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General practice has always seemed a secure career, but now locums, associate GPs and even partners should be on their guard, warns

Dr John Couch

The first green shoots of spring have finally emerged, bringing with them unpleasant news for all of us working in the NHS. The NHS finance pendulum has swung back to austerity after what seems like a very brief period of growth.

Some hospital trusts have made the headlines recently by making hundreds of staff redundant. These include consultant posts ­ illustrating that nothing is holy. Doctors spend many years of training to reach their chosen specialty and, with the exception of obstetrics and gynaecology posts at the turn of the millennium, have come to take job security for granted. It is clear that this is no longer the case as medical unemployment in secondary care has become a reality.

Some predict that primary care will face similar issues soon and that this year we will see the first GPs made redundant.

There has been no formal GP principal pay rise this year, making life tighter for all practices. In addition PCTs have been instructed to scrutinise PMS income.

PMS practices make up 40 per cent of primary care. Until the new GMS contract, associate GPs were employed almost exclusively by PMS practices. But GMS practices have since followed suit, albeit to a lesser extent, as partners have left or retired.

One only needs to scan the BMJ jobs section to see that the vast majority of posts advertised are salaried.

Practices facing large cuts in PMS income will undoubtedly look at staff costs, their largest expense. There are no prizes for guessing that some associate posts will be at risk, with partners taking up the slack in

order to prevent a large fall in profits.

In the past it was relatively easy to obtain a new post. However, this is not the case now. It has been apparent for some months that there has been a large increase in applications for associate jobs, reflecting a growing pool of GPs looking for work. Redundancies will not only increase this pool, but also the numbers of posts available will fall further.

Again, locum work used to be a relatively safe standby, but reduced demand along with increased competition could make this route tougher too.

Finally, even GP partners are not protected completely. In theory, at least, contracts can be withdrawn from PMS practices. Increasing private competition may eventually make this a reality, particularly for under-performing practices.

The key point for all of us is not to panic. A careful review of our individual current and medium-term danger should provide useful strategies to avoid redundancy or at least to take appropriate action to minimise the impact if things go wrong.

GP associates

Associates, especially those employed by a PMS practice, face the most immediate danger and should ideally be making a risk assessment now.

First, check your contract of employment to establish the period of notice you would face if the worst happened. An average figure is three months ­ which is more than the majority of lower-paid medical jobs and private sector medical posts. This at least would give you a reasonable breathing space in order to find alternative work.

Next, check your position within your practice. How long have you worked there? Do you offer extra skills? Are you a good team worker?

Put yourself in the place of your employer. If you had to look at medical redundancy within your practice, who would you feel is the most likely victim and why?

Having done this, if you decide there is anything more than a slim risk to your position, draw up an action plan. It may look something like this.

·Offer more skills to your practice. You can do this either by exploiting to the full the skills you already possess or by training for areas where your practice has obvious gaps.

·Raise your profile. Start to show more interest in areas of work currently performed by partners only. Practices vary, but in

general partners tend to run clinics, e

nhanced services and lead in QOF clinical areas. By taking on some of this work you are enhancing your value to the practice (as well as your own experience base if you eventually apply for partnership).

·If you are part-time and this is your only job, consider extra work elsewhere as an

associate GP, GPSI, clinical assistant or locum. Having two or more jobs gives you more options if you lose one, and cushions the effect on cash-flow.

·Keep your eye on the jobs market. You will at least have an idea of the best areas to

apply to if necessary. You may also find a better or more secure job than your current post and can jump before you are pushed.


GPs working as locums are a diverse group. Some have other jobs, some are between employed posts, and some rely on locum work only. Locum quality has generally been good, but while there has been plenty of work available it has been possible for standards to vary. If work gets more scarce this will no longer be acceptable.

Locums can increase the chances of work by:

·going that extra mile by being prepared to offer more than the average locum

·maintaining good contacts and

relationships with contracting practices,

especially practices that offer plenty of work

·keeping standards consistently high

·avoiding a walk-in walk-out attitude

·reviewing rates ­ it is better to have plenty of work at a slightly lower rate than little work at a higher rate

·broadening scope and skills ­ eg GPSI, out-of-hours work, and prison medicine.

GP principals

If PCTs do increase their use of private primary care providers over the next few years, they will aim to replace practices that fail to satisfy their patients. Competition is designed to act as a stimulus for improved standards and a cost-effective NHS. Practices that ignore this fact will be vulnerable. All practices should strengthen their position. The following should help.

·Be proactive ­ be the first to recognise opportunities or say Yes to PCT requests.

·Be more business-like ­ look at your

market and aim to foster high levels of patient satisfaction.

·Grow ­ by whatever means it takes. Attract more patients, amalgamate with neighbours. Size will matter more in future.

·Improve access ­ this really matters to patients and none of the above will be

possible without it.

·Maintain high levels of patient continuity ­ this is general practice's best weapon, something a private company is unlikely to match.

·Maintain high levels of GP and staff education and training.

Finally if you need any more persuading, consider this. Would you prefer to stay in your partnership, employed post or locum work or be employed by a private company?

Reports from the few GPs who have applied for these posts have painted a bleak picture of terms of service. We should all ensure that the fresh growth of the early millennium do not contain any weeds.

John Couch is a GP in Ashford, Middlesex

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