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Q&A: How to claim reimbursement for GP sickness cover

GPC deputy chair Dr Mark Sanford-Wood explains how to claim funding and what to do about top-up insurance

What is the new sickness reimbursement scheme?

In April 2017, rules on sickness reimbursement for GPs in England changed. The BMA’s GP Committee had become aware of growing inconsistencies in the way discretionary payments were made by different NHS England area teams and resolved to address the problem. The result was a new deal.

Practices are now entitled to claim clearly stated sums from NHS England, to help pay for the backfill of sick doctors. This was a major achievement in last year’s negotiating round and one I am particularly proud to have played a part in.

A major, often overlooked, feature of the deal is that there are no exclusions for pre-existing health conditions, a fact that is likely to revolutionise sickness cover for GPs living with chronic, relapsing conditions that can render them either uninsurable or insurable only for enormous premiums.

We also removed the list size criterion that denied help to smaller practices, and established the scheme as mandatory rather than discretionary. It is now available to all practices as a right.

Who is covered and how much money is available?

The new regulations state that a practice may claim funding to pay for the backfill of any doctor who is ‘party to the contract’ (a partner) or who is ‘already employed or engaged by the contractor’ (a salaried doctor).

If the practice employs a locum to cover for a doctor’s absence, the costs can be reimbursed on production of an invoice for that cover. However, there is a cap of £1,734.18 per week for the first 26 weeks and then half of that amount, £867.09, for the remaining 26 weeks of payments.

This cap is not dependent on the number of sessions worked by the sick doctor. Previously, a number of area teams were applying a pro-rata calculation, but this condition has now been abolished.

Also, the costs that are claimed during the first 26 weeks have no bearing on what can be reimbursed in the remaining 26 weeks. So, if the practice claimed less than the capped rate of £1,734.18 per week in the first six months, it could still claim up to the full allowance of £867.09 per week in the second half of the year, if needed.

When can practices claim the reimbursement?

The practice may begin claiming the financial assistance after two weeks of continuous certificated absence of any partner or salaried doctor.

Importantly, locum sessions worked by doctors already within the practice can be reimbursed under the scheme, as well as those done by locums engaged from outside. Sessions worked by an internal doctor must be demonstrably in addition to that doctor’s normal working week, and the additional sessions worked must be clearly invoiced for, as the invoice is the trigger for the payment mechanism.

The amount invoiced by the internal doctor must be reasonable and in line with locum charges the practice would expect to pay if they hired a locum doctor from outside.

What if the GP went off sick before this change?

The Statement of Financial Entitlements is clear about entitlements – there are no restrictions or limitations on claims made from 1 April 2017.

If a GP was already off sick before this date, the clock would start ticking from their first date of absence and the practice would be able to claim the usual reimbursement for the period of absence beyond April.

So, for example, if a full-time partner went off sick on 1 February 2017 and remains ill and certificated with backfill costing more than £1,734.18 per week, the following calculation would be made:

• The first two weeks of absence represents the qualifying period, with the first 26 weeks’ entitlement starting on 15 February.

• The first 26 weeks from 15 February ends on 16 August. As the scheme began on 1 April the practice would be entitled to claim reimbursement of £1,734.18 per week against locum invoices from 1 April to 16 August.

• Starting on 16 August the practice would be entitled to claim up to half of this, or £867.09, for the next 26 weeks – again, subject to producing locum invoices for at least that amount.

What if a GP is off sick more than once within the same year?

Any claim for locum cover for sickness in the previous 12 months will be counted toward the total 52-week claim period.

For example, if a practice claims for 12 weeks of cover, then the GP returns for three months and then goes off sick for 20 weeks: the first 12-week period would be coveredat the higher rate, then the first 14 weeks of the second absence would be paid at the higher rate (totalling 26 weeks at the higher rate), and the last six weeks would be paid at the lower rate.

What types of absence are covered by the new scheme?

The payments are clearly marked for sickness cover and do not extend to any other form of absence. So practices cannot claim for periods of absence due to, for example, jury service, compassionate leave or revalidation purposes.

How do these new rules affect locum insurance?

This scheme will reduce the practice’s requirement for sickness insurance. The sum of £1,734.18 does not usually cover the entire backfill for a full-time doctor so the practice may wish to insure itself for any shortfall in the event of a full-time doctor going off sick.

However, this top-up insurance should be at premiums significantly lower than those previously paid by the practice. A number of sickness insurance providers have begun offering such top-up products, although the GPC advises each practice to consider whether it needs this extra cover according to its specific circumstances.

Dr Mark Sanford-Wood is deputy chair of the GPC and medical director of Devon LMC  

This article was amended on 17-04-2018 to correct the response regarding a GP's earlier period of absence within the same 12-month period; the BMA originally stated that this would have no bearing and that each absence period would be treated separately, but has now clarified that any time off within the same year is aggregated

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