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How do we solve the problem of locum GPs?

Dr Naureen Bhatti

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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)

  • Locum pay is the most honest market signal as to the state of the job in a post truth world.

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  • I used to be a locum but changed to salaried work for continuity of care with my patients and to be part of a practice team.

    However financially I am much worse off and my work-life balance has suffered. My indemnity isn't paid, I have received limited maternity pay and when I work out my hourly rate based on the hours I actually work rather than my contracted hours (because who works their contracted hours?!) I earn about £34 per hour before tax, indemnity, GMC etc. I didn't receive a pay rise last year despite this being promised when I started the job.

    I enjoy my job but now I have a baby I have to prioritise and 11-14 hour days are not possible with a young family and such terrible wages so unfortunately I will go back to locuming

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  • salaried doc, given your circumstances you have made the right choice. I myself would go back to locuming if being a partner becomes too onerous or if pay drops further. And extended hours will be dropped!!

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  • It is the endless bureaucracy and micromanagement that make GP currently so unattractive, a situation for which GP "leaders" and the RCGP share some of the blame.
    And as long as NHS GP remains free at the point of use we shall remain undervalued.

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  • I am a locum by choice. We do not get paid silly amounts up here in scotland. Locum pay is far less than down south. I take home much less than a partner but i wouldnt want to be one.i think the continuity argument is misplaced as, certainly where i work, i very often see the same patients repeatedly over a period of time. I chose to be a locum despite the uncertain nature of the work as i love working in a few practices and i think it adds to an individual.practice as i ofen can bring suggestions of new ways of doing something i have seen elsewhere. Practices should value our contribution and the us and them mentality adopted by some needs to stop or the whole system is just going to implode

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  • Should State educated GPs take shelter under "free market"...?

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  • CENSORSHIP?

    As everyone is now locumming... there are less jobs to go around
    Hopefully practices will go for experience and quality...
    Actually no one cares.. so long as the session is completed

    One of the agencies has made a valiant effort to reduce locum stress
    by ensuring adequate catch up slots..
    But then some locums forgoe this and allow practices to overbook patient numbers
    Or to not factor in adequate catch up slots
    Of course practices love those locums who happily subsidise the NHS by running very late but this only means that everyone gets abused

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  • CENSORSHIP?

    A lot depends on how you locum
    If you are a regular locum then you may actually be denying yourself the entitlements of a salaried position..sick pay etc

    All inclusive day is a good way to get used and abused by less scrupulous practices

    Morning session only / Afternoon session only
    No visits / Admin
    Provides the best option to retain ones sanity

    The rate has always been the going rate ... little negotiation
    The Agency takes their cut

    In theory you would think a private booking would be close to
    what the practice would pay an agency...but very unlikely ...

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