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At the heart of general practice since 1960

How do we solve the problem of locum GPs?

Dr Naureen Bhatti

Great GP debate logo

Great GP debate logo

These are difficult times. Chronic underfunding of the NHS with escalating workload, costs and bureaucracy has caused many GPs to vote with their feet and choose to work as locums with fewer taking salaried or partnership roles. Locum GPs have long been an essential part of the GP workforce, often working in challenging circumstances while making an invaluable contribution to patient care. However, there is now concern that the increasing culture of locum working among disaffected GPs is itself contributing to the crisis in primary care.

Ultimately of course the real problem is political policy

Locums have traditionally covered periods of sick or maternity leave and occasional annual leave. With no guaranteed hours they received an enhanced pay rate to compensate for the lack of superannuation and other benefits. However, locums have now become a necessity to cover, not only the increasing hours needed by different provider companies, OOH, urgent care centres, hubs etc but also regular practice clinical sessions. The high level of pay has made locum work an increasingly attractive option with remuneration that competes with that of partners without the same stresses and without the risk of unlimited liability.

We now have a problem, a vicious cycle which has seen progressively increasing workload and declining numbers of salaried GPs and partners while the free market allows spiralling rates of locum pay. The inequity of current funding models, delivering variable and inequitable reimbursement based neither on measured workload nor population need, further exacerbates the problem, with practices better remunerated more able to budget and allow for these costs than others, particularly in inner city areas where high demand due to deprivation is currently not accounted for in GP pay. Ultimately everyone struggles as no practices are funded well enough to pick up the additional workload when neighbouring practices fail.

For me, what is even more important is the loss of what made us choose general practice - continuity of care, an unintended consequence of increasing locum engagement. The core strength of general practice is the ability to provide care to a dedicated patient list. While current trends show some groups of patients prefer to see any doctor at a time that suits them evidence does show that continuity of care is not only linked to patient satisfaction but also to improved chronic disease outcomes, lower use of antibiotics, effective wait-and-see management of self-limiting conditions, reduction of harm from unnecessary and potentially harmful medical interventions and fewer A&E attendances and admissions. I would also argue that it leads to greater job satisfaction as shared decision making is underpinned by a doctor-patient relationship built on a foundation of mutual knowledge and trust established over time.

Ultimately of course the real problem is not locums but a political policy that has created the situation of massive underfunding of the NHS destroying morale. Surveys show that the majority of young GPs and many locums want to be more permanent practice-based post. What can be done to facilitate this? A fee cap was widely rejected by the GP body at the national LMC conference in May this year but NHS England are now asking practices to say when they pay over the new locum indicative rate. NHS England says this is not a cap but a data collection exercise to enable targeted support where it is needed but the BMA have criticised this citing that it has not worked in secondary care and will worsen the workforce crisis. I hope it will allow a calibration of what is an acceptable locum rate but it is unlikely a cap will work as it will further alienate GPs.

But it isn’t just the pay. GPs who choose to work as locums often welcome the flexibility that is missing from permanent roles. Measures, such as schemes to actively retain GPs including a new enhanced retainer scheme from 2017, support for CCG/federation commissioned pools of portfolio GPs and the development of innovative posts such as salaried doctor schemes for new GPs that allow development opportunities, will help, as will support with the rising cost of indemnity.

When debate arises on whether the independent contractor status is sustainable the majority of GPs support the practice-partnership model, seeing it as a way to retain autonomy. However, this will only work if we ensure GPs remain working in practices now which can only be done with adequate remuneration and manageable workloads for salaried GPs and partners, making these posts a more attractive career option.

Dr Naureen Bhatti is a GP partner and trainer in Tower Hamlets and Vice-chair of Tower Hamlets LMC

This blog 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 (18)

  • "Ultimately of course the real problem is not locums but a political policy that has created the situation of massive underfunding of the NHS destroying morale." Quite. What a fantastically unhelpful title. I would have liked to have seen the evidence for "spiralling rates" of locum pay presented, too.

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  • spiralling rates ... out of control.. my a..e..
    i get paid 90 per hr including everything no pensions no travel etc .. take home is far less than a partners unless you do ooh which the pay sucks esp in our area in yorkshire where we get paid 65 on weekday if you work directly with provider or 80 including everything if through agency no wonder they are struggling to recruit gps- pay properly and everyone will work either locum or partner..

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  • Azeem Majeed

    Thank you for your article Naureen.

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  • I would argue that locum pay isn't spiralling out of control at all. They are demanding the pay commensurate with their extensive knowledge, skills and experience.

    In fact, quite the opposite is true. For far too long, partners (and salaried)have accepted the gradual erosion of their pay, through both decreased funding and mushrooming workloads - thereby decreasing the hourly rate of pay.

    Instead of complaining about locums, we should applaud them for recognising their worth in a free market. Why is that so hard for Partners to do?

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  • I do both partnership and locum - partnership pays less but is more constant and longer - also gives me continuity - however it's not sustainable for me - so mix in some locum work too (as well as CCG) - doens't have the hassels as a partner - at least not the non-clinical ones - and yes I do charge more than as a partner but locuming comes with none of the benefits ie consitant work, longer hours to increase income etc

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  • I do more locum work now after a long stretch doing 16 hour days as a partner in the past. 10 sessions, last in our area to give up OOH in 2014 etc. We should combine both roles and present a GP Chambers national solution to the NHS together. If we choose to be undervalued as partners, and neglect our rights to bargain for better, it is hardly the locums' fault. The vast majority of locums do long hours and a lot of us have done your job already, possibly more than some of you have, but then had the courage to move on: it's about doing what's best for your work life balance. Don't start feeling indispensable, that way madness lies!

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  • should read "last to give up...2004" Sorry!

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  • as the funding for general practice reduces, we reduce the practice sessions proportionally. we then locum in the local out of hours and ED department. income maintained and we are still serving our patients but in a different guise. our PPG are informed at each step and support us in this. The local FT are happy for the extra pair of hands. our own personal income and workload has not changed in reality. The only loser is the CCG.

    i advise people to speak to your FT's to see how GP's can support them in areas that they are struggling with.

    - anonymous salaried!

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  • Shaba, you hit the nail right on the head!

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  • Having worked as a locum for over 10years before becoming a partner I do not think locums are overpaid. Locum work in a marketplace. If an institution does not want to pay a locum a certain rate then they can go back to the market to see if someone will do the work cheaper. Of course they may find that the market cost is higher than what they are willing to pay. This is just plain business and nothing else, it works in many other industries.

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