Dr Neman Khan gives his top 10 tips on reducing the costs of clinical cover.
In these times of austerity, practices are under pressure to cut costs. One option is to look at the amount you pay for locums and how to plan your work more efficiently to avoid the need for clinical cover.
Nobody seems to know quite how many GP locums there are. Adding up figures for fully qualified partners and salaried GPs working in the UK, we get 41,460. But the GMC has 57,000 GPs registered, suggesting locums number around 15,500.(1)
Locums are increasing in number as partnerships dry up and younger doctors avoid being tied down to a salaried post. They are our colleagues and friends, a valuable pool of help to practices, and not simply a subclass of our profession. Eventually, many locums may join practices as salaried doctors and partners.
Locum pay can vary vastly across the UK, from £50 to £110 per hour. Locums generally work hard and deserve the money they are paid. Practices can forget charges include pensions, holiday pay, sick leave and CPD costs, and there is variation in and competition for the work available, and limited job security. So for a practice, the priority should be not so much reducing locum pay, but rather reducing the overall cost for providing clinical cover.
1. Circumvent locum agencies
The most straightforward way to reduce costs is to pay a fair wage, but cut out the middle man. By employing a locum directly it allows you to build a relationship with your locums, rather than being given a random body to fill a clinic. Where locum agencies are required, use those who are fair and blacklist those who operate like cowboys, trying to rip you off by ramping up their fees.
2. Book absences in advance
Ensure you have a system requiring holidays and other absences to be booked well in advance. The longer in advance you know you will need cover, the longer you have to fill the position, making it easier for the practice to maintain its usual pay scales. An immediate need to cover a session may require you to call a locum agency, which may charge you through the nose as it will know it has you over a barrel.
3. Cover each other
In small practices a holiday means a locum, but in a large practice, have a policy of only one or two doctors on leave at a time, so there may be enough slack in the system to absorb the loss of appointments. If everyone wants half-term off, you can choose to pay for the privilege.
In larger practices there can be multiple partners and salaried doctors. There are few who work 10 sessions, so if you know there is a busy period, consider asking partners to work on days off and take the time in lieu in quieter periods. Alternatively, internal locums mean money spent is retained within the practice and can supplement pay for those who work longer.
4. Try to predict high and low demand periods and adjust locum cover accordingly
Every year there are peaks in need, where doctors are on holiday or the whole country is on a break, so knowing that Easter and school breaks are busy is not rocket science. It makes sense to plan your cover for busy periods now, rather than wait for the locums to all be booked up, forcing you to turn to locum agencies and higher costs.
5. Affiliate locums to your practice
Simple things make it easy for locums to settle in, like a locum welcome pack, a smiling receptionist and a cup of tea. Treating them like part of the team and inviting them to join you for coffee after a session can make a big difference. Don't cancel locums at the last minute or you probably won't see them again, which will reduce your local choice of doctors. Once locums feel welcome they will be keen to come back. Our practice has set up in-house educational sessions and we invite our locums to attend, allowing them to gain educational credits for their appraisal.
We are also happy to host locums who work with us regularly, so their significant events, complaints and audit requirements can be fulfilled. The locum feels part of the practice and this provides an excellent relationship, helping to keep the fees at a fair level, while also assisting locums to meet the requirements for appraisal and future revalidation.
6. Draw up a top-five locum list
Where there is loyalty it works both ways, so having a shortlist of locums who are emailed out dates needing cover before it is circulated more generally may allow you to work at a set locum rate. This keeps down the number of different doctors used, facilitating familiarity between the doctor and your staff and patients. The locum can also get to understand the ethos of the practice, as well as its policies and referral pathways. It is a nice way to get to know doctors, prior to hiring a new permanent member of your practice team.
7. Book longer and more regular sessions
Paying an hourly rate works out more expensive than half-day or day rates. Where a doctor is out of the practice doing non-clinical work, it make more sense to negotiate a half- or full-day rate, so visits, paperwork and clinics are covered.
A regular session can be negotiated over, as can a complete week or a full-time locum or maternity locum. Where there is job security and certainty of work, fees can often be reduced, as a degree of loyalty develops between the practice and doctor.
‘I liked it so much I bought the company!' – just like the advert from years ago, if you find a quality locum, make them an offer and add them to your practice. Where you have regular need for cover, it makes sense to take on a regular doctor, partly financially, but also because of what the doctor brings to the practice. Sessional costs vary around the country as much as locum rates, but generally it would be more cost-effective compared with locum charges.
A salaried GP rate of £8,000 to £10,000 a session works out at £32,000 to £40,000 for four sessions a week plus national insurance contributions, but they usually work full sessions including clinics, paperwork and visits. However, the practice is responsible for holidays, sick pay and educational sessions.
The average pay for a salaried GP in 2008/09 was £57,300, an increase of 2.7% on the previous year.(2) The difference in earnings between salaried GPs and partners is largely related to a greater proportion of salaried GPs working part-time, but is also a reflection of the additional responsibilities borne by partners.
8. Change working patterns and work smarter
After long bank holidays and times of high demand, reduce the number of pre-booked appointments and use more emergency and book-on-day slots to soak up the increased demand. You could also change the way the practice operates by making use of telephone triage so there is more capacity for face-to-face slots, while avoiding the need to provide more clinical sessions. Many issues after a break do not require a consultation, such as medication that is running out, extending sick notes and informing patients of results.
9. Network and share resources
Local vocational training schemes provide a ready-made group of doctors who qualify – usually each August – and are launched into the world of working for themselves. There are often lists of contact details for them available from the postgraduate centres associated with the training schemes, and the newly qualified GP registrars are happy to get offers of work and usually available in busy holiday periods. Networks such as the practice manager groups, practice-based commissioning groups, and newer clinical commissioning groups (CCGs) provide opportunities for practices to share lists of locums. Or you could share resources – small practices could buddy up or federate to provide cover for each other when they close for half days and educational sessions.
10. Plan for commissioning
The need for GPs to work for CCGs, attend meetings and work on changing clinical pathways will pull more and more doctors from clinics and open up sessions that need filling.
CCGs could employ salaried doctors who could be shared out to provide cover for meetings, or hire locums centrally so practices are not penalised for participating in commissioning and spared the hassle of booking up regular sessions and the time claiming back locum costs.
Dr Neman Khan is a GP at a training practice in Woking
1 National Association of Sessional GPs. Excluding locums. www.nasgp.org.uk
2 British Medical Association. General Practitioners. October 2010