities for satisfactory
mutually exclusive. Previous chapters have dealt outcomes.
with the various distinctive job descriptions in
General Practice and negotiation is relevant to all
of them.

Mutually satisfying business arrangements foster 7.3 Negotiation to Deadlines:
better professional working relationships within - Time scale for Negotiation
the practice which benefit all involved, including It is imperative from the outset that there is
the patient. There are implications for patients agreement on the period of time that the process
and patient care in these matters as well; consider of negotiation will take, from commencement to
the effect on patients, whom, having built up a conclusion. Finalising agreements can take longer
relationship of trust, find it no longer available than anticipated giving rise to frustration if there is
each time a doctor moves on. not a consensus on the date for conclusion.
Finally, and importantly while this chapter
considers in the main the perspective of the - Time scale for conclusion of the contract:
establishing GP the concepts outlined are equally Frequently GPs may have a pre-negotiation
applicable to principals. period e.g. new GP works for 6 months as salaried
employee. However, if there is the prospect of
further progression, this and the review period
7.2 Knowing What You Want should be made clear. In the past, arrangements
The first step before commencing a negotiation frequently have not progressed due to conflicting
is to know what you want and to have a realistic expectations as to timescale and conclusion of
understanding of the ‘market’. This may seem negotiations.
self-evident, however, it is surprising the number
of GPs who initiate discussions on terms but
have failed to fully think things through (authors 7.4 The Process of Negotiation
included!). It is often a case of not anticipating The model1 below applies equally to both parties
all the issues and therefore being in less than involved in the negotiation.
optimum position to achieve a good outcome. It
is equally important to be able to express clearly By applying a simple model to each condition
what one wants from the ‘deal’ in clear terms, one can fully prepare for negotiation. This model
unambiguous to both parties. broadly comprises three sections.2
1. Best outcome
One must consider short term medium term and 2. Must have
long term needs. For example, a job that may suit 3. Trade off
immediately after graduation may not necessarily
be where one wishes to remain long term but The desired approach is to work down through
it may on the other hand offer experience in an the list of conditions, completing what you’re
aspect of clinical practice that one may need or Best Outcome, Must have and Trade Off is for
suits current lifestyle needs. each category. This clarifies and orders competing
priorities and makes it easier to discern:
Being clear on what you want also needs to take
into account what a prospective practice(s) can 1. The important conditions on which one can
match, there is little point in having expectations negotiate
which a practice cannot possibly fulfil.
1 Adapted from the RACGP Employment Kit: Reaching a Fair Deal. 2nd ed. RACGP,2006.
2 This does not substitute for legal advice which will be crucial in the finalities of drawing up any
contract.

2. Conditions on which one is not prepared to • Education, teaching and supervision (e.g.
compromise with medical students)
3. Conditions which, on reflection are not • Cover for GPs on leave
important in the context/current situation.
2. Leave
Example • Sick leave, bereavement leave
Condition being Out-of-hours • Annual leave
negotiated: commitment • Long service leave or agreed sabbaticals
Best outcome: No after hours work • Study leave
Must Have: No more than 2 nights • Maternity/Paternity leave
per month on roster • Payment of public holidays if appropriate
Trade off: Remuneration for same
3. Occupational Health and Safety: Are they
covered?
Working down through the checklist of conditions • Safety of working environment from
listed below, using the grid - the best outcome, physical, chemical and biological hazards,
must have and trade off template, will clarify what e.g. Personal alarms, staff presence, list of
the individual wants/needs from the negotiation. patients posing threat to GPs, medicines
The conditions listed below allow the individual storage, adequate car park lighting. It is
to consider their needs and will be of assistance a legal requirement to have a health and
in preparing themselves for discussions with the safety statement in place
other party(ies) and hopefully make the discussion • Presence of staff when the practice is open
more productive. The relevance of any or all of and closed
these conditions will obviously be dependent • Safety measures outside practice, e.g.
on the context and type of contract anticipated home visits and after hours
e.g. statutory leave does not apply in case of a
contract for services. 4. Work Related Expense Reimbursement:
• Telephone expenses
These conditions can be considered under the • IT expenses
following headings: • Mileage allowance for home visits
1. Job Tasks • Medical indemnity
• Times or days to be worked e.g. week days • Education and training costs (e.g. skills
only, or Monday – Wednesday morning. courses)
• Number of hours/sessions worked per week
• Number of hours per session 5. Remuneration
• Appointment lengths • Employment status as this pertains to
• Patient to be booked by appointment remuneration e.g. employee, contractor,
• Flexibility to book longer appointments etc.
• Proportion of appointments pre-booked • Contract duration and remuneration review
• After hours and on call periods, (if any).
• Home and residential aged care visit • Calculations of sessional payments – by
requirement, and share and distribution time or percentage of earnings or hourly
between GPs rates.

• Different rate for after hours, home or • Premises and physical work environment
residential aged care visits, (premises location, including branch surgery
• Payment cycle – weekly, fortnightly or if relevant)
monthly • Reception area
• Pay slips (in the case of an employee) , • Sharing consultation room
invoices, and other payment documentation • Working in other practices i.e. multi-centre
• Superannuation practice
• Associateship or partnership at the end of • Decision making involvement in practice
the contract. Consideration of share and • Practice equipment and facilities
goodwill in the practice • Access to practice nurse and other allied
health personnel
6. Other Conditions of Contract: • Administrative support and practice
• Who’s patient? Who retains the patient list management protocols and procedures
–the GP or the practice? • Availability and access to other resources
• Patient notification on cessation at practice (e.g. pathology or radiology, other health
(notification pre- or post-departure/ professionals)
responsibility for patient records) • Computer system and upgrades may be
• Required qualifications and skills high priority for incoming GP
• Scheduled contract review periods
• Probationary period 8. Professional development and continuing
• Medical indemnity insurance – practice or education:
individual to purchase? Same insurer for all • Support/educational activities within
GPs in the practice? the practice (e.g. attendance at courses,
• Vicarious liability for practice clinical staff? practice/ staff meetings, emergencies)
• Steps in place to negotiate conflict – written • Scope to develop special interests
protocol • Ongoing study and professional
• Restraint of trade conditions: (A development
restraint of trade is a condition to • Role in practice accreditation
protect employers’ business interests • Practice’s involvement in general practice
by restricting an employee’s future work projects, ICGP projects and other initiatives,
for a specified period of time within a e.g. Heartwatch – does practice get
defined geographical area3). Legal advice involved and what are the commitments?
is required to determine if such clauses are
enforceable and/or legal, e.g. competition Reflecting on any or all the above conditions,
law. one can use the grid below to cleary define one’s
negotiation position. Two parties that are well
7. Practice Environment: prepared and clear about their own respective
• Suitability of town/city. Is this area going to agenda are always more likely to reach a
generate the type of practice envisaged? successful outcome.
3 For more on the Competition Act 2002 & Competition Amendment Act 2006, see www.tca.ie

Priority Grid starting point to then address salary and related
Condition terms.
e.g. After hours work
In determining salary there are two key questions
Best Outcome Complete First to address:
e.g. No after work hours 1. How much can the practice afford to pay?
2. What can the prospective incoming GP bring
to the practice?
Must Have Complete Second
e.g. no more than two nights per month
By looking at patients seen per hour/hours
worked/average fee/GMS breakdown (including
Trade Off Complete Third subsidies) and then factoring in bad debts and
e.g. Remuneration overheads generated, it is possible to estimate
how much the practice can afford to pay/fund the
Remuneration incoming GP. This figure will also be balanced
Salary and related conditions can often be the against lifestyle benefits to the existing principal(s),
first thing people will focus on but it may not e.g. time off.
always be the most important – there are many
factors, as outlined above which will influence the There is an owner margin to be taken into account
achievement of a satisfactory outcome. However, when calculating the remuneration figure as
at that very least if these issues are addressed various partners or principals may be drawing
first it can provide a good starting point for different percentages of profit from the practice.
proceeding to negotiate on salary. Renewing There are of course other considerations to be
all the relevant factors first, provides a better made, such as, flexibility to cover holidays, home

visits or after hours commitment. It is likely that The opening offer in any negotiation is a crucial
the more flexibility you can offer, the greater the step. There are 5 recommended steps to an
salary one is likely to be able to negotiate. opening offer:
Negotiating What You Want 1. Know your walk away point

Having drawn up a list of conditions and clarifying For example, this could be a salary level
for yourself the must have, best outcome and or important life style condition, and once
trade off for each, one can then progress to decided upon is obviously not for revelation!
putting the best case forward.
2. Avoid being the first to present an offer
Prioritise the conditions of most value in order This allows one to get a better idea of what
to more easily negotiate conditions that are the other party expects. It is reasonable to ask
less crucial and thereby protecting the factors what the position is offering.
/conditions which are most important.
3. Unreasonable first offer
List the conditions not met or fully satisfied (must If the initial offer is unreasonable then it should
haves) and then the ones where a better outcome not be countered with a concrete one. This
is preferred (best outcome). Detail a separate can back you into a corner. Simply request
column to reflect on the reasons for the other that they return with a more reasonable offer if
party not meeting these. Then in a final column negotiations are to continue.
detail what one may be prepared to do and
negotiate in order to achieve your best outcome. 4. Caution is needed in immediately accepting
The following example illustrates the approach: the first offer
It is always a sensible approach to fully
1. Wish to finish at 3 pm on a Wednesday consider the first offer and all related
2. Reason other party does not agree: patient conditions and to do so without haste.
demand is not met One may need independent advice or seek
3. Compromise: reduce salary so can pay extra clarification on specifics. It is not usually just
administration and nursing staff in order to free the financial offer that needs examination but
up time for doctor and patients the whole ‘package’ being offered.
5. Don’t use your walk away point as your first

7.5 Negotiation - a Structured Process offer
A. The Opening Offer This obviously leaves both parties with no
It is important not to sacrifice one’s own position, room to manoeuvre or bargain and limits all
certainly not beyond a ‘no trade’ point. However, opportunity of an acceptable outcome.
it is also important to understand the other party’s
perspective as well in order to identify areas for B. Moving Negotiations Forward
compromise. It is important to understand that When the stage has been reached where both
in negotiation the point is not to “out-do” or parties proposals have been put forward the next
gain an upper hand on those with whom you are step is to attempt to close the gap between the
negotiating but rather to reach a deal that best fits parties. This might be achieved by the following
the needs of both parties. approach:

1. Improve offer 5. Fait accompli
Bring the other party closer by offering Most people will at a certain point accept
something they want. You may offer to do a done deal rather than going on with
procedural work or do extra after hours to negotiations. If you have an agreement for
cover the rota in exchange for a higher salary. example with one clause that you cannot
When discussion is focused entirely on factors accept maybe re-word it and sign the
such as salary then people are more likely to agreement highlighting the change. Both
dig in their heels and become entrenched. parties if presented with a signed document
Equally, long term gains financial (and other) are more likely to finish the deal.
may be lost if relatively unimportant factors are
insisted upon at the outset. C. Dispute Resolution
In addition to scheduling regular review periods
2. Making concessions in the contract /business relationship which
At some point you will need to make some allow terms to be updated to match changing
concessions. Depending on what you prioritise circumstances it is also important to have a
then you can try to concede the things that process planned for dealing with disputes.
don’t matter to you as much but may matter Outlining/agreeing on a dispute resolution process
to the other party. As in any negotiation, your in the initial agreement/contract is recommended.
own demands require reflection and need to This may include the following:
be realistic.
1. The other party must be notified about the
3. Decelerate your concessions issue and given adequate time to respond.
For example if you reduce your salary offer/ 2. If a suitable response is not provided a peer
request initially by e.g. €5,000 and then by could provide an independent view to both
€10,000 it may set a tone that you can keep parties and provide mediation between the
going this way. Instead, bring the level of your parties.
reduction lower and lower to where your half 3. Should this view not be acceptable to both
way point will lie. parties, an independent mediation process,
facilitated by a skilled independent person
4. Uncover hidden agendas should be sought. The ICGP can assist in this
Don’t always assume that you know what the regard.
other party wants. Attempt to explore their 4. If mediation is not successful, the process
perspective, encouraging explanation of could move to arbitration i.e. both parties
stance on issue(s) in question, may uncover willing to accept the independent decision
different concerns than initially expected, of the arbitrator. The ICGP can assist in this
e.g. the quality of life issues may be more regard.
important to some than the direct financial 5. If after all the above have been tried it may be
benefits. necessary to seek recourse to legal advice.

8:
Sample Models of
Partnership

Introduction working arrangements. Decisions also have to be
made as to what constitutes practice expenditure
The frequently asked question by both and what is to be regarded as personal
establishing GPs and Principals alike when expenditure of individual partners e.g. PHI,
negotiating the entry of a new GP to a practice, phone expenses, motor costs, medical indemnity,
is what is the ‘norm’ and is there a ‘formula’? subscriptions etc.
Without objective data it is impossible to answer
this question with any level of accuracy. Formulae
are quoted and vague descriptions given but 8.1 BUY-IN MODEL 1
there isn’t a norm that will satisfy every situation. In this practice a buy in figure was agreed.This
It ultimately is down to the negotiation of an was calculated in terms of income lost to the
arrangement acceptable to those involved. current partners by the addition of a new partner.
The buy-in figure equated to two years projected
That said it was felt worthwhile to illustrate how minimum gross earnings of the incoming partner.
some practices have arrived at solutions which
were right for them. It must be stressed that the The rationale being that this would compensate
case studies below are anecdotal and the authors the existing partners for loss of earnings
are grateful to the practices who have contributed due to the additional division of profits.
this information.
Essentially, this was calculated by assessing the
It is hoped that this will give readers a starting previous three years of the existing partners’
point and a variety of options when commencing gross earnings, estimating the growth level and
negotiations on entry to or expanding a practice. then projecting what approximately this would be
with an additional partner. Therefore a partner’s
There is no one perfect/ideal formula that will suit projected annual income could be ascertained.
all practices but it is our experience that often
neither the principal nor the incoming assistant A multiplier of 2 was then applied to this figure
knows where to start, it is hoped therefore that the (projected partner income) and paid as a one-off
models described below will be of assistance. payment to the practice partners.
The models as described in this chapter The formula’s objective logic may be questionable
are examples of how GPs have ensured the but it provided a way of arriving at a figure which
development and continuity of their practices. is agreeable to all.
The ‘value’ of practices may fluctuate over time
and will be influenced strongly by the prevailing The incoming partner used a tax efficient
‘market’ conditions. Ultimately, the value is commercial loan to raise the amount. Instantaneous
determined by what the ‘buyer’ / incoming partner partnership has an impact on gross salary and
is willing to pay. obviously on personal financial planning including:
mortgage approval implications, repayments,
Factors which can influence the type of model pension contribution etc., all of which the
used include: ratio of GMS: private income, individual needs to manage and work out in detail.
number of existing partners, ownership of
premises, time commitment and flexibility of

8.2 BUY-IN MODEL 2 It is also important to point out that this was a
In this case study the new partner progressed to recently established practice and the original
partnership as follows: model was to use 3 years profit averaged and
multiply by 1.25 for the “whole egg” figure but 3
Incoming GP worked as a sessional GP for a years full trading had not occurred at the time of
period of 1 year. During this year the sessional rate partnership.
was agreed as 80% of the requested sessional rate
in order to offset the eventual ‘buy-in’ amount.
8.3 WORK -IN MODEL 1
In year two the incoming GP became a partner In this case it was agreed that full partnership
in the practice by paying a ‘buy in’ figure. This would be progressed over 3 years as follows:
figure was arrived at by averaging the previous
2 years practice gross profit and multiplying this Year 1:
figure by 1.5. This was then the full figure used In this year, the new party’s status was that of
to calculate the buy-in amount (the whole egg!). ‘Assistant with a view to partnership’, and the
Including the new partner, there were a total of 22 assistant worked for agreed salary.
sessions worked per week. The incoming partner
wished to work 6 sessions per week. Therefore, Year 2:
the buy-in amount that had to be paid was 6/22 (6 In year two assistant progressed to status of
of the 22 sessions) of the “whole egg” figure, less partner with an 80% profit share for the first six
the amount foregone i.e. the reduced sessional months which increased to 85% of profits in the
payments in year 1 (the number of weeks worked second six months.
multiplied by 20% of going rate)
Year 3:
In year three the new partner progressed to a 95%
of profit share for entire year.
Year 4:
In year four, the new partner achieved 100%: full
partnership.

The percentages above are relative to the number 8.5 WORK-IN MODEL 3
of partners in practice, i.e. 80% of one quarter if In this case study similar to work-in Model 2, a
there are 4 equal partners. method of work in while progressing to parity with
the two existing principals is used:
In this model there is an adjustment according to
the relative number of sessions worked by each The objective is to enable working in with
partner respectively i.e. it is calculated by the incrementally increased share of profits, e.g.
fraction that the individual doctor works of the New GP Existing GP Existing GP
total number sessions worked by all doctors. #1 #2
Year 1 22% 39% 39%
For example: Doctor A works 6 out of the total of Year 2 25.6% 37.2% 37.2%
27 sessions worked in the practice so he/she will
Year 3 29.4% 35.3% 35.3%
get 6/27 = 22.2% of profit share at full partnership.
Doctor B who works 9 sessions gets 9/27 of 100% Year 4 33.3% 33.3% 33.3%
which is 33.33% of profit share.
8.6 ASSOCIATESHIP MODEL

As mentioned in Chapter 2 some practices
8.4 WORK –IN MODEL 2 operate as an ‘associateship’.
At commencement and during the initial 6 These are essentially group practices where
months, the assistant works for agreed salary and incomes are separated between each associate
this period provides an opportunity to assess within the same premises and overheads and
whether parties can work together. administrative supports are shared. Various
mechanisms can be used in the allocation of
After the first 3 months (probationary period) these overhead costs. e.g. Proportioned on
if matters are satisfactory to both parties, then the percentage of patients seen by each doctor
commence discussion on salary for one year of respectively.
‘assistantship’ – salary plus bonus payments
(at the discretion of the partners and based on Cross cover can be an advantage of this system,
increase of practice income in the period) but agreement as to fees needs to be reached
regarding patients seen by the other associates.
After this period if matters are satisfactory, progress The associates operate as independent
to partnership and profit share are as follows: businesses. The organisation and management
of this type of practice formation works efficiently
New GP Existing GP Existing GP when supported with an effective IT system
#1 #2
Year 1. 25%: 37.5%: 37.5% of profit
Year 2. 28%: 36%: 36 %
Year 3. 31 %: 34.5%: 34.5%
Year 4. 33.33 %: 33.33%: 33.33%

8.7 Corporate Models of General PRIMARY CARE TEAM MODEL
Practice:
In recent times corporate models of general In 2001 the Government launched the Primary
practice have been introduced into Ireland. Care Strategy. This involves a new way of working
as a team with professional colleagues to deliver
This involves a legal cooperation between quality care for patients. It is envisaged that
a corporate entity and a number of general Primary Care Teams would look after over 90%
practitioners. of all health and social needs and would be the
central focus of the health system.
Some of these corporate models merge existing
practices and the company (corporate entity) The core team consists of General Practitioners,
itself becomes a partner in the new business. Public Health Nurses, Practice Nurses,
Such models propose to facilitate the business Occupational Therapists, Physiotherapists and
organisation of general practice which may suit Home Helps. Other services such as Social
some general practitioners. As with other models, Workers, Community Welfare, Dieticians,
establishing GPs typically enter such arrangements Podiatrists, Mental Health professionals and
as ‘salaried’ employees at least in the initial stages. Disability services may be shared between teams
or considered as core team members depending
Other models rely on GPs as anchor tenants in on the needs of an area.
their business relationship. The corporate entity in
this case purchases a purpose built premises and Primary Care Networks encompass several Primary
sells part of the premises to a group of GPs i.e. the Care Teams and would provide access to services
GPs may have an option to purchase their section such as Dental, Psychology and Speech and
of the premises at a preferential rate. In turn Language therapists.
the corporate entity benefits from other ancillary
services which may be attracted to the building A total of 530 Primary Care Teams and 134
by virtue of its medical centre: physiotherapy, Networks have been identified for development
radiology, pharmacy, etc. by 2011. The target set for 2008 is to progress the
development of 97 Primary Care Teams (including
The details and specifics of each corporate the 10 pilot teams) to fully functioning stage (1st
arrangement is beyond the scope of this Phase). These 97 teams cover approximately 22%
publication, but as in every model described there of the population. It is also planned to advance
are advantages and disadvantages to be aware of the development of a further 113 teams in 2008
and expert advice should be sought. (2nd Phase). The breakdown of the Primary Care
Teams for development is as follows:
It is also worthwhile evaluating the experiences
from other countries where similar models have
developed.

Some factors to consider when reviewing
models of Practice Formation:
• Autonomy
• Financial base
• Legal entity
• Complexity
• Access to accurate information (inc financial)
• Taxation issues
• Professional compatibility
• Personal compatibility
• Continuity
Individuals will be encouraged to enrol with a • Management supports
primary care team and with an individual doctor • Status of incoming partner
within the team. It is intended that many services • Growth potential
will be provided on an extended-hours basis and
out-of-hours cover for defined services will be
enhanced.
From a GP’s perspective , all of the models

described for partnership in this chapter can still
apply within a Primary Care team as ultimately
it is up to the group of G.Ps as to what their
partnership arrangement is within themselves.
Further information on Primary Care Teams is

available from the Local Health Office where an
official (TDO or Transformation Development
Officer) is available for help and advice on local
Teams. Discussion with one of these officers
would be advised especially if commencing a new
practice.

9:
Practice Management

Introduction The Practice as a Business
Chapter 4 addressed general practice as a
This chapter outlines basic management principles business. A typical practice is analogous to a
and describes the management of the key assets small/medium size enterprise. A business is any
of the practice/business. The establishing GP activity supplying goods or services for profit;
needs to acquire and develop the skills necessary in this context, general practice is certainly a
for effective management, including: financial business enterprise. As such there are fundamental
management, the management of people, management principles that apply in the same way
management of time (one’s own and others’), as for other businesses.
create and organise practice systems, use and
management of IT systems, generation and use of 9.1 What is Practice Management?
information. The management function is both general and
specific, and frequently GPs set up de novo (or
The skills, knowledge and competencies needed join an existing practice) without giving serious
to effectively manage a practice1 are perhaps consideration as to how the practice operates,
acquired progressively. This process should ideally or how it should be managed. Management is
commence in the GP Registrar years. Equally, about knowing how to make the right choice
the opportunity should also be taken to observe between competing demands and utilizing the
and gain management experience in a variety limited resources of the practice in an optimal
of practices in the period immediately following way. It is about knowing how to delegate, how to
training. Astute observation (and participation) on communicate, how to set objectives and monitor
the part of the locum, assistant, or sessional GP, achievements, as well as leading, supporting
provides valuable knowledge on how to manage, and motivating those who are employed in the
or indeed mismanage, a practice. It is also very practice. It requires that the GP and/or practice
worthwhile if the opportunity presents itself to manager (frequently one and the same person) to
gain an insight into how other businesses are know how to take decisions and how to exercise
operating using ‘normal’ business/management authority. The primary function of management is
conventions. to ensure that the practice is and remains a viable
and profitable business. Another key function of
This chapter provides an overview of requirements good management is about enabling the GP and
for the successful management of a practice other clinical care providers to maximise their
and is supported by the specifically dedicated time in performing their primary role - treating the
Management in Practice Programme webpage, patient.
available at http://www.icgp.ie/mip. There
are also specific sections dedicated to Practice
Management and GP IT issues in Forum, the
ICGP’s monthly publication.2
1 And/or participate in the management of the practice

2 Forum is free to ICGP members. For information on subscription, non-members should contact the publishers,
Med Media at http://www.medmedia.ie

Some of these skills will be new and must be If the GP is to improve their performance in
acquired, some the GP will already possess. providing a health care service to the patient
However, one will need to be flexible enough to (including the promotion and preservation of
adapt to a new role, and be capable of moving health, as well as its restoration), he/she must
between the role of doctor/care provider and enhance the organisational performance of the
business manager/entrepreneur. Sometimes GPs practice. To optimize income, systems of allocating,
experience role conflicts, such as being both coordinating, recording and billing of services
doctor and employer to practice staff, addressing provided are necessary. This is an administrative
the question of outstanding fees with patients, function as distinct from a management one.
closure of lists, etc. Effective administration promotes organisational
efficiency through systems which achieve a better
Defining Management quality output for a given input. Administration
A well managed practice is a content place to be is the means of achieving a certain purpose.
- for patients, for staff and the GP. Patients are Management provides the vision.
likely to receive a better quality of care, while the
GP (and staff) enjoy a better quality of working life. It is the role of management to decide and define
Well managed organizations/businesses are more the purpose(s), and where others are involved, to
profitable, productive, and more responsive to evoke their commitment to that purpose.
change and more competitive.
Defining the Purpose
GPs should be no strangers to management. In In undertaking the management function the
the clinical care of patients, the GP attempts to establishing GP must define the following:
assess the problem, develop a treatment plan • What ‘business’ am I/we in?
and review the outcome. Clinical management is • What is the distinctive competence of my/our
more effective if the patient is actively involved in practice?
the process. Managing the business side of the • What is the potential of the practice?
practice involves many of the same processes; it • What do I/we want the practice to become?
similarly involves a diagnosis of issues/problems,
decision making, planning, implementation and These are fundamental questions, the answers to
review, and active involvement of the other person which give meaning, purpose and focus to the
in decision making process. work of the GP and the services provided by the
practice. Answers to these fundamental questions
The well managed practice does not necessarily must be fully explored by the individual and the
have to grow bigger but a practice which is partners/potential partners before one can get to
effectively managed will grow better. grips with the management function.
Strategic Questions
In order to manage the practice the GP(s) must
decide and define the objectives of the practice
(and their personal objectives) and set the
direction. Without this no real management can
occur. In order to determine practice objectives
it is necessary to ask a number of strategic

questions, which include but are not limited to: Pritchard (1988)3 has defined practice
• Where do I/we want the practice to be in 2, 5, management as ‘the systematic applications of
or 10 years time? common sense and specialist knowledge in order
• What do I/we need to do in order to get to achieve aims now and in the future’.
there?
• How will we know when we have arrived. Planning
• If I/we don't succeed, will I/we know why and Planning is management’s most important
what alternative strategies are available? function. The principle purpose of planning is to
• What is the optimum list size? define goals and to answer the questions posed
• What is a viable practice size in terms of no of above - where is the practice going? It sets the
partners, staff, etc? boundaries for all subsequent decisions and the
• What is the actual and projected income level context for all activities. This statement on the
of the practice? objectives of the business must be clearly defined
• What level of services do I /we wish to and agreed by all stake holders concerned - staff
provide? and partners (and spouses!). A statement of
• Where does the practice position itself, objectives becomes the compass by which the
in terms of its external environment, i.e. progress of practice will be directed. A common
competitors, ‘allies', regulators, etc? purpose is integral for any organisation or
business, with all resources and actions geared
Strategic management involves setting objectives, to the achievement of common objectives. The
optimum allocation of limited resources, and setting of objectives helps to highlight the issues
implementation/action in a predefined time frame, facing the practice and can suggest various
as well as reviewing the ensuing results. Plans solutions to problems when they occur.
are made based on best available information.
Strategic management involves both risk and There will always be constraints limiting the
reward - opportunity costs. Making a choice(s) achievement of objectives: limited finance,
mean that other opportunities must be foregone. reluctance to change, time limitations, and
attitudes, external forces, etc., all of which the GP
Management is about getting things done as planner must take into account. The planning
– achieving results process, once the objectives have been agreed,
Management is essentially about getting things is to formulate clearly the rationale decisions - the
done, and involves: stating of the problem, analysing the problem and
• Planning putting forward alternative solutions. One must
• Organising consider all known factors and their implications,
and then map out how the objectives are to be
• Controlling
achieved. An example of a business plan has
• Directing already been given in Chapter 4, ‘The Business of
General Practice’.
3 Pritchard, P. and Whalen, M.1984. Management in General Practice. Oxford, University Press.

Organising Directing
Organising is concerned with the sequencing, Essentially, achieving results through managing
systemisation and coordination of work tasks in and directing others and involves delegation,
the practice. The establishing GP needs to be instruction, training and review and appraisal of
fully au fait with standard practice systems and the work performance of others.
how they are organised/can be organised, e.g.
systems for repeat prescribing, for processing
results, controlling access, data security, call/recall 9.2 Time, People, Money and
systems, and so on. Organising is also concerned Information: Managing the Key
with structure, i.e. the reporting relationships, Resources of the Practice
decision making, implementation. In a typical 9.2.1 Time
general practice it may not be immediately Time is probably the key resource in the practice;
obvious what the structure is to a GP who has each clinical provider can provide services to one
recently just joined. Equally, when setting up a patient at a time. Time needs to be managed
practice the establishing GP needs to define the appropriately to allow for:
structure as the practice expands, particularly in
relation to decision making and delegation. Consulting Time Time for Professional
Development
Controlling Management Time Planning Time (inc
The control function is about setting down strategic planning)
standards, markers, benchmarks, procedures and Administration Time Time for Review
systems that allow control to be maintained and to
indicate that objectives are being achieved and to Time also needs to be managed to ensure that
flag (in good time) the need for corrective action. the individual’s work/life balance is optimised.
Examples of control markers include: Time management is challenging in a
busy general practice.
• Comparison of projected income with actual
income, equally.
• Pre-determined expenditure and matching Fundamental to the success of any practice is
against actual costs allows for control. the appropriate management of patient access
• Determining acceptable level of bad debts to services/service providers (GPs and Practice
and comparing actual level when reviewed. Nurses). Effective systems, operated consistently
• Time set for completion of work tasks provides will allow for appropriate consultation time. These
a monitor - if consulting time is continuously systems also need to be flexible enough to deal
conflicting with given appointment length then with e.g. unplanned /urgent work and necessary
action is needed. interruptions. Time management for the individual
• Estimates for performance indicators can GP is also important. Everyone recognises
be established from past performance for (although only after some time has elapsed) that
equivalent period and conditions and/or in a start up situation the amount of time given
comparisons with other practices /similar to new patients is usually not sustainable as the
businesses. practice grows access has to be controlled. The
old adage of commencing as you plan to continue
may be more challenging to follow in reality than
expected.

As the practice grows or in the case where the At some point, usually sooner than expected, the
establishing GP joins an existing practice his/ establishing GP will become an employer and/
her personal time management will have a key or have direct responsibility for the supervision
influence on the ‘business’ performance of the /management of staff: practice receptionist,
practice. Being in independent professional secretaries, administrators, practice nurses,
practice gives one a lot of flexibility but as in other practice managers, locum and sessional clinical
workplace situations, this needs to be balanced staff, and GP employees.
with due regard to punctuality and efficiency.
To some degree the management of partners may
Good time management is that which maximises also be included in this context.
patient/doctor contact time while all the other
functions of the practice are ideally delegated to This management function may be broadly
competent and effective staff. Moreover, effective divided into the following areas:
time management also achieves the objective
of healthy balance between work and protected People Management Skills: the recruitment,
personal time. selection4, training, induction, supervision,
motivation and appraisal of the individual
Well managed control of access to services – clear employee all require specific knowledge, skills and
communication with patients, high level reception competencies to be successful.
skills, use of the IT supports (e.g. appointment
waiting prompts, electronic patient records), Knowledge: understanding the psychology
consistency in application of policies, appointment of work and what promotes or detracts from a
systems, allowance for unplanned demand, healthy and productive work environment and how
average consultation times congruent with this informs the management role.
clinician’s consultation style - all support optimal
time management. Skills: interpersonal communications skills, ability
to persuade, skills of leadership.
9.2.2 People Management
Whether in a start up situation or joining an Competencies: to conduct performance appraisal
existing practice in whatever role (including of another’s work, to conduct effective training.
where the one is an employee), the establishing
GP needs to have knowledge of best practice All of the above relate to the management of the
people management and the ‘normal’ constructs individual employee but people management
that pertain in the workplace environment. Such should also address how people work together
constructs are informed by the law, statute and as part of a team, with each functional role
common law, custom and practice, societal contributing to the overall performance of the
expectations, and accepted management practice as a unit.
practices. To some extent medical training
and education has in the past not exposed the
establishing GP to such norms and up to now
there has been a significant deficit in this area.
4 For further detailed information on an approach to practice staff recruitment and selection refer to
The Practice Nurse: a guide to nursing in General Practice, ICGP’

The Employment Contract: Legal Compliance Employer Rights and Entitlements
Human Resource Compliance: There is a The GP employer has a right to expect the
legal framework which defines the employee following from practice personnel:
and employer relationship. At its core is the
employment contract. • Compliance
• Competence
Where a job offer is made and the offer accepted,
• Adherence to practice policies, protocols
where consideration is present (payment) a legal
relationship exists.5 This is the fundamental core of and procedures
the employment relationship providing as it does • Confidentiality
both rights and entitlements to both parties. • Safe conduct
• Professional standard of work
From this fundamental legal concept a
continuingly expanding regulatory frame work, is
built by both the courts and the legislators. The
rights and obligations of both employees and
employers are continuously being redefined and
therefore the employers maintain their knowledge
in this area e.g. legislation governing minimum
wage rates, minimum statutory leave entitlements,
unfair dismissals protections, notice periods,
access to pension fund, etc.
5 A legal relationship exists whether or not the contract is expressed in writing, a point frequently misunderstood by
general practitioners, both established and establishing.

Employee Rights and Entitlements Remuneration and related costs
• Written terms and conditions of employment Salaries and other expenditure related to
• Fair procedures employment of staff typically represent a high
percentage of overall practice expenditure. The
• Minimum leave under the statutory
provisions for employment leave level of salary negotiated will be dependent on
qualifications and competencies, the ‘going rate’,
• Healthy and safe work environment
supply/demand in the market, the type of post
• Freedom from harassment and bullying offered, existing precedents in the practice.
• Access to a Personal Retirement Savings
Account (PRSA) Prospective GP employers frequently do not
• Maintenance of employee records consider the full cost of employing staff and in
addition to salary costs may include:
Legislation under which all employers must
operate Employers PRSI, pension contribution (if paid),
• Adoptive Leave Act training and development, continuity of payment
• Data Protection Act during absence if this is a condition of the
contract, ‘locum’ costs if staff are temporarily
• Electronic Commerce Act
replaced during periods of absence, employers
• Employment Equality Act liability insurance, professional indemnity if paid/
• Equal Status Act sub-vented, equipment, furniture, other facilities
• Industrial Relations Act required to enable the individual to undertake
• Maternity Protection Act their work, etc.
• Minimum Notice & Terms of
Employment Act Personnel Administration:
• National Minimum Wage Act Apart from the fact that the maintenance of good
personnel records is in keeping with best practice,
• Organisation of Working Time Act
there are also legal requirements with regard
• Parental Leave Act to maintenance of such records. This includes
• Payment of Wages Act the terms and conditions under which staff are
• Protection of Employment Act employed, general rules of conduct e.g. telephone
• Redundancy Payment Act usage, email and internet access/use, formal
• Safety Health and Welfare at Work Act communications with individual e.g. performance
appraisal reports, grievance and disciplinary
• Terms of Employment (Information) Act
procedures, salary calculations, deductions from
• Transfer of Undertakings Regulations salary and deductions and payments of taxation.
• Unfair Dismissals Acts
The ICGP Management in Practice Programme
As an employer the GP must be fully aware of provides human resources compliance (HRC)
practical implications for both employer and consultancy service to members. Further
employee. For comprehensive information on information on human resource management
human resource compliance in the practice refer is available on www.icgp.ie/mip Practice
to the ‘GP as Employer’ section of www.icgp.ie Management under GP as Employer.

Taxation: IT communications applications are also
Where staff are employed the employer is obliged developing at an exponential rate providing
to operate PAYE - (pay as you earn) and PRSI both challenges and opportunities to practices.
- (pay related social insurance) deductions on the Information, advice and training is provided to
employee’s salary. general practitioners by the General Practice
Information Technology Group (GPIT) a College
The administration of the payroll is best done and Health Service Executive initiative, which
using computer based systems. Confidentiality is provides IT education and training delivered
an issue to consider regarding delegation of this by a country wide network of GPIT facilitators
work. The payroll function may also outsource, to (GPs). The GPIT group publishes information and
the practice accountant and /or book-keeper. practical guidelines. It will also within the next 12
www.revenue.ie provides an on line guide (pdf months provide an accreditation system for GP
format) entitled ‘ Employer’s Guide to PAYE, software systems.
which is recommended reading for the first time
employer. Managing IT in the Practice
The key issues with regard to IT from a
9.2.3 Information Management and IT6 management perspective are:
The technology is now available to allow for
almost completely paperless practice. The selection of efficient hard ware and
To achieve this, or at least to the extent software systems, effective use and consistency
desired, the establishing GP must have a good with regard to authorised access, daily usage,
understanding of the hard /software applications input/changing of data, data security, training
available and appropriate to GP setting. The of all users, ensuring the practice obtains value
establishing GP needs to be aware of main issues for money in relation to IT support. This is likely
concerning: to be an ongoing process given the rate of
change and development in IT applications.
• Set up, maintenance and development costs
(both time and money) As well as the management of data – technology
• Training and utilisation protocols allows for data to be translated into information
• Security of the data base – including back up, which should inform both clinical planning,
password protections, encryption organisational management and to generate
• Legal issues regarding record management information on e.g. chronic disease management,
and access to personal data demographics, work load, financial analysis,
• Internet usage and security and transfer of equipment usage, phone call patterns. All of
data e.g. tests results which illustrate the key resource available to all
• Health and safety of the computer user practices, now made accessible through IT.
6 Refer to GP IT section of www.icgp.ie/gpit for relevant publications, guidelines and information on the GPIT
support network

9.2.4 Money • A listing of all purchase invoices received in
This asset has been discussed in detail from many the practice. As the invoice is paid the cheque
perspectives in other chapters but it is worthwhile number and date should be recorded on the
reiterating a number of the key principles with invoice to avoid payment duplication.
regard to financial management: • A listing of all withholding tax certificates
received with the notification of the GMS
The separation of private income/earnings from Payment. This list should detail the number of
business/practice income – conceptually and the certificate, the date, the gross amount, tax
practically. Practice fee levels need to be set at a amount and net amount received.
level that cover costs and creates a profit margin.
Fees charged must be collected – whether from The analysis books should be totalled weekly.
individual patients or from the state In addition weekly bank reconciliations should
be prepared to ensure that the GP is aware of
Income ‘collected’ needs to be recorded both for the accurate bank balance at the end of each
management purposes and as required by tax law. week. Regular checks should be performed on
statements such as the merchant services card
Cash flow needs to be managed so that income statement to ensure that all credit card and laser
matches expenditure – monthy, quarterly, annually. card transactions have been honoured. Also the
GMS statements should be checked to ensure that
Practice income needs to be sufficient to cover: all payments due have been received.
Practice expenses, drawings of the practitioner, tax
liability, income protection, pension, re-investment Where practical it makes sense to outsource the
in practice development. practice bookkeeping to a book-keeper who has
experience of working with GPs. The book-keeper
Financial Administration could attend the practice one half day a week to
The following is a list of the books and records process the accounting records. Not only does
that should be maintained for monitoring this mean that there is a person with experience
and management of all practice income and maintaining the records but it also frees up the
expenditure: practitioner’s time to develop the practice.
• Daily list of patient visits, amounts paid and As the practice grows practice administration staff
method of payment. may be equally adept at financial administration if
• Details of all lodgements made to the business trained or qualified
bank account, to include manual lodgements,
GMS lodgements and laser / credit card To ensure that the record keeping is accurate it
lodgements. is recommended that the GP should arrange for
• Analysis book containing details of all the accountant to periodically review the records
payments made from the practice bank being maintained. This process can cease once
account. This should include all cheques the accountant is satisfied that the bookkeeper is
written together with all direct debits, standing competent. This will protect against any significant
orders and charges on the bank account. additional time being input at year end to unravel
errors throughout the year.

Accounting software
It is recommended that the GP should purchase Information and services provided by the
an affordable accounting software package. The practice accountant
most appropriate will depend on the needs and
financial applications of the clinical software used The firm of advisors will prepare the year-end
in the practice. The accountant should assist in financial statements from the records maintained
selecting an appropriate package. Using Microsoft by the practitioner. It is therefore in the best
Excel a relatively simple spreadsheet system can interest of the practitioner that the records be
be designed (A template is available from ICGP). maintained in the most professional manner
Accounting and book-keeping software is also possible.
available as off-the-shelf programmes, varying in
complexity e.g TAS Books, Big Red Books and The accountant will require details of all financial
SAGE. transactions carried out by the practitioner in
running the practice during the financial period.
Most of the GP software systems incorporate some If this can be provided in the form of reports from
accounting applications eg fees management an accounting software package then this should
and it is important to discuss your requirements result in a reduced time input by the accountant
with the supplier in relation to the integration of and a reduction in the level of queries to the
systems. accountant.
It is very important that records are maintained for INCOME FROM STATE CONTRACTS7
the required period of time. The Health Service As well as the administration and management
Executive recommends that financial records of income from private practice one must set up
should be kept for a period of 7 years. The systems for the administration and management
Revenue Commissioners require records to be of income in respect of services provided to
kept for 6 years. Among the financial records that patients under State schemes. The objective is to
need to be retained are: claim for all services provided and ensure that full
and timely payment is received for all claims made
• Bank statements and in addition that all additional benefits and
• Cheque books entitlements under the terms of these schemes
are received. GPs are remunerated under the GMS
• Lodgement books
contract in a number of different ways:
• Supplier invoices
• GMS payment statements Capitation
• Payroll records Capitation payments are received monthly and are
calculated based on panel size and age, gender
and distance codes (the distance of patients’
domicile from practice centre).
7 also refer to Chapter 10, State Contracts
Practice Allowances & Subsidies 9.2.5 Marketing Practice Services
Practices will also be in receipt of allowances and Marketing of practice services (and of the service
subsidies for the costs of employment of practice provider) is essentially about approaching the
staff, locum allowances in respect of annual leave, practice from the perspective of the patient
sick leave and study leave. and using this to inform your approach to
communicating key information on the practice, its
Supplementary Grants/Practice Maintenance/ services and how to access them. It is about telling
Development Grant the patient as consumer about yourself, the type
Additional or supplementary grants are also paid of practice you operate and how your patients and
to GPs which are supplementary payments under potential patients can engage with you and the
a number of headings, are paid automatically and practice
which do not require claims to be initiated by the
practice. Refer to the monthly summary listing for The four Ps - key business marketing principles
details of these automatic payments. The objective is to build up and maintain a
sustainable patient base.
This grant is payable towards practice
maintenance, equipment and development. Key business marketing principles apply to all
The HSE is entitled to satisfy itself that practice business including General Practice.
premises meet the relevant criteria laid down in Product/service: the services that are offered,
the GMS contract. The grant is dependent on the these need to be differentiated.
overall number of ‘live’ patients on the GP’s panel
and is calculated as a percentage of the individual Price: consideration needs to be given to standard
doctor’s panel size, up to a maximum of 1,500 fees and fee schedule for additional services.
patients. This payment is made automatically Information on payment methods, payment
without the practice being required to submit a policies also need to be communicated.
claim.
Promotion: reputation is the single most
The Cycle of Claims & Payments important factor in promotion of a professional
From a practice management perspective the service like general practice. As a provider, one
key objectives are that the practice claims for needs to reflect on how that reputation is built up
payment within the appropriate date cycle for all and this extends to GP colleagues and practice
services. Secondly, the practice must ensure it staff as well.
receives accurate and timely payments from the
State through the HSE Shared Services Primary One also needs to analyse the specific needs of
Care Reimbursement Service (formerly the GMS sub groups within the practice population and
Payments Board). promote services accordingly. Content and quality
of presentation is important – business cards,
Payments are issued and received by the practice practice information literature, posters, signage,
and the GMS patient panel is the key determinant reference in directories, practice website are all
for the calculation of payments. methods of promotion.
Place: convenience and accessibility is a ICGP Information, reference, advice and
requirement for patients as well as the quality of consultancy
care provided so the old adage location, location, The ‘In the Practice’ section of the ICGP website
location applies. (www.icgp.ie) provides members with access to
detailed up-to-date information and advice on the
To some extent in the context of joining an full spectrum of practice management issues. A
existing practice the establishing GP can be management consultancy service is also provided
regarded as marketing themselves – to both to members on request.
principals and patients of the practice.
Further information on publications, guidelines,
9.2.6 Management Training protocols, support, consultancy, training, and
The ICGP Management in Practice Programme related aspects of practice management, is
provides specific web supported management available from the ICGP Management in Practice
training and development for GPs and Practice Programme:
Managers. The following areas are covered on the
MIP Diploma course: Email: margaret.cunnane@icgp.ie
Webpage: www.icgp.ie/mip
• Management Principles/The Role of the
Manager The following organisations may also be of interest
• Practice and Health Care Services in Ireland to establishing GPs as their careers progress.
• Financial Control
• The Irish Small/Medium Size Firms Association
• Strategic Business Planning
(ISME) http://www.isme.ie/
• State Contracts • Irish Business and Employers Confederation
• HR Legal Compliance (IBEC) http://www.ibec.ie/
• Taxation
• Systems/Processes 9.2.7 Physical and psychological health of the
• IT/Communication GP and practice staff:
In a corporate setting typically the HR department
• Marketing Practice Services
has the specific responsibility for the occupational
• People Management health of all who work in the organisation.
• Health & Safety Irrespective of the size of the organisation worker
• Stress Management health, psychological as well as physical needs
• Personal Effectiveness/Time Management to be appropriately managed. This also includes
the health and psychological well being of the
practitioner and ‘self- care’ is an important area for
Postgraduate Masters programmes (MBA or the establishing GP to address.
MSc.) are another means by which one can avail
of management training. Shorter, subject specific
training may also be available locally and should
be considered.
Many of the risks to health in general practice are Management training can provide the knowledge
common to most work place environments there and skills to cope with work related stress and
are however some which are unique to general health and safety issues in the practice. In addition
practice settings. Regular health and safety audits it is important to know how to access individual
culminating in ‘active’ health and safety policies in support when this is needed. One example of
the practice are a management responsibility and the external supports available to GPs and their
a legal requirement. families is the ICGP Health in Practice Programme.
From an individual perspective the GP needs to ICGP Health in Practice Programme

be self aware and be in a position to manage the The Health in Practice Programme consists of
stressors that are likely to occur in the clinical care healthcare networks and an information and
of patients and in the management of a business advice service provided by the programme
enterprise. Moreover, the GP as manager/ director. HiP provides confidential healthcare
employer needs to be able to effectively manage through four networks.
the potential negative effects of stress on practice
staff. Network GPs - a GP for GP service.
Network Occupational Physicians - for
The following headings are useful in considering occupational health advice.
the relationship an individual (GP or practice Network Psychiatrists - for when you might
staff) has with their job in the context of ‘stress need one.
management’: Network Counsellors, Psychologists and
• Workload - excessive overload, especially Psychotherapists - developing solutions, life
emotional work. management skills and coping resources to help
• Control - insufficient control over resources, resolve your work-related and personal problems.
overwhelmed by responsibilities.
• Reward - lack of appropriate reward: financial, Health in Practice also provides education
social recognition. and tutorial materials and workshops on stress
• Community - isolation from work colleagues, management as part of its education, information
conflict. and advisory service for GPs.
• Fairness - lack of respect, inequity of work or
pay, no voice. For further information on the programme log on
• Values - conflicts of personal principles. to http://www.icgp.ie/hip
Burnout arises from chronic ‘mismatches’ between

the individual and their work setting in some or all
of the six areas.
10:
State Contracts held by
General Practitioners
Introduction A choice of doctor scheme
A key feature of the GMS contract is that it provides
This chapter describes the state contracts held by for a choice of doctor for the patient. Under
GPs for the provision of services to eligible patients the contract, the GP is expected to be routinely
and outlines the contractual terms and conditions available for consultation with eligible patients
of these contracts. The subject is complex given for a total of 40 hours per week (although actual
the incremental manner in which these schemes contracted surgery hours would be significantly less
have developed. The chapter is presented in two than this and agreed with the HSE) and the contract
sections, the first deals with the General Medical commits the GP (personally or in conjunction with
Services (GMS) while in part 2 the other state his or her deputy) to providing 24 hour cover. An
schemes/contracts held by GPs, separate from the out of hours fee will be paid in respect of non-
GMS Scheme are discussed including: the Mother routine consultations necessarily carried out outside
& Infant Care Scheme, the Primary Childhood the hours 9am to 5pm Monday to Friday, and all
Immunisation Scheme, and the position of Medical hours on Saturday, Sunday and Bank Holidays
Certifier with the Department of Social & Family excluding consultations made during normal
Affairs. contracted surgery hours which are outside the
above hours and excluding consultations made as
10.1 The General Medical Services (GMS) part of an overflow occurring during normal surgery
Scheme Contract hours. Other important provisions of the contract
The most significant State contract held by General allow for the assignment of a patient to a GPs
Practitioners is the GMS contract. The current panel by the HSE and for the removal of a patient
capitation based contract was introduced in 1989 from the doctors panel at the request of the doctor
and the terms and conditions of GPs under this (paragraphs 4 and 9 of the GMS contract refer).
contract have been amended from time to time
following negotiations between the IMO and the For the establishing GP it is worthwhile considering
Department of Health & Children / Health Service the GMS Scheme/contract under the following
Executive. The revised terms are given effect by headings:
means of Circular letters from the Department
of Health & Children. There are currently A. The modes of entry to the GMS Scheme
approximately 2,095 GPs in the State who hold Contract by GPs, including the Once off entry
GMS contracts. The GMS Scheme provides for free agreements from 1999, 2001 & 2005
General Practitioner services to 32% (approx.) of
the population through the ‘full’ medical card and B. The eligibility of a GMS principal to appoint
the GP visit card schemes. an ‘Assistant with a view to Partnership or /a
Partner in the GMS’;
A separate GP visit card contract was introduced on
the 1st. July, 2005, to allow for the introduction of C. Sample contractual templates provided by
up to 200,000 GP visit card patients. This contract is the IMO for GPs entering into Assistantship
available to all GPs who are eligible for GMS entry / Partnership arrangements along with some
and who have been in practice for a period of one advice for GMS Assistants / Partners in contract
whole year prior to 1st. July, 2005 (or has, on or matters including some useful contact points.
before that date, entered into a partnership with, or
a legally binding contract to acquire a practice from D. The GMS interview process: some practical
an existing practitioner or practitioners). advice.
A. Modes of Entry to the GMS 1999 & 2001 Once-off Entry Agreement:
1. GMS Vacancy Once off entry agreements were concluded in
2. Assistant with a view to Partnership / GMS 1999 and 2001. Refer to Appendix 6 on these
Partner agreements.
3. Once off Entry Agreements (1999, 2001, 2005)
2005 Once-off GMS Entry Agreement
The two most common forms of entry to the GMS A further once off agreement on GMS entry was
Scheme are: agreed in 2005 in the context of agreement on
the introduction of up to 200,000 GP Visit Card
1. by means of filling of a GMS vacancy, for patients.
example, where a single handed GP retires
and his/her panel is advertised by the HSE as a The Labour Relations Commission brokered
single handed vacancy. agreement provided as follows:-
2. by means of appointment as an Assistant with
a view to GMS Partnership by an existing GMS Entry to the GP Visit Card Contract
principal. • A one-entry arrangement for doctors to
the GMS Scheme (and to the GP Visit Card
In both cases, the posts are advertised by the HSE Contract) which gives the right to entry to
and in the latter case, i.e., in the appointment any fully qualified and approved vocationally
of an Assistant / Partner by an existing principal, trained General Practitioner (meeting the
the principal or his or her nominee will sit on the General conditions relating to eligibility for
Interview Board. appointment to the GMS Scheme) who is in
practice on the 1st July 2005, such a person
3. Once off Entry Agreements: The Background having been in practice for a period of one
whole year prior to that date (or has, on or
• In 1989, the 5 year rule on GMS entry before that date, entered into a partnership
(whereby if a suitably qualified GP was in with, or legally binding contract to acquire
private practice for 5 years s/he was entitled a practice from an existing practitioner or
to obtain a GMS contract) was abolished practitioners)
• The last doctors to enter under this
mechanism were to do so by the 31st • This right of entry to be limited for a period of
December 1993 five years to the acceptance of such GP Visit
• The Blueprint for the Development of Cards patients as acquire their GP Visit Cards
General Practice envisaged entry to GMS under the new eligibility provision. However,
practice by way of either Vacancy or in the case of a person in a partnership on the
Assistantship / Partnership as a means of date s/he acquires limited entry that five years
encouraging group practice period will be reduced to two years if s/he
• The Blueprint did not prevent GP’s from continues in that partnership for the period of
setting up de novo in private practice two years.
• After the period on limited entry has passed, • The IMO is anxious to ensure adequate
the doctor concerned will be free to accept ongoing entry arrangements for GPs
any medical card patient nominating him or
her as their doctor of choice. This provision is • The IMO has been to the forefront in securing
subject to the normal rules of good character recent GMS entry agreements. These
and suitable premises and does not restrict or agreements have resulted in an increase in the
affect other existing rules on entry. Further, number of GMS GPs as follows:-
persons having limited entry contracts under
this provision will enjoy appropriate benefits 1998 – 1,629 GMS Doctors
determined on a pro-rata basis, in accordance 2006 – 2,095 GMS Doctors
with existing arrangements. Any interpretation 2007 – 2,129 GMS Doctors
which arises under this provision should be
subject to joint examination by the parties to B. Eligibility of Principal to appoint an Assistant
this agreement. or Partner in the GMS
In order for a GMS principal to be eligible to
• Doctors who currently hold limited GMS appoint an Assistant with a view to Partnership
contracts or are entitled to limited contracts or Partner in the GMS Scheme, he or she should
under existing entry agreements will also be meet the following criteria:-
eligible to hold the GP Visit Card contract.
• Ordinarily be five years or greater from his/her
Many GPs have availed of their entitlements under normal retirement age, i.e., 65 or younger in
the 1999, 2001 and 2005 GMS entry agreements the case of those doctors who have the option
detailed above in order to gain entry to the GMS of retiring at age 70 (those GPs in the GMS
Scheme. It is likely that a number of additional prior to 1989) or 60 or younger in the case of
GPs have not exercised their rights to date under those doctors who have to retire at age 65
these agreements and it remains open to such (those doctors who entered the GMS after
doctors to avail of the provisions of the above 1989)
entry agreements. Such applications are made to
the Primary Care Manager of the local HSE Area. • And have 500 or more GMS patients
Doctors who wish to clarify their entitlements
under the above agreements should contact the Where a GP fulfils both of these criteria, he/she
IMO for further advice. is automatically eligible to appoint an Assistant
/ Partner in the GMS. Where a principal does
Future GMS Entry Arrangements: not fulfil these criteria, it is at the discretion of
• Future GMS entry arrangements are to the CEO of the HSE as to whether he/she will be
be considered as part of ongoing review allowed to appoint an Assistant / Partner in the
of the GMS and publicly funded primary GMS.
care schemes between the IMO and the
Department of Heath & Children / Health
Service Executive. The IMO is seeking a formal
job sharing agreement under a revised GMS
contract.
Process for Appointment of an Assistant / Rights of Assistants to GMS panels on
Partner in the GMS dissolution of two handed Partnership
• The GMS Principal applies to the local HSE Circular 3/1996 provides as follows:-
Office, Primary Care Manager In general terms, the following arrangements
• The HSE consults with the IMO for its view apply:-
on the application. The IMO has a formal • On the death of the senior partner, the
consultative role in relation to the filling or assistant retains his / her contract and panel of
dissolution of all GMS vacancies, the creation patients provided their junior partner’s entry to
of new GMS posts, or the appointment of the Scheme as a partner had been approved
Assistants / Partners in the GMS. by the health board
• The HSE approves application and advertises • On the retirement / resignation of the senior
post nationally partner, the junior partner retains his / her
• Short listing of candidates and interview contract and panel provided he / she has
process put in place by HSE served for a period in excess of three years
• The GP principal has the right to sit on the • On retirement, resignation of the senior
interview board partner, where this arises as a result of the
• Panel of successful candidates created senior partner:
• Once successful candidate is appointed, this
is followed by a 6 months trial or probationary (a) Resigning to take up another GMS post;
period (b) Retiring to take up a post in another section
• Assistant gets his/her own GMS number of the health services;
/ contract at this point where Principal / (c) Forfeiting his / her GMS contract as a result
Assistant are happy to proceed with the of disciplinary proceedings;
Partnership or
• Point at which Assistant / Partner becomes a (d) resigning on the grounds of ill health;
full partner is a matter for negotiation between
Principal and Assistant. The junior partner continues in the Scheme
provided he / she has at least two years service as
Rules governing the rights of Assistants / Partners a partner.
in the GMS.
Where the partnership is dissolved for any other
The rules governing the rights of Assistants / reason, the junior partner retains his / her contract
Partners in the GMS are set out in Department and panel of patients provided the partnership has
of Health & Children Circulars. The principal existed for a period of five years.
Circulars are numbers 9/1980, 9/1981, 3/1996,
3/2001. The Circulars are complex and have to be Circular 3/1996 was updated by Circular 3/2001
read in conjunction with each other as no single following agreement between the IMO and the
consolidated Circular exists in this area. Access Department of Health & Children and updated
to all Department of Health & Children Circulars the rules on the rights of Assistants / Partners on
relating to the GMS Scheme from 1972 to date dissolution of two handed partnerships providing
can be obtained on the following websites: as follows:-
http://www.icgp.ie/egms
Rights of Assistants / Partners to panels on in the Partnership. The Board’s decision is
dissolution of two handed partnerships (Updated made having regard to the requirements for
by Circular 3/2001) consultation with the IMO.
In the case of such a partnership: C. Contractual Matters – GMS Assistants /

• Where one partner dies, retires through Partners
illness or resigns to take up another contract The IMO would offer the following advice to GPs
or forfeits his or her contract as a result of entering into working relationships.
statutory or contractual proceedings the
remaining partner shall, subject to the approval • It is essential to enter into formal written
of the Health Board (and provided his entry contractual arrangements
as partner in the Scheme had been approved • Protects both parties – Principal and Assistant /
by the appropriate Health Board prior to that Partner
date) retain his GMS Scheme contract and • Provides clarity on rights / responsibilities of
succeed to the panel of the outgoing partner. both parties
• Where the partnership is dissolved by mutual • Specific Legal and Financial advice should be
agreement of the partners, the remaining obtained
partner shall, subject to the approval of the
Health Board (and provided his entry as a The IMO provides the following Sample
partner in the Scheme had been approved Contractual Templates to Members:
by the appropriate Health Board prior to that
date) retain his GMS Scheme contract but not • Sample Partnership Contract
succeed automatically to the contract of the • Draft – Assistant with a view to Partnership
other partner. (involving GMS) Contract
• In both of the above cases, the approval of the • Draft – Assistant with a view to Partnership
Health Board to retention or succession should (General) Contract
be given unless there are reasons consistent • Draft – Associate General Practitioner – Fixed
with the proper operation and integrity of the Term Contract
GMS Scheme that indicate clearly that such • Draft – Sessional General Practitioner
approval should not be so given, for example Contract
where the combined panel numbers exceed
2000 patients. The ICGP Management in Practice Programme
also provides information on www.icgp.ie/mip
Dissolution of Multiple Partnerships on employment legislation, statutory rights,
Circular 3/96 provides as follows:- entitlements and obligations as well as information
on partnership and other forms of practice
Where a multiple partnership is dissolved formation.
on the death, retirement or resignation of
a doctor the health board is required to
freeze the panel of that doctor and decide
whether to continue with the partnership, fill
the vacancy as a single-handed vacancy or
disperse the panel among remaining doctors
In addition, the following sites provide useful web • The interview board should not have to extract
links regarding employment legislation, statutory information from candidates which should be
rights, entitlements and optional benefits: provided in the application / CV.
• It is recommended to make sure that the
- National Employment Rights Authority (NERA) application form includes all relevant material.
Website www.employmentrights.ie Telephone: Applications should be typed. Attach a CV or
Lo-Call 1890 80 80 90 bring three copies of your CV to the interview,
- Equality Authority if you consider you have ‘more to say’ than will
Website www.equality.ie Telephone 01-4173333 fit on the application form.
• Referees – should be contacted in advance of
Department of Health & Children Circulars contact from HSE as a matter of practice and
relating to the GMS (1972 to date) courtesy.
- Website http://www.icgp.ie/egms Marking Schedule

• Uniform marking schedule since 1996
- Website: www.imo.ie • Probably needs updating
Note: This marking schedule is currently under
D. Preparing for GMS Interviews review by the IMO, the ICGP and the HSE.
Irish GP Manpower 20061
• 9% now part-time (3% in 1992) Provides as follows:-
• 30% now female (15% in 1992) Professional Qualifications & Research 100 marks
• 50.5% now 50 years or older! GP Training and Hospital Experience 100 marks
• Only 16% of all GPs plan to work beyond the
General Practice Experience 100 marks
age of 65 years
• 65% now in group practice (31% in 1992) General Suitability 100 marks
Total 400 marks
Application Process:
Currently GMS posts are advertised by the HSE on The marking schedule is set out in Department
the Careers with the Health Service Executive on of Health & Children Circular 3/1996 and can be
www.careersinhealthcare.ie accessed on the following website addresses:-
• Standard Application Form http://www.icgp.ie/egms
• Uniform recruitment process across HSE www.imo.ie
• Rights of candidates set out
• Additional information may be supplied. Candidates should familiarise themselves with the
Interview boards commented on the extent to marking schedule and the contents of this Circular
which some candidates present themselves to prior to interview.
GMS interviews and sell themselves short.
1 O’Dowd T, O’Kelly, M and O’Kelly, F. 2006. Structure of General Practice in Ireland: 1982 - 2005. Dublin: ICGP and
Trinity College. Available online:
http://www.medicine.tcd.ie/public_health_primary_care/research/reports/GP_Structure.pdf
Preparation for the Interview The HSE have produced a publication entitled
• Know the job! ‘Candidate Guide to Application Interview and
• Know the area! Recruitment Process’ which may be of assistance
• Know the practice you are in now, for example, in writing a CV and preparing for interviews. This
the immunisation uptake rates. is available from the local HSE office and /or from
• Brief the Principal (Assistant -with-a-View) the HSE Human Resources Department.
• Know what is topical at the time and take a
view, for example, the Primary Care Strategy. Information on preparing CVs and interview
Also be knowledgeable on current public performance is also available on www.icgp.ie
health issues.
Payment and the
The Interview administration of payments to
• Composition of Board. The structure for the practices under the GMS System:
composition of the Interview Board is set out Payment is made under a capitation system.
in Circular 3/1996. Normally, the Board will In addition contract holders are paid practice
comprise of at least three individuals; usually allowances, subsidies and supplementary grants
the chair is a HSE official, an administrator (practice maintenance and development grants).
usually from the primary care sector but not These payments contribute to the costs of
always. There will be a Director of Public locum, practice staff (practice secretary, practice
Health or a deputy on his/her behalf and a nurse and practice manager), rural practice
GP taken from a nominated panel by either allowances, medical indemnity, computerisation
the IMO or the ICGP. In the case of partners/ and equipment. The payments are processed and
assistant with a view post, the GP principal or administered by the HSE Shared Services Primary
nominee will also be included on the interview Care Re-imbursement Service. Online processing
board. is available. Once registered (obtained contract)
• Structure of Interview – normally the HSE online processing of claims and other interactions
official runs through the procedure. The are on the SSPCRS portal. (https://www.sspcrs.
technical / vocational questions tend to come ie/portal/listings/pub/login.jsp). Additional
from the two doctors. The interview will information is also available on ‘eGMS’ section of
generally last for about half an hour. the http://www.icgp.ie/egms
• Speak honestly
• Say what you think, not what you think the Chapter 9 Practice Management discusses aspects
interviewers want to hear of the claiming system in greater detail.
• Opportunity to Ask Questions – avail of the
opportunity provided. Schedule of Fees and allowances under GMS
Contract
Feedback and Debriefing Appendix 1 gives the current capitation payments
• From HSE schedule, subsidies and allowances as at 1st.
• From Interview Board colleagues March, 2008 under the GMS contract.
• Learn from your mistakes or shortcomings
10.2 Other State Contracts services under the Scheme, which is available free
General Practitioners hold a number of non - GMS of charge. If a woman chooses to avail of services
State contracts with the Health Service Executive under the Scheme she will be under a programme
and other State bodies: of joint care provided by a General Practitioner
of her choice who has a contract with the HSE
A. The Mother & Infant Care Scheme (held with to provide services under the Scheme, and by a
HSE) hospital Obstetrician.
B. Primary Childhood Immunisation Scheme
Contracts (held with HSE) A General Practitioner who wishes to provide
C. Contract for Social Welfare Certification (held services under the Maternity & Infant Care
with the Department of Social & Family Scheme must apply to the HSE to do so. The
Affairs).2 standard agreement will be issued to all General
Practitioners to be completed and returned to the
D. In addition to the above contracts, GPs may HSE. It is the responsibility of the HSE to ensure
be requested by the state to undertake that the General Practitioner is appropriately
examinations, testing, provision of reports and registered and insured, and that there is no reason
the duties of professional witness. While this why he/she should not be given a contract for
is not specifically a ‘contract’ there is a defined the provision of maternity services. A copy of the
fee payment schedule. Refer to Appendix 4 signed agreement should be sent to the General
Practitioner by the HSE.
A. The Mother & Infant Care Scheme Contract
The Maternity & Infant Care Scheme provides for In June 1998, the IMO reached agreement on a
the delivery of services under Section 62 and 63 restructuring of the terms and conditions of GPs
of the Health Act 1970. It comprises an agreed under the Mother & Infant Care Scheme. It is
programme of care arising out of her pregnancy to important that GPs and their administrative staff
an expectant mother and to her newborn baby for familiarise themselves with the new arrangements
six weeks after birth. All expectant mothers who so as to ensure that correct payments are
are ordinarily resident in Ireland are eligible for received. The new arrangements are as follows:-
2 Note: these contracts are renewed on a periodic basis.
Revised Schedule of Visits
Week of Pregnancy Visits to GP Visits to Hospital
Before 12 weeks (preferably as soon as possible
*
after conception)
Before 20 weeks *
24 weeks *
* *
28 weeks (except in case of 1st (in case of first
pregnancy) pregnancy)
30 weeks *
32 weeks *
34 weeks *
36 weeks *
37 weeks *
38 weeks *
39 weeks *
40 weeks *
Birth of Baby
2 weeks after birth for baby *
6 weeks after birth for mother and baby *
The new contractual arrangements provide that N.B. Care in respect of illnesses which are co-
GPs are not obliged to undertake domiciliary incidental but not related to pregnancy do not
births. form part of the Scheme. Where additional visits
are required by patients suffering from major
The diagnosis of pregnancy forms part of the conditions e.g. diabetes, hypertension, a fee of
Scheme and pregnancy-testing kits should be €34.48 per visit, subject to a maximum of five
supplied by the HSE. visits, may be paid with effect from 1 March 2008.
Agreement has been reached on a fee of €287.27 The revised fees paid to General Practitioners
in respect of GP attendance at emergency under the Mother & Infant Care Scheme with
deliveries with effect from 1 March, 2008. effect from 1 March 2008 is listed in Appendix 2
B. The Primary Childhood Immunisation Scheme C. The Social Welfare Certification Contract
Contract General Practitioners hold contracts with the
General Practitioners hold contracts for the Department of Social & Family Affairs as Medical
delivery of the Primary Childhood Immunisation Certifiers. The duties of a Medical Certifier under
Programme under an agreement with the Health Social Welfare Legislation are to:
Service Executive. The terms of the agreement are
negotiated between the IMO and the Department • examine patients who are making claims to
of Health & Children and the HSE. illness or disability schemes and
• complete and issue, free of charge to the
The contracting General Practitioner will deliver patient, a medical certificate on the official
the Primary Childhood Immunisation Programme form, where s/he is satisfied that the patient
agreed under the Scheme. With the Childhood is incapable of work due to some specific
Immunisations currently available it is possible to disease or bodily or mental disablement;
eradicate the diseases in question, if an uptake • complete and issue medical certificates of
level of not less than 95% of the child population confinement, free of charge to the patient, on
is achieved and maintained. The objective of the the official form in respect of Maternity Benefit
immunisation programme, therefore, is to achieve Claims;
and maintain the required uptake of not less than • complete and return medical report forms, free
95% in the total child population for the childhood of charge to the patient, when requested to do
immunisations listed in the schedule. so by the Department.
A General Practitioner who wishes to provide For further information on medical certification,
services under the Primary Childhood the Department of Social & Family Affairs has
Immunisation Scheme must apply to the HSE to issued a booklet entitled “The Medical Certifier’s
do so. The standard agreement will be issued to Guide to Medical Certification under Social
all General Practitioners to be completed and Welfare Certification”, Ref. MC/1/49 (revised
returned to the HSE. It is the responsibility of March 2007)
the HSE to ensure that the General Practitioner
is appropriately registered and insured, and that - available on line: http://lists.welfare.ie/foi/
there is no reason why he/she should not be medcertifiers.html
given a contract for the provision of immunisation It can also be obtained by contacting the
services. A copy of the signed agreement should Department of Social & Family Affairs at 157/164
be sent to the General Practitioner by the HSE. Townsend Street, Dublin 2, telephone 01 /
The revised fees paid to General Practitioners 6732072.
under the Primary Childhood Immunisation
Scheme with effect from 1 March 2008 are given in GPs who wish to become Medical Certifiers should
Appendix 3 contact the Department of Social & Family Affairs
in order to register as Medical Certifiers.
The fees are payable to Medical Certifiers GP Services not covered under the GMS
under an agreement between the IMO and the Contract
Department of Social & Family Affairs as of 2008 The Medical card scheme entitles current card
Fees Payable to Medical Certifiers are: holders to a wide range of services provided by
their General Practitioner. There are a number of
Medical Certificates €8.35 services for which the GP is not paid by the state.
Medical Reports €44.44 Refer to Appendix 5 for services not covered.
Administration of GMS and other State

D . Dept of Justice Fees Contracts – ‘GMS Starter Pack’:
In addition to the above contracts, GPs may be Detailed information on administration, claiming
requested by the state to undertake examinations, procedures and other relevant information on the
testing, provision of reports and the duties of operation of GP state contracts is provided in the
professional witness. While this is not specifically Primary Care Reimbursement Service’s Information
a ‘contract’ there is a defined fee payment and Administration arrangements for General
schedule. Refer to Appendix 4 Practitioners Handbook.
http://www.hse.ie/eng/PCRS/Contractor_
E. Other State Contracts Handbooks/PCRS_Handbook_for_Doctors.pdf
Other State contracts held by GPs include Level 1 Also refer to Chapter 9 Practice Management
and 2 Contracts under the Methadone Treatment to read further on the management of claims
Protocol, District / Community Hospital & Long systems.
Stay Unit for the Elderly Medical Officer Contracts,
GP Unit Doctor Contracts, GP Trainer Contracts, This chapter was facilitated by Mr. Finbarr
Director and Assistant Director of GP Specialist Murphy, Director of Industrial Relations, IMO
Training Scheme Contracts, C.I.E, Port & Docks
and An Post Medical Officer Contracts. For further
information on these agreements, contact Mr
Finbarr Murphy at IMO House, fmurphy@imo.ie or
telephone 01 / 6767273.
Palliative care
While there is no specific contract for the provision
of Palliative care services there is an agreed fee.
Current fee as at the 1st. March, 2008 is €217.80.
References & Further RACGP. 2006. RACGP Employment Kit: Reaching
a Fair Deal. 2nd ed.
Reading
WONCA Europe. 2002. The European definition
Ball, John. 2006. Extra services a plus for of general practice/family medicine.
establishing practices. Forum, 23 (11), Available from: http://www.globalfamilydoctor.
November: 28-9. com/publications/Euro_Def.pdf [Accessed 12
August 2008].
Department of Social & Family Affairs. 2007.
Medical Certification under Social Welfare Additional Publications by Dermot Folan
Legislation – Instructions for Medical Certifiers.
Available from: http://lists.welfare.ie/foi/ • Building for General Practice: an introductory
medcertifiers.html guide to designing your practice premises
Health Service Executive - National Shared • General Practice – a “Business Enterprise”:

Services - Primary Care Reimbursement a guide to financial management in general
Service. 2006. Information and Administrative practice Part I and Part II
arrangements for General Practitioners. Available
from: http://www.hse.ie/eng/PCRS/Contractor_ • People in the Practice – the GP as Employer
Handbooks/PCRS_Handbook_for_Doctors.pdf
• The Practice Nurse – a guide to nursing in
ICGP. 2006. Managing Occupational Health & general practice
Safety in General Practice. 2nd ed. Dublin, ICGP.
Available from: http://www.icgp.ie/library Websites
Companies Registration Office www.cro.ie
Irish Medical Council, 2004. A Guide to Ethical
Behaviour and Conduct. 6th edition. Dublin, Irish The Competition Authority www.tca.ie
Medical Council. Available from:
http://www.medicalcouncil.ie/_fileupload/ Data Protection Commissioner
standards/Ethical_Guide_6th_Edition.pdf www.dataprotection.ie
Kelly, Suzanne. 2007. Getting to Grips with taxing Department of Enterprise, Trade and Employment
matters for GPs. Forum, 24 (10), October: 21-2. www.entemp.ie
O’Dowd T, O’Kelly, M and O’Kelly, F. 2006. eGMS www.icgp.ie/egms

Structure of General Practice in Ireland: 1982
- 2005. Dublin: ICGP and Trinity College. Available The Equality Authority www.equality.ie
from: http://www.medicine.tcd.ie/public_health_
primary_care/research/reports/GP_Structure.pdf eTenders Public Procurement www.etenders.gov.ie
Pritchard, P. and Whalen, M.1984. Management in Europa – SCADPlus: Medicine: mutual recognition
General Practice. Oxford, University Press. of qualifications europa.eu/scadplus/leg/en/lvb/
l23021.htm
Health Service Executive – Careers Medical Defence Union (The MDU) – GPs &
www.careersinhealthcare.ie primary care professionals
www.the-mdu.com/gp/index.asp
HSE - Finance Shared Services – Primary Care
Reimbursement Service www.sspcrs.ie/portal/ Medical Protection Society (MPS Ireland)
listings/pub/login.jsp www.medicalprotection.org/ireland/
Irish Business and Employers Confederation (IBEC) Medisec Ireland www.medisec.ie

www.ibec.ie
National Employment Rights Authority (NERA)
Irish College of General Practitioners (ICGP) www.employmentrights.ie
www.icgp.ie
Acts
ICGP - Find a GP www.icgp.ie/findagp Most available online via Irish Statute Book:
http://www.irishstatutebook.ie/
ICGP - Health in Practice section www.icgp.ie/hip
Adoptive Leave Act
ICGP – GPIT www.icgp.ie/gpit Competition Act
Data Protection Act
ICGP – In the Practice section Electronic Commerce Act
www.icgp.ie/in_the_practice Employment Equality Act
Equal Status Act
ICGP - Library section www.icgp.ie/library Industrial Relations Act
Maternity Protection Act
ICGP – NEGs (Establishing in Practice) section Minimum Notice & Terms of Employment Act
www.icgp.ie/neg National Minimum Wage Act
Organisation of Working Time Act
ICGP - Practice Management section Parental Leave Act
www.icgp.ie/mip Partnership Act 1890
Payment of Wages Act
Irish Medical Council www.medicalcouncil.ie Protection of Employment Act
Redundancy Payment Act
Irish Medical Organisation www.imo.ie Safety Health and Welfare at Work Act
Succession Act
The Irish Revenue Commissioners Terms of Employment (Information) Act
www.revenue.ie and Transfer of Undertakings Regulations
www.ros.ie Unfair Dismissals Acts
Irish Small & Medium Enterprises Association

(ISME) www.isme.ie
A:
Appendices
Appendix 1
Payment and the administration of payments to practices under the GMS System:
Payment is made under a capitation system. In addition contract holders are paid practice allowances,
subsidies and supplementary grants (practice maintenance and development grants). These payments
contribute to the costs of locum, practice staff (practice secretary, practice nurse and practice manager),
rural practice allowances, medical indemnity, computerisation and equipment. The payments processed
and administered by the HSE Shared Services Primary Care Re-imbursement Service.
Fees and allowances payable under Capitation Agreement (Effective 1st. March, 2008)
Capitation Fees
Age 0 – 3 miles 3 – 5 miles 5 – 7 miles 7 – 10 miles Over 10 miles
M F M F M F M F M F
0–4 €81.62 €79.61 €85.96 €83.99 €92.36 €90.44 €98.71 €96.77 €106.56 €104.59
5 - 15 €48.39 €47.93 €49.18 €49.72 €51.81 €52.42 €54.39 €54.94 €57.59 €58.11
16 - 44 €60.48 €98.90 €62.81 €101.25 €66.27 €104.66 €69.65 €107.48 €73.80 €112.21
45 – 64 €120.80 €132.48 €137.43 €138.32 €133.54 €146.56 €142.78 €154.75 €152.70 €164.82
65 – 69 €127.25 €141.98 €142.80 €157.53 €165.92 €180.64 €188.60 €203.33 €216.82 €231.56
70 & over €139.08 €154.25 €155.11 €170.31 €178.99 €194.18 €202.41 €217.62 €231.54 €246.76
The capitation Rate of €655.66 per annum for persons aged 70 years or over in the community requiring
a Medical Card for the first time regardless of income.
A Capitation rate of 949.99 per annum will apply to anyone aged 70 years or over in a private nursing
home (approved by a HSE) for any continuous period of five weeks.
Supplementary out-of-hours fee: €3.99 has been incorporated into Capitation fee rates.
Homes for the aged – out of hours fees
A Medical Practitioner is remunerated by way of capitation payment in respect of a person on his/her
list in a Home for the Aged and may claim an Out-of-Hours fee for Emergency Services provided out of
hours.
0-3 miles 3-5 miles 5-7 miles 7-10 miles Over 10 miles Additional fee
Out of hours fees €49.42 €65.93 €74.22 €82.37 €98.87 €38.56
Temporary residents/Emergency
Temporary residents/Emergency /EEA visitor fee rates on claims for special type consultations and for
outside normal hours consultation.
Surgery Domiciliary
Urban 0-3 miles 3-5 miles 5-7 miles 7-10 miles Over 10 miles Additional fee
€49.42 €49.42 €49.42 €65.93 €74.22 €82.37 €98.87 €38.56
Asylum Seekers: A one off super-annuable registration fee of €190.09 per relevant patient will be paid to
doctors in respect of each such patient on their GMS Scheme panels
Special Type Consultations (STCs)

As well as remuneration under Capitation, GMS contract holders are paid on a ‘fee per item’ basis for
specific special type services provided to patients, these include: suturing, cryotherapy, ECG tests, fitting
of a diaphragm, influenza vaccine and hepatitis B vaccination.
For further detailed information on STCs and relevant payments refer to:
Primary Care Reimbursement Service’s Information and Administration arrangements for General
Practitioners Handbook.
http://www.hse.ie/eng/PCRS/Contractor_Handbooks/PCRS_Handbook_for_Doctors.pdf
CONTRIBUTIONS TO LOCUM EXPENSES AS AT 1st MARCH 2008
Locum Expenses: Annual/Sick/Study/Maternity/Paternity
Entitlement is dependant on Panel Size.
Annual Leave:
Leave Entitlement dependant on panel size
per day €245.78
per week €1,720.46
PANEL SIZE NO. OF DAYS Rate at 1/06/07 €239.79 Rate at 1/03/08 €245.78
100 14 3,357.06 3,440.99
200 16 3,836.64 3,932.56
300 18 4,316.22 4.424.13
400 20 4,795.80 4,915.70
500 21 5,035.59 5,161.48
600 22 5,275.38 5,407.26
700 23 5,515.17 5,653.05
800 24 5,754.96 5,898.83
900 25 5,994.75 6,144.62
1000 28 6,714.12 6,881.97
1100 29 6,953.91 7,127.76
1200 30 7,193.70 7,373.54
1300 31 7,433.49 7,619.33
1400 32 7,673.28 7,865.11
1500 35 8,392.65 8,602.47
Study Leave:
10 days for all Doctors with a Panel of 100 Upwards
Per day €245.78

Per week €1,720.46
Sick Leave:
Panel of 100 Upwards
Doctors with panels between 100 and 700 shall be entitled to Sick Leave Payment equivalent to their
capitation earnings during the second and subsequent consecutive 24 weeks and half that amount for the
second 26 weeks.
SICK LEAVE - PANEL OF 700 UPWARDS

WEEK 1 WEEK 2 – 26 INCLUSIVE WEEK 27 – 52 INCLUSIVE
€245.78 PER DAY €245.78 PER DAY €122.89 PER DAY
€1,228.90 PER WEEK €1,720.46 PER WEEK €860.23 PER WEEK
Leave for attendance at meetings of Statutory Bodies or G.P. Committees
Per day €245.78
Maternity Leave: Panel of 500 Upwards

A medical practitioner with a list of 500 or more is entitled to locum payment in respect of 26 weeks
maternity leave
Per day €245.78 Per week €1,720.46
Medical practitioners with panels of 100 and less than 500 shall be entitled to locum payments in
respect of 26 weeks maternity leave. The level of payment shall be equivalent to their capitation
earnings during the first and subsequent weeks of maternity leave (not exceeding the current
weekly locum payment as specified in the fee schedule published by the HSE Shared Services
Primary Care Reimbursement Service).
Locum payment in respect of such leave shall not apply to doctors with panels of less than 100.
Panel of 100 or more can also avail of an additional 16 weeks at their own expense on grounds under the
Maternity Protection Acts, 1994 -2004.
Rural Practice Allowance
Rural Practice allowance recipients are entitled to full contribution irrespective of their panel size.
Per day €245.78

Per week €1,720.46
Paternity Leave
Fathers may take three days special leave with pay in respect of children born on or after 1st. January,
2001. This leave may be taken at the time of the birth or up to four weeks after the birth.
Per day €245.78
In the case of adoption, the leave may be taken on or up to four weeks after the date of placement of
the child. In the cases where two or more children are born or two or more children are adopted, the
entitlement to Paternity Leave will be three days for each child, e.g. where twins are born, the father
would be entitled to six days paid leave. The agreement also contains provisions in respect of stillbirths
after the 24th week of pregnancy.
Source: HSE Shared Services Primary Care Reimbursement Service of fees and allowance payable to GPs.
Effective date 1st. March, 2008.
PRACTICE SUPPORT SUBSIDIES

Subsidies payable to a Doctor towards the employment of a Practice Secretary and / or a Practice Nurse.
Panel of 100 Upwards:

Fees applicable from 1st. March, 2008
PRACTICE SUPPORT SUBSIDY SCHEDULE AS AT 1ST. March, 2008
Practice Nurse Practice Nurse Practice Secretary Practice Secretary

Panel Size
1st. June 2007 1st. March 2008 1st. June 2007 1st. March 2008
1200 €41,606.24 €42,646.40 €26,476.68 €27,138.60
1100 €38,139.04 €39,089.44 €24,270.30 €24,877.05
1000 €34,671.87 €35,538.67 €22,063.92 €22,615.50
900 €31,204.68 €31,204.68 €19,857.51 €20,353.95
800 €27,737.49 €28,430.93 €17,650.08 €18,092.33
700 €24,270.31 €24,877.07 €15,444.74 €15,830.86
600 €20,803.12 €21,323.20 €13,238.35 €13,569.31
500 €17,335.93 €17,769.33 €11,031.95 €11,307.75
400 €13,868.75 14,215.47 €8,825.31 €9,045.94
300 €10,401.56 €10,661.60 €6,619.17 €6,784.65
200 €6,934.38 €7,107.74 €4,412.79 €4,523.11
100 €3,467.18 €3,553.86 €2,206.38 €2,261.54
Tiered Calculations:
Practice Secretary:
In the case of the Practice Secretary, the following tiered allowance structure will apply: €23,261.66,
€25,511.67, €27,138.60 the Practice Secretary having one, two and three years relevant experience
respectively.
Practice Nurse:
The scale for Practice Nurse is on the same tiered structure with an allowance of €34,892.51, €36,830.97,
€38,769.44 and €42,646.40 with 1, 2, 3, or 5 years relevant experience respectively.
Relevant experience is defined as 1,2,3 or 4 plus years of a Practice Support Subsidy being claimed for
the individual employee.
Appendix 2.
Mother& Infant Care Scheme Fee Schedule as of 1st March, 2008
1 March 2008
€
1st Visit – Antenatal €47.86
2nd Visit – Antenatal €34.48
3rd Visit – Antenatal €34.48
th
4 Visit – Antenatal €34.48
5th Visit – Antenatal €34.48
th
th
8th Visit – Postnatal (Baby) €34.48
th
9 Visit – Postnatal (Final Mother & Child Visit) €47.86
Total Fee Per Birth:
€302.60
First Pregnancies
All Other Pregnancies €337.08
Please note that the above fee schedule is currently under review.
Appendix 3.
The Primary Childhood Immunisation Scheme Contract
NATIONAL PRIMARY CHILDHOOD IMMUNISATION PROGRAMME AND

INFLUENZA, PNEUMOCOCCAL, HEPATITIS B AND MENINGOCOCCAL C IMMUNISATIONS
Primary Childhood Immunisation Programme

Vaccinations under the Childhood Immunisation Programme are provided free of charge to all children.
Parental consent is required for the administration of vaccinations to children and young people up to
the age of 16. Vaccination is not mandatory in Ireland, but is strongly advised by the health authorities.
Fees are payable for the registration of infants and each primary immunisation, i.e. Diphtheria/Tetanus/
Pertussis, Hib, Polio, MMR, Meningitis C. A bonus is paid if target levels are met for the infant population
registered by each practice. All GPs (including non-GMS contract holders) are entitled to apply for a
contract with the local HSE office to provide these services.
Fees Payable to GP’s in respect of the Primary Childhood Immunisation Programme from
1st. March, 2008.
A. Primary Childhood Immunisation Programme €

1. Normal Payment
(i) Registration of child with a GP 39.84
(ii) Complete course of immunisation against DPT/DT; Hib; Polio and MMR 132.75
(iii) 95% uptake bonus 63.95
2. Pro-rata Payments - Change of GP
(i) Change occurs before immunisation

First GP (registration fee) and 39.84
Other GP(s) for each course (DPTIDT, Hib; Polio & Meningococcal C) x 3 + MMR 49.17
(ii) Change occurs between 1st and 2nd immunisation 39.84

First GP(s) (registration fee) and One Immunisation Course 19.27
Other GP(s) (DPT/DT, HIB. Polio & Meningococcal C) x 2+MMR 59.14
(iii) Change occurs between 2nd and 3rd immunisations 78.44

First GP(s) (registration fee) and Two Immunisation Course 59.14
Other GP(s) (DPT/DT; Hib; Polio Meningococcal C) x1 + MMR
(iv) Change occurs between 3rd and 4th immunisations 39.84

First GP (registration fee) and Three Immunisation Courses 132.75
other GP (MMR) 63.96
3. Pro-rata Payments – Opportunistic Screening, Incomplete Immunisation €
(i) Opportunistic screening e.g. child not registered with GP 43.14

(ii) Incomplete immunisations course
Registration Fee and 39.85
One immunisation course 3.32
Two immunisation courses 46.48
(iii) Where MMR is not administered by the nominated (registered) GP deduct 43.14
Fees payable to GPs in respect of Immunisations

B. Influenza/Pneumococcal Immunisation
(i) Influenza – per immunisation of GMS patient in at-risk categories 38.00
(ii) Pneumococcal – per immunisatioin of GMS patient in at-risk categories 38.00
(iii) Pneumococcal/Influenza – per immunisation of GMS patient in at-risk categories (where
both vaccines are given on the one occasion) 56.99
C. Hepatitis B
Per immunisation of GMS patient in at-risk categories for the administration of full course of 137.02
injections, including post-vaccination testing where necessary
D. Meningococcal C Immunisation
Per visit for immunization of persons in at-risk categories in accordance with arrangements 38.00
under “catch-up”programme.
Booster Immunisations
Fees payable to GPs in respect of the first booster vaccination with a 50% reduction in respect 38.00
of the second vaccination administered on the visit.
This would equate to this fee where the “4-in-1” and MMR are both provided 56.99
Booster immunizations are normally provided by health board vaccination teams in schools.
The fees apply only where booster immunizations are provided by the GP.
Vaccinations in certain situations

Fees payable to general practitioners who are involved in the provision of vaccinations in
situation such as a disease outbreak in a specific area. 38.00
Appendix 4.
DEPARTMENT OF JUSTICE MEDICAL FEES AS AT 1 MARCH 2008 FOR SERVICES

PROVIDED ON REQUEST FROM THE GARDA.
Schedule 1
Special Examinations and reports in cases of criminological character –
service requested by the Garda. 1/03/08
1. Medical examination in cases of attempted murder, grievous bodily harm, accident, etc.
2. Medical examination in case of sexual offences
3. Medical examination in cases under drug acts 9am to 5pm €92.28
4. Medical examination in drunk-driving cases under the Road 5pm to 9am €147.60
Traffic Act, 1961
5. Medical examination and taking of blood and urine samples under part V
of the Road Traffic Act, 1968 and part III of the Road Traffic Act, 1978
When more than one examination is carried out at the same time an 9am to 5pm €56.35
additional fee for each case inclusive of report if required of 5 pm to 9am €101.50
6. In the case of medical examination at scenes of road accidents where the doctor has been called
by the gardai, the patient whom they treat (or his dependants) to be primarily responsible for the
payment of fee but if the fees are not forthcoming within a reasonable period (say, two months) the
fees at 1 above to be payable from state funds
On the principle of a 5 day week medical examinations carried out on

Saturdays, Sundays and public holidays €147.60
Additional fee where more than one examination is carried out at the same time €101.50
In addition 50% extra where more than one hour of doctor’s time per examination
At the garda station or at the scene of a road accident is required.
In addition where total distance travelled is over 5 miles the appropriate CS mileage Rate
The above are special fees arising from the criminological nature of the work.
7. Treatment of persons taken ill or injured, including prisoners – primarily patient is responsible for fee,
but in cases of default, fees to be the same as normal treatment fee
8. Furnishing of report only in case of medical examination or treatment where fee €258.32
does not expressly include report.
Schedule 2
Medical Witnesses giving professional evidence on behalf of the state in criminal prosecutions
Daily attendance fee 1/03/08
1. Where absence from home is Half day €369.04

Full day €738.06
In addition vouched locum expenses up to a maximum of Half day €138.41
Full day €276.77
2. Where a summoned doctor’s attendance is not required a fee will be allowed where:
(a) the court is within 5 miles of the doctor’s home and less than 24 hours notice is given
(b) the court is more than 5 miles from the doctor’s home and less than 4 days notice is given.
Subsistence
Where a doctor attends court outside his home town subsistence at CS class A rates
Travelling Expenses
Travel by first class rail, where suitable, or otherwise mileage at appropriate CS rate.
Schedule 3
Psychiatric reports on accused persons requested by the courts and subsequent attendance in 1/03/08
Court by psychiatrists, if required
Examination and report €220.48
Subsequent report €187.38
Consultation with Counsel (on day other than court sits) €70.87
Attendance in Court
High Court (per day or part thereof) €168.92
Circuit Court ( per day or part thereof) €153.58
District Court (per day or part thereof) €102.31
Schedule 4
Service provided by a consultant psychiatrist for prisons and courts 1/03/08
Fee per session of 3 hours and pro rata (travelling expenses are not paid)* €268.09
Examination and report (travelling expenses are payable from doctors base to prison) €220.48
Subsequent report €187.38
Appendix 5 –
Services not covered under the GMS contract
Services Not Covered By GMS:
A number of services are not covered under the GMS contract and patients are required to pay directly
for these services.
• Medical examinations or reports for legal purposes.
• Examinations relating to insurance policies.
• Examinations relating to fitness to drive including eye test.
• Pre-employment examinations.
• School entry examinations.
• Examinations in connection with fitness to take part in sports.
• Some vaccinations.
• Some family planning services.
• Pregnancy tests.
• Screening tests; including cervical smears, cholesterol testing.
Practices providing any of the above services are entitled to charge the patient directly.
Appendix 6 -
Once-off entry Agreements 1999 and 2001
1999 Once-off GMS Entry Agreement 2001 Once-off GMS Entry Agreement
A further once off GMS entry agreement was
The IMO secured a once off agreement with the reached in July 2001 in the context of the granting
Department of Health & Children on GMS entry in of automatic medical card eligibility to all persons
1999 for GPs established in private practice in the aged 70 and over.
context of the Government’s decision to extend The agreement provides as follows:
the GMS Scheme to Over 70’s patients by means
of trebling the income eligibility guidelines for this • A one off entry arrangement for doctors to the
age group. GMS Scheme which gives the right of entry to
any fully qualified and approved vocationally
The agreement provided as follows:- trained general practitioner (meeting the
general conditions relating to eligibility for
• A general practitioner, having such appointment to the GMS scheme) who is
qualifications as would make him or her in practice on 1st July 2001, such a person
currently eligible for entry to a GMS Scheme having been in practice for a period of one
position and who, on March 1, 1999, is year immediately prior to that date (or has, on
engaged in full-time general practice in or before that date, entered into a partnership
one location in the State for a period of with, or a legally binding contract to acquire
5 consecutive years or who from a time a practice from an existing practitioner or
commencing before that date subsequently practitioners.
accumulates the five consecutive years, shall
be entitled to take on any of their patients • This right of entry to be limited for a period of
who become eligible for a medical card for five years to the acceptance of such medical
the first time on or after that date (or the date card patients as acquire their medical cards
of the relevant accumulation of the five years under the new eligibility provision. However,
referred to, as appropriate) in the case of a person in a partnership on the
date s/he acquires limited entry that five years
• Three years subsequent to the first limited period will be reduced to two years if s/he
entitlement referred to above, the General continues in that partnership for the period of
Practitioner shall be entitled to take as two years. After the period on limited entry has
medical card patients any person holding such passed, the doctor concerned will be free to
a card; this three year requirement will not accept any medical card patient nominating
apply in the case of bona fide partnerships him or her as their doctor of choice. This
which have existed for five years and the provision is subject to the normal rules of good
onus for demonstrating the existence of character and suitable premises and does not
the partnership and its duration will be the restrict or affect other existing rules on entry.
responsibility of the general practitioners Further, persons having limited entry contracts
involved. under this provision will enjoy appropriate
benefits determined on a pro – rata basis.
Appendix 7.
Current GP Software 2007/2008, (last updated 17/12/2007)
SOFTWARE COMPANY CONTACT
GPMac Freagra Software Ltd Unit 1, Lisa O’Sullivan, 021 4505233,

Ballyvolane Commercial Park, info@freagra.ie www.freagra.ie
Ballyhooly Road, Ballyvolane, Cork
Health One Health Ireland Partners Ltd, Tel: 1800 700 111, Declan
Ballynattin House, Arklow Business Rossiter/ Dr Rory O’Driscoll
Park, Arklow, healthone@hip.ie declan.
Co Wicklow rossiter@hip.ie
www.healthone.ie
Practice Manager, Dynamic Helix Health 52 Broomhill Road, Crevan O’Malley Main: 01 463
GP & GP Clinical Dublin 24 3000 Fax: 01 4633011 Email
sales@helixhealth.com
www.helixhealth.com
Socrates PMS & PCTS Technical Ideas.com Ltd ITSBIC, Colin O’Connor,
Institute Of Technology, Campus, Phone: 071 91 94007
Ballinode, Sligo Support: 071 91 94007
Information on Costs, Support & Training should be sought from the provider.
Appendix 8.
Locum Services Agencies Locumlink

PO Box 7137
Contactors Ballsbridge
330 North Circular Road Dublin 4
Dublin 7 Managing Director: Rod McGovern
Operations Manager: James Webberley
Medical Director: Dr. Conal Hooper Tel: 01-4956666
Administrator: Mr. Terri Byrne Fax: 01-4936102
Email: terri@contactors.ie Email: info@locumlink.ie
Telephone: 01-8300244 Website: www.locumlink.ie
Fax: 01-4539301
Combined medical paging and deputising service Irish Locum.ie
IrishLocum.ie was founded and is run by Dr
Doctor on Duty Matthew Mac Gabhann MRCGP and by Mr.
344 South Circular Road Michael Smith BE hDBS MIEI.
Dublin 8 Email: info@irishlocum.ie
www.irishlocum.ie
CEO and Medical Director: Dr. Pearse Phelan
Email: info@mediserve.ie
website: www.mediserve.ie
Tel: 01-4533030
Fax: 01-4085153
Provides out-of-hours surgery cover for GPs in

the Dublin area, and as far as Maynooth in Co.
Kildare and Bray in Co. Wicklow. They also provide
surgery locums for GPs countrywide.
Locumotion
Rockfield Medical Campus,
Balally, Dundrum, Dublin 14
Tel: 01-2993550
Email: info@locomotion.com
Notes
Notes
Notes
A handbook for the
establishing General Practitioner
http://www.icgp.ie/neg
Irish College of General Practitioners

4-5 Lincoln Place, Dublin 2
Tel: 01 676 3705
Email: info@icgp.ie €75 for non-members, €35 for members
www.icgp.ie Order from info@icgp.ie or 01-6763705

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Signposts

Dr. John Ball

A handbook for the establishing General Practitioner

Dr. John Ball

Published by ICGP September 2008

ICGP Network of Establishing General Practitioners

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 1

2 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 3

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 5

ICGP Network of Establishing General

6 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

Mr. Laurence Daly, Director of Financial Planning at

Mr. Finbarr Murphy, Director of Industrial Relations Disclaimer:

Thanks also to ICGP staff especially - Ms. Margaret

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 7

8 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 9

10 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 11

(Refer to Chapter 10)

12 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 13

3 Current fee is €180.

14 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 15

16 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

1 See appendix 8 List of Locum Contractors.

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 17

2 See Chapter 4, ‘The Business of General Practice’

18 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

3/4 See Chapter 4 ‘The Business of General Practice’.

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 19

5 See Chapter 7, ‘Negotiation’

20 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

6 See Chapter 10, ‘State Contracts’

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 21

22 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

1 See Chapter 4, ‘The Business of General Practice’.

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 23

24 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 25

• Negotiate an extended rent free period: three 3.3 Practice Name

26 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

One can request an easily remembered phone

5 See Chapter 4, ‘The Business of General Practice’

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 27

Professional advice from an appropriate advisor Personal Drawings/remuneration:

28 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 29

Many companies will offer a support system ‘on-

30 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 31

32 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

3.15 State Contracts (other than GMS):

3.16 Registration with Health

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 33

34 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 35

2 Refer to Registration at www.medicalcouncil.ie

36 • Signposts to Success - a handbook for the establishing General Practitioner - ICGP

Signposts to Success - a handbook for the establishing General Practitioner - ICGP • 37

5 See ‘GP as employer’ in the Management in Practice section of www.icgp.ie/mip