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At the heart of general practice since 1960

We need to use locum GPs to their strength – seeing only ‘acute’ patients

Dr Richard Fieldhouse

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One of biggest behavioural changes I’ve noticed in my 20 years as a GP is that a lot of us are moving from substantive salaried and partnership posts to becoming freelance locum GPs. But rather than empowering locum GPs to support practices, the NHS seems quite content to let locums flounder without any concerted efforts to help organise us into a healthcare system that’s getting more complex by the day.

Rather than resist the move to locuming by simply ignoring locums, we must embrace a model whereby locums are wholly supported to form chambers-like organisations (almost like locum federations) that can work intelligently with local practices to fully support them. In this model, the practice-based GPs are properly enabled to be the ‘named GP’ for patients with chronic or complex needs who need relationship as well as management continuity; 30-minute appointments allowing holistic care, with each named GP at the heart of a team of admin support, practice and community nurses, allied health professionals and social care navigators and givers, all responsible for the same named patients and all with excellent links with any secondary care teams.

At the moment we’re in a situation of chaos, with no formal mechanisms to support locums

Members of the new locum federations could be flexibly deployed to manage patients who still need excellent continuity of management, but do not have such complex problems requiring a ‘named GP’ approach. For example, if the regular practice-based GPs are triaged to see patients who have an existing condition, locum GPs could concentrate on new symptoms for patients with all other existing conditions, or any presentation in a patient with no chronic conditions (chest pains, a mole, a rash, depression). GPs with special interests or skills could also put these into use across different settings, even across different practices.

This is necessary because at the moment we’re in a situation of chaos, with a legacy of absolutely no formal mechanisms to support locums in managing their work or operating in multiple settings.

This vacuum left by the absence of support from the NHS is, to me, fundamental to the position that general practice currently find itself in. Among other things, it’s being filled by locum agencies competing with each other to offer the highest pay to their locums in a bid to attract GPs to work for their client practices, that in turn drives up resentment towards ever more expensive locums, making life even more difficult for practices. Then add to that the eye watering restrictive contracts that agencies and online locum networks get practices to sign up to in their small print like a time bomb that, should the locum take up a substantive post, the practice is then charged 15% of the GP’s annual salary. All this is hardly conducive to bolstering the future of general practice.

Yet despite all this expenditure, all that cash being spent to get a GP locum to the practice, none of this enables a system-wide coordinated approach that whole areas can use to actually intelligently manage their local workforce. Instead, it’s the better-organised practices (arguably those that need it the least) that get their GP locum cover.

The ultimate inefficiency though lies with the caseload that’s finally presented to the locum, which this new model would fix. GP locums are experts in fitting into new practices, adapting to new systems, being that fresh pair of eyes, and seeing a patient objectively without any previous prejudices, good or otherwise. This can be the locum’s strength; research suggests that locums may have the edge in spotting certain cancers and many patients either don’t mind, or even positively appreciate, getting a different opinion. But for a substantial group of patients with long term, complex problems it makes little sense for them to be popped into a 10 minute ‘on the day’ appointment with a GP who has no soft knowledge of them and is probably never going to see them again.

As well as seeing a much-needed increase in funding to primary care, an increase in the number of GPs, I hope we can start seeing the estimated 17,000 GPs who work as locums as part of the solution and build systems that properly engage with them to intelligently support a revised version of practice-based care.

Dr Richard Fieldhouse is chair of the National Association of Sessional GPs (NASGP), director of a locum chambers and a GP in West Sussex

This is part of our ‘Great GP Debate’ season. If you would like to write a blog on how you see the future of general practice, then please email the Editor at editor@pulsetoday.co.uk.

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Readers' comments (5)

  • This is a very thought provoking article Richard and I totally agree that locums need to better engaged with the system as a whole because this is best for all involved.

    Our practice access model is a little unique - we have GP led telephone triage distributed through all permanent GPs so there is no one GP doing all the calls. This is to encourage continuity of care throughout the system. Locums are not involved with this and have a mixture of pre-booked and on the day appointments but we would try to avoid a locum seeing a complex patient on same day triage.

    In future, I predict that these locum chambers will be taken over by large provider organisations and many locums will be employed flexibly to work across multiple sites. This would offer the benefits of a salaried post, team based care but the benefits of flexibility of a locum.

    Without a doubt, all stakeholders need to be reflecting more on how they interact with locums because this is what the new generation are doing (some of them reluctantly) owing to the state of our partnership contracts.

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  • The problem is an ever increasing move amongst GPs to do jobs involving NOT taking responsibility.
    Everybody wants somebody to take RESPONSIBILITY for the patient WITHOUT PAYING FOR IT. It seems that the more responsibility you take, the less you get paid.

    So locums end up on £100/hour for seeing ear wax and re-booking them in with a partner meanwhile the partner is seeing hugely complex patients for £40-50/hour.

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  • Anonymous Locum GP

    GP Partner/Principal31 Jan 2017 3:18pm

    1. where do you get £100 per hour from ? I think you've made that up.
    2. if the GP contract 'negotiated' by the GPC (sic) was up to scratch - we (locums) would be falling over ourselves to be partners
    3. we don't have pension, annual leave, study leave included or the option to sit on a nice CCG board for a day - hence the rates.
    4. most of the locums i've end up doing are trouble shooting practices that would be shut if it wasn't for locums helping out.
    5. easy shifts attract less money - i.e. for looking at 'ear wax cases' etc the rate is more £55 an hour. I know as occasionally i take on an easy locum but charge an appropriate rate.
    6. if you are offering £100/hour for those cases please let us all know as you won't have a problem getting a locum.

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  • Ear wax has to be seen again in a few weeks to see if the drops have resolved it... and then usually with the nurse or district nurse team who do springing... not all partners syringe...
    safe review and follow up is part of good practice for any condition and managing uncertainty

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  • It's the opposite locums are paid about £300 a session in which they see 13 patients at that kind of price it's best for the patient the practice and indeed the locum that they see relatively complex cases. The acutes are best dealt with by any other prescriber. I audited our locums activity and of the 13 only 2 were problems that could not have been dealt with by and ANP.
    The drive to letting locums firefight the acutes leads to massive deskilling, over investigation and prescribing. The fact that they rarely if ever follow up their results means that they miss out on the learning that continuity of care brings.
    I don't begrudge them their choice of employment pattern but they are expensive highly trained professionals who need to be clinically challenged.
    Patients need to accept that they don't need and can't have a GP for everything.
    The answer for us has been to triage into the locums.

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