Two GPs debate whether partners are eschewing the use of locums amid an increase in GP unemployment
YES: ‘There is no viable alternative to a GP locum
The relationship between locums and practices has always been a dynamic one, with supply and demand ebbing and flowing over time, with consequent impact on services offered as well as rates paid. Covid, and the immediate aftermath, resulted in a lot of remote-only locum work, which was slower to return to the normality than the rest of general practice. Fees were high and many partners felt that their needs couldn’t be well met.
Nonetheless, times were very challenging and us partners took what we could get. As time moved on, things settled and the additional roles reimbursement scheme (ARRS) became more established. We found that we had more support with duty surgeries as a result of our funded ARRS staff and our need for locum input was less. Market forces evolved and gradually the remote-only, high-rate services that we were limited to became broader.
But there really is no substitute for a GP. The ability to take risks in a measured way is pretty much exclusive to our profession. GPs are able to take a salient history in a fraction of the time of most other professionals and the ‘gut instinct’ that comes from years of medical training is something that is irreplaceable. We’ve found investigation rates to be lower, and the ability to ‘complete’ cases in a single contact is higher with locums than any group other than substantive GPs.
The lack of need for supervision relieves us of discussion time, so we are able to get on with our own tasks while the locum works largely independently. There is an element of patient satisfaction which comes from having had contact with a doctor that is sometimes missing when a non-GP consults. That’s not to say that they are any more or less competent, but positive patient perception is a useful thing when it comes to avoiding repeat presentations.
We have increased our advanced practitioner (AP) usage to release usual GPs from duty work as an alternative to funding locums, as generally their role as a duty practitioner is similar to that of a GP, while the cost is considerably less. The difference is starker in routine care. Operating a total triage system, patients presenting to GPs are typically more complex as the simple cases are usually filtered out at source to ARRS staff, other allied professionals, or other services. Medical complexity, with non-protocolised care, is really the domain of the GP.
Although, at present, we have a full complement of GPs, when annual leave exceeds our threshold of what is acceptable, or in the past when GPs have been off for an extended period, there really is no viable alternative to a GP locum. We’ve been fortunate in the past to have long-term locums who have been willing to hold their own list, and we have reimbursed them accordingly.
Locums who are willing to be flexible in their ways of working are invaluable, and we are willing to reward them financially, as well as in reputation. At present the locum market is less buoyant than it has been, and a good reputation is invaluable. This doesn’t mean that we’re out to exploit locums, but equally the memory on how partnerships have been treated by locums in recent times is fairly fresh.
In our practice, we find that there is no substitute for a partner. We go to internal locums first line because of the ‘unseen’ work that we naturally commit beyond anything that we’d get from outside. However, we are all very stretched, as most partners are, and for our sanity we have to look externally from time to time.
If we need routine cover, it’s locum cover at the forefront of our minds. Duty cover is more the domain of our excellent advanced practitioners, but with the complexity of current general practice being what it is, the efficiency and system-wide awareness of a locum is what we need.
Dr Emma Nash is a GP partner in Portchester, Hampshire
NO: ‘There are thousands of GPs who struggle to find a job’
A lot of negative connotations are now associated with the term ‘GP’, a result of a rather vicious smear campaign launched against the profession from all sides over the past decade in particular. This negativity is even more pronounced when using the term ‘locum’. A locum GP is still a fully qualified GP – indeed many are ex-partners or ex-salaried.
Locum work has fallen off a cliff in the past year, with some regions in England seeing reductions of up to 90%. I know from searching for work across various platforms that – where previously there would be up to ten advertisements/requests a day – there may now only be one across a whole week. It is not just locum work – indeed salaried and partnership vacancies are now also increasingly scarce, including in some of the largest cities in England. There is a striking north-south divide, with the North West, North East, Yorkshire and Midlands severely impacted; London/SE less so. As a result, several GP groups across the country have been set up to discuss and tackle these problems, with members now running into the thousands, urging the BMA and RCGP to take action.
It is bizarre that at a time of an alleged shortage of GPs there are thousands who either can’t find a job or secure enough work, and were it not for out-of-hours shifts, would be completely without income. There are even reports of GPs using food banks and having to drive taxis. How is this acceptable? As per the GMC, there were 66,000 GPs on the GP register in 2022/23 – does the oft-quoted figure of 27,000 FTE GPs include the thousands of GPs now struggling to find work? The NASGP estimates there are more than 20,000 GPs who are not partners or in salaried roles – so the GPs are clearly there, in the tens of thousands, they are deliberately not being utilised. On top of this, there have been record numbers of GP trainees entering the training program in recent years but it appears many will struggle to find a job upon qualification as things stand.
The reason for this is primarily the ARRS. It is important not to focus solely on PAs. ANPs, paramedics, pharmacists and ACPs far outnumber PAs – this large cohort are all seeing undifferentiated patients, of all ages. NHS Digital data has shown consistently that less than 50% of appointments in primary care are now with an actual GP, and the number of patients per GP has arguably never been higher.
The cut in funding for practices has not helped, of course. But an increasing desire to cut costs and maximise practice profits does appear to be coming before patient safety and quality of care, in the form of recruiting and using non-doctors instead of GPs.
What is clear is we cannot have doctors with decades of training and experience sat at home without work. This situation is untenable, dangerous, a massive betrayal and a huge waste. It is estimated to cost c. £250,000 to train a doctor over the standard five year medical degree and c. £400,000 to train to the GP level.
A red line was crossed when non-doctors were hired to replace real ones. Would you knowingly get on a plane flown by a fake or less qualified pilot? When you factor in higher levels of repeat attendances, misdiagnoses, complications, supervision time, referrals, A&E attendances, ambulances, deaths and litigation, is there any monetary saving at all in hiring non-GPs? Highly unlikely. Should cost even be coming before patient safety? Would you not want yourself or your family/friend to be seen and treated by the person most qualified?
A portfolio GP working across the north of England. They have asked to remain anonymous
READERS' COMMENTS [17]
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I agree there is no good replacement to a GP.
However for some time locums have held practices to ransom with escalating fees coupled with restrictions on what they will or won’t do.
There are obviously good and bad locums.
But many will offer only an “on the day ” assessment, opting for the easiest/lowest common denominator diagnosis and offering no long term solution. I this case an ARRS will offer a similar service for a fraction of the cost.
I believe all GPs should have a substantive post, offer some form of continuity and be subjected to reasonable supervision & regulation. Continuity is the cornerstone of our profession and short term locums undermine this.
Every fully trained GP should have to take one a regular substance post, even for a limited number of sessions and then choose to offer supportive care as a locum for better renumeration on that basis.
It is a concern that for quite some time there are a large number of fully trained GPs who only work for large, short term renumeration, no significant commitment or continuity, who are therefore difficult to assess clinically.
The new generation gps don’t want to be partners . They want freedom to work when and where they want to work. with this and additional clinical staff and financial restrain in practice locums are having difficult time. In 1980’s it was very difficult to become partners. Partnership was like getting married to practice.. is history repeating itself?
Of course fully trained doctors are preferable to other staff in dealing with complex patients. The issue here however is that they are now unaffordable or have been unaffordable it makes financial suicide to pay locums 50 to 100% more than full-time GPS per hour. In addition our experiences that locoms have been very didactic about the number of patients they will see whether or not they will be willing to do visits or paperwork or referrals so all in all although having the skill set to be really useful the motivation and the costs have made them impossible to employ in our practice
Putting costs/income aside working purely as an itinerant locum (rather than regularly in one or several practices) one needs to consider the softer aspect of keeping up to date both medico – politically (what the NHS provides , where and how to access it) and also from reading hospital letters, discharge notes and following up on ned own investigations and referrals. Coffee break chats, practice meetings and other soft moral enhancing get togethers usually wont be paid but hugely important long term (in my view)
GP contractors know that they have the authority and power in their unequal relationship with their equally qualified colleagues who choose to be locum GPs.
I have had the luck to come across some clinically excellent, caring principals and, equally, locum colleagues that a practice is lucky to have.
For the sake of balance in this debate, it’s worth considering some of the reasons locum GPs in my city give for not wanting partnership which include: partnerships who chase profit at the expense of quality of patient care; principals earning £200,000+ out of the NHS, usually a sign of wrong priorities; terrible partnership agreements or, equally bad, no written agreement; sale of goodwill; long time to parity; hierarchical paternalistic structure; feudal governance with senior partner acting like a mediaeval baron, etc….
Since last year, GP locum work has dried up and this is tough on younger colleagues with mortgages and young children. Not sure why principals don’t empathise with their situation, as they themselves were once young, with mortgages and kids..
Principals should put their own houses in order and stop thinking with a shop-keeper’s mentality about only their own shop’s patients and profits. This sort of thinking is what’s allowed HMG to drive a wedge between GPs and fragment primary care (latest with the device of ARRS).
Instead of GP principals punching down at locums (who are relatively powerless), for the sake of a united response to HMG’s decade of underfunding, they should give employment to their locum colleagues, resign from ARRS schemes, and find the courage to punch up. (yes, this might involve taking a financial hit, but GPs will never be less than well paid members of society).
NHS Dr for 34 years (7 hospital, 27 GP, principal and locum)
Some interesting viewpoints, and I agree with Nicholas and ‘the bird’s excellent assessments.
To Mark and Michaela, I am sorry you have had bad experiences with locums.
The “escalating fees” are just inflation (130% cumulative last 4 years!), and Partners are tending to undervalue greatly both themselves, and locums, and other staff! Many still employee receptionists on minimum wage – and they triage phone calls that the NHSE has recently indicated PAs should not do before a GP triage ! Locums also have to pay GMC, MDDUS, travel expenses, consumables, etc.
Some Practices offer fees considerably in excess of what I charge, and still cannot attract locums, salaried GPs or Partners – I wonder why?
I have been Salaried, and Senior Partner, and also experienced bullying and illegal sale of goodwill attempts, and bad (questionably legal) Agreements, or ignored Agreements!
Doing serial ‘short locums’ in several practices, I can cover Partner leave (planned or unexpected), offering a degree of continuity probably better than if patients saw a different ARRS person at each visit. I am not averse to doing on-call paperwork, urgent triage, HVs, ward rounds, and emergencies – although everyone knows paperwork and results are done far more efficiently when done by the requester! Indeed, I am probably more cost-effective than having to employ an extra substantive staff member full-time! And far more flexible employment-wise.
The real problem is that Partners do not negotiate strongly enough on income or workload from NHSE and hospitals, and severely undervalue themselves. You should USE the example of locums who follow BMA/RCGP guidance on safe workload, and apply same to yourselves too, and pay staff better to keep the good ones – even at minimum wage!
GP Partners need to look to their own house, and join with salaried/locums in much stronger negotiation for the benefit of Practice incomes and Patient outcomes, together, rather than dumping on each other blame for poor political decisions.
If partners can genuinely no longer afford to recruit GPs then it is time to end the partnership model. No alternative.
It has to be understood that replacement of GP’s by ARRS is false economy. People who vouch for them are doing it for their own reasons as free substitutes and are not supervising them with which ARRS is not viable . Triage and treatments been given to patient would make a person cringe with fear by this cohorts. But as the dust settles-many locums will move abroad,seniors will reduce work , go private or others retrain we will be back to square one with a service with no quality. GP will get only complex case or cases complicated by ARRS and the market will again open. It also strikes you when you are as a patient finding half cooked therapies by by noctors.
As a locum the rates include employers NI, holiday pay, sick pay, travel, and the fact that you are willing to work somewhere just for a few days or weeks. So not that expensive and similar to getting in a temp in many other areas.
So not really that expensive for short term GP cover.
In my experience I am seeing patients being reffered into secondary care by ARRS who I would have directly managed myself. This will soon prove costly for limited secondary care resources..
@ Dr David Church, “ The real problem is that Partners do not negotiate strongly enough on income or workload from NHSE and hospitals, and severely undervalue themselves. You should USE the example of locums who follow BMA/RCGP guidance on safe workload, and apply same to yourselves too, and pay staff better to keep the good ones – even at minimum wage!
GP Partners need to look to their own house, and join with salaried/locums in much stronger negotiation for the benefit of Practice incomes and Patient outcomes, together, rather than dumping on each other blame for poor political decisions.”
I agree 100%. Quite a lot of locums, including the survivors of Forge Road, have done the partnership bit already. Worked long and uncosted hours, made big efforts to improve the care of their patients and staff and finally refused to be complicit in an indefensible system. I am not at all impressed with the light touch compromises that some “expert, saintly GP principals” pass off as the true RCGP continuity. Somewhere in between your average locum and average partner is about right. FRCGP means not rocking the boat in many cases. Not much hope for the profession if we bicker, and sorry if this adds to it. Staying in the same practice with the same patients for decades can be very suffocating: when I left my Snr Partner role, my horizons widened and I spent more time on CPD, not just some hurried certificates from Pulse (sorry!) done 2w before appraisal.
Dear Subhash,
Freedom comes with its own risks, and lack of locums for desired £££ at a desired location is a risk that Locums choose. It is exactly similar to the risks partners take on accepting late nights, management issues, fulfil contractual obligation.
The fact is life in primary care is miserable whether one is a partner, locum GP or Salaried. It is all due to poor funding settlements.
Like many other Practices we saw our GP number drop from 5 to 2 in a few short years, with expensive adverts going unanswered. Locum fees were making the business unviable, so we reluctantly took on an ANP, CP and PA. Is it as good as the old days? No, but beggars can’t be choosers, and the new staff are hard working dedicated professionals providing an excellent service, albeit not to the standard of a GP. The solution is that Locum doctors need to apply for more permanent posts to restrengthen the GP model, But will they be willing to ditch their freedoms for the daily slog of the average salaried/partner doctor?
To reiterate, if practices can truly no longer afford to recruit/retain GPs, whether that be salaried, locum or GP registrars, then it is time to end the business/partnership model.
The GP partnership Model has been highly effective for many years – but the lack of funding as resources diverted to pay for secondary care overspends means the percentage share of funding has not matched the workload shift to primary care.
This contract renegotiation needs to have a partnership payment (Basic GP partner practice allowance) to encourage locums back into practices to re-stabilise the dropping number of partners.
Many salaried/locum colleagues have been unwilling to take on the unlimited workload of partners – while remuneration was poor and work/life balance worse.
The answer for colleagues unable to get work is to take on substantive posts – my own practice paid out tens of thousands in agency fees to try and find new partner/salaried colleagues and failed to find people willing to work the long hours, made only worse by reducing partner numbers. There has to be a way to fill vacancies, and stop colleagues being left without work, but the equation requires investment in primary care staffing budgets so partners are not left bankrupt paying locum fees and salaried wages they can’t afford, as the DOH continues to reduce funding and squeeze out any remnants of the funding increase that was originally introduced with QOF.
The comparison of medical pay per hour vs professional colleagues is not even comparable, and the rates locums want to charge should be basic rates expected throughout medical services – its just lacking the funding from the DOH to pay them. Return unfunded work back to the hospitals, and safe limits to patient contacts, with greater funding per patient than it costs to insure a pet for a year would be a good starting point
There is work out there for those who want to work. Just not extortionate levels of pay to do a 2 hour surgery. With no visits. No Admin. Charging for 1 hour admin for every one hour seeing patients. This is not possible for any practice to absorb. Especially when those without a simple acute problem will not be sorted out and will just come back. Martker forces is going the correct way. Something needs to give. There is work out there . Just not as a locum with rediculous terms.
So I guess you are a locum “Not on your Nelly” ..so you know?