Can retired GPs and underemployed locums be convinced to rejoin the permanent workforce, asks Nicola Merrifield
It may seem a long time ago that the recruitment crisis was the most pressing issue for general practice. But although Covid has focused minds elsewhere, recruitment problems rumble on in the background.
The latest figures1 reveal a 2.3% decrease in full-time-equivalent GPs
over the past year – including a 1.2% drop in total numbers of GPs – and a 1.4% decrease in the three months following April 2020.
However, taking into account Winston Churchill’s old maxim ‘never let a good crisis go to waste’, NHS England has been looking into how it can attract more full-time doctors to post-Covid general practice.
Its ‘People Plan’, released in July, said: ‘To become a modern and model employer, we must build on the flexible working changes emerging through Covid-19. This is crucial for retaining the talent that we have across the NHS.’
A letter sent to GP practices and commissioners in August by NHS England’s primary care director Dr Nikita Kanani provided more details for the plans to bring locum and retired GPs into permanent roles.
The NHS England letter said: ‘Systems and CCGs will want to develop supportive routes back to practice for Covid emergency registered practitioners, in order to secure their fullest possible deployment, and work with PCNs to create highly flexible GP salaried roles for those who previously thought that only a career as a locum could offer them the flexibility they need.’
The pandemic has provided some encouragement for leaders looking to attract more doctors back to full-time general practice. According to the People Plan, more than 500 returning GPs and 1,000 locums registered to join the Coronavirus Clinical Assessment Service (CCAS) – the NHS 111 service for reviewing potential Covid-19 cases.
This followed the ‘Your NHS Needs You’ rallying cry of the NHS campaign launched in March to entice retired GPs, other healthcare staff and volunteers to help with the pandemic effort.
And some recently retired GPs also contacted their local practices to offer their services as salaried staff.
But it seems that, eight months after that rallying call, the deep-seated problems in general practice have meant this was only a temporary fix.
Locums loath to stay in salaried roles
Locum GPs are ideal candidates for helping to shore up the permanent workforce, the NHS England letter said, because they are increasingly ‘interested in more secure employment’. The flexible roles in the pipeline would help to attract them, it added.
There’s no doubt the initial lockdown was a tough time for locum GPs. Pulse reported that some found themselves having to claim state benefits.
Ruth Hennessey, who runs The GP Locum Agency, which works regularly with around 1,500 UK GP practices, says: ‘Within a 48-hour period almost all our locum shifts were cancelled.’
Most GP practices cancelled annual leave and training as they dropped everything to deal with Covid-19. This was reflected in the agency’s bookings, with demand for practice work dropping by around 85%.
NHS Digital figures emphasise this, revealing a significant drop in the number of locum GPs working at practices. In June 2020 there were 25% fewer than the year before, with the total falling to 3,875.
NHS Digital said there were some issues with underreporting by practices, but there was plenty of evidence of locums beginning to seek permanent roles as a result of locum work drying up. ‘We’ve had a few take up salaried roles. One GP said she wasn’t keen on doing it but panicked and said she needed to secure her income,’ says Ms Hennessey.
Unfortunately for NHS England’s attempts to tempt locum GPs back with flexible roles, this doesn’t look like a permanent trend. First, the NHS Digital figures show there was no corresponding spike in the number of salaried GPs in general practice as locum numbers went down, with the increase remaining similar to its pre-pandemic level (see chart, below).
More importantly, as National Association of Sessional GPs chair Dr Richard Fieldhouse points out, the shift to salaried roles has already started to swing back the other way.
‘Over the summer we certainly were getting members leaving to become salaried GPs – but about a month after that we saw more locum GPs join us. There’s a lot of churn going on.’
Six months on, many will now be looking to get back to locum work: ‘That’s often the time when you are appraised and a lot of these posts that were vacant for so long and suddenly got filled, some will have been unfilled for good reason.
‘A GP I know of recently came back to locum work because they were concerned about patient safety at the practice they’d joined.’
Many practices still face major challenges and a lack of resources – the pandemic has not changed that, Dr Fieldhouse says.
‘I worry people have made the move from locum over to salaried work more out of desperation than as a positive career choice.
‘We’re at the six-month point where people have done that time in salaried posts and I wouldn’t be surprised if a lot say “I tried it. I gave it a shot and got some good money but it’s not for me – I remember now what being a salaried GP was like”.’
Retired GPs discouraged
The other side of the recruitment strategy during Covid revolved around attracting retired GPs back to the profession. NHS England’s letter claimed ‘retired doctors who have offered to return to the workforce’ are part of ‘the pool of qualified GPs looking for employment’.
But many recently retired GPs have had experiences that confirmed their decision to leave general practice. Those who saw CCAS as a route back into the NHS have seen the service beset with problems, leading many to abandon the process.
Although 500 returning GPs, including some who had retired, did sign up to CCAS, this was a fraction of the almost 4,000 who had re-registered with the GMC to help with the Covid effort. But the long-term issue of bureaucracy reared its head. Many gave up trying to join the service after red tape meant it was taking around a month to get GPs fully on board.
Dr Tessa Barton, a retired GP from Devon, told Pulse in May that she and her husband were both ‘close to giving up’ on their own attempts to join after ‘going around in circles’.
At that time neither had yet had a shift at CCAS, despite applying in March.
Retired Northamptonshire GP Dr Hadrian Moss said he also ‘nearly gave up more than once’ after delays getting signed up.
Dr Andrew Green, who practised in east Yorkshire until his retirement last year, tells Pulse: ‘When the letter came out from NHS England I filled out all the forms to assist with NHS 111 and got an acknowledgement and that was it – no one bothered to get back to me.’
BMA Sessional GPs Committee chair Dr Ben Molyneux tells Pulse there was a ‘big attrition rate’ during the set-up.
He says: ‘There are seven separate agencies required to get you from expressing an interest to doing your first session and on average it appears to be taking about a month.’
And there is a more fundamental factor in play for many recently retired GPs: their loyalties lie with former colleagues, rather than the wider system.
Dr Green approached the local practice he retired from to offer his services on a salaried basis.
He says: ‘They let me come back on my own terms. From March to August I worked mornings from home doing remote work, dealing with prescribing requests and laboratory results.’
Dr Green says he will make himself available if there is a second peak of the virus, but won’t come back for good: ‘The minute I get contacted saying I have to do an appraisal will be the minute I stop completely.’
Ultimately, if NHS England wants locums to switch to salaried roles or late-career GPs to stay on, it needs to improve conditions in the profession.
Dr Fieldhouse says it hinges on reducing workload: ‘It’s all very well
to come up with these fantastical salaried contracts but the reality of the workload is that there are so many patients who need to be seen and we just need more GPs.
‘As a locum you in a position to say “I have to finish at 6pm and I’ll see 18 patients – but I can’t do a whole load of blood tests”. As a locum you can control that up front.’
But even if workload is reduced, Dr Molyneux warns locum GPs may have already left the NHS to work with private digital GP providers, making the Government’s target of recruiting 6,000 GPs to the NHS by 2024/25 more difficult to achieve.
He says: ‘I really hope those locum GPs lost to the private sector in the past few months aren’t lost forever.
‘It’d be a massive blow – especially politically to the Government, which has been trying to recruit greater numbers of GPs. This mismatch can only be harmful to the target of 6,000 more FTE GPs.’
‘A lot of people took salaried roles they were not happy taking’
As a locum, at the start of the pandemic I was forced to go on benefits. I was previously only working as a locum at two practices and then I got Covid while working. At that point I was seeing 30 patients a day without PPE, because we were in denial about the pandemic.
I’ve started to get more work over the past few weeks, and I’m now getting two sessions a week.
I run a Whatsapp group which includes about 250 locums doctors across the country and they’ve found the same. Now the surgeries that used to employ them frequently have started to come back and they say they’ve got a few more shifts.
A lot of people took salaried jobs when the pandemic first hit that they were not completely happy taking, to try to bide their time. Some left those roles because they took it in haste and the workload and pay was not worthwhile – so they handed in their notice.
I don’t know what is meant by the NHS creating ‘flexible’ roles. I am quite sceptical as to what true flexibility looks like to NHS England. They need continuity of patient care, but they need flexibility as more doctors are going into portfolio roles – and that’s also because people are getting burned out.
In the first five years after graduation there are lots of initiatives – for portfolio careers, research or leadership programmes – but for mid-career GPs like me, there are few. We’re going to be the ones who are prone to burnout.
Dr Saumya Jha is a locum GP based in north London
1 NHS Digital. General Practice Workforce – 30 June 2020. tinyurl.com/GP-workforceJune2020