‘The GP partnership model is threatening locum life as we know it’
Dr Burnt Out mulls over how the GP partnership model is affecting the existence of locums
Working as a GP locum has always been a (relatively) financially precarious existence. Finances depend on many factors: availability of work, terms and conditions, current rates of pay and how quickly you will get paid. Oh, and whether you even get paid for the work you do at all.
Money ebbs and flows. There will be months where you have been working non-stop and there’s a sudden influx into your bank account; and there are other months where your bank account is about as arid as the Atacama Desert. That unpredictability has long been part of locum life.
But it has become much more pronounced in recent years. This is in major part due to the squeeze on funding, a result of years of mismanagement from successive governments.
However, this funding squeeze is exacerbated by the current partnership model of general practice. The system feels as though it has ground to a halt, slowly rusting while the current partners try and make it across the line into retirement. You can see the strain across different GP surgeries: skeleton staffing, clinically overloaded salaried GPs, partners under pressure, and the sense that everyone is practically on the brink of burnout.
This is because not only do partners have to make do with less money, they also also have a huge amount of risk sitting with them personally. When funding is insufficient and risk sits heavily with individual partnerships, financial pressure does not disappear. Instead, it is redistributed and often lands on the most flexible part of the workforce: locums. Sessions dry up, with a dearth of locum positions in many parts of the country, and some regions offering little or no work at all. Rates are squeezed. Terms worsen. Delayed payments and disputes are not uncommon. All the traditional advantages of being a sessional GP, such as autonomy and control, disappear. The financial fragility experienced by locums is no longer incidental but ingrained in the way that general practice operates.
Some practices have countered this risk in the only way the partnership model allows, through the increasing corporatisation of general practice, with greater numbers merging into larger and more commercial entities. This might benefit some, but definitely not sessional GPs, whose bargaining power from is sidelined, with the divide between partners and sessional GPs widening.
For those not taking corporatisation route – like those who value the continuity that comes from having a traditional partnership – this funding squeeze is sounding the death knell for the model. Their joint liability in the modern healthcare environment leaves them at greater individual risk. At the same time, it offers little stability or progression for sessional GPs; so, who is it actually serving?
Therefore, while increased funding is a must (nothing can happen without general practice receiving the budget it should), this in itself is not enough. So I propose reform that addresses both structure and funding mechanism. Firstly, in terms of structure, a transition to Community Interest Companies (CICs) – limited companies which operate to provide a benefit to the community they serve – could provide a more suitable vehicle for general practice. This would remove unlimited and personal liability for GP partners and would offer more secure employment models for GP locums.
Second, a payment model for the CICs that more accurately reflects the work that is done. For example, a model that is much more weighted towards fee for service (like in Scandinavia) rather than capitation. If workload is rising, funding should rise with it.
The GP partnership was designed in a different era of healthcare. Today it is not fit for purpose and sessional GPs are suffering because of it. Moving away from it could re-invigorate the profession for all GPs – partners and locums. The financial systems that underpin general practice hugely influence the model of care, jobs and welfare of GPs and how effectively it performs as a system for patients.
As those famous Scandinavians did once say, it really is about the money, money, money…
Dr Burnt Out is a GP locum in London
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READERS' COMMENTS [6]
Please note, only GPs are permitted to add comments to articles
I think you’ve put your finger on a really good rescue option for the declining partnership model. We have CICs providing specialised healthcare for homeless and refugee patient groups. They’re transparent, accounts are publicly available, there’s a stakeholder element and they’re excellent in delivering a same-GP service. Healthcare lends itself to a polycentrically governanced organisational structure (Ostrom), horizontally nested rather than vertically hierarchical, and would be viable and sustainable particularly for managing the commons of general practice care. And I think with significant stakeholder input, we can retain the continuity of care gold standard, as well as provide a nourishing, remunerative workplace for caring GPs, relieved of the pressure of the bottom line.
I hope elite-captured ministers can see the value of this for their families and society. Funding, of course, is all important (instead of printing £trillions since the 2008 crash and giving socialism for the corporates, but neoliberal austerity for the rest of us).
Most GP partners don’t have the time or luxury of freedom to think of another possible way, imprisoned as they are by mortgages, costs, overheads, diminishing returns and an impotent trade union.
Yes we need new models of care- mainly in poorer areas as the more affluent have thriving partnerships and time to plan ahead. We need teams supporting GPs that deliver to patients…because good public health and good patient care is the goal in the NHS and should be for all not just in the shires where RCGP committe doctors live. Those teams need to commit for the long term as patient continuity of care is essential. I used to locum until I found the right team to join permanently and I only hope that opportunities in neighbourhood health centres allow this chance for locums to test where they want to work long term with others whether employed by GPs, Trusts or others.
Interesting- but sharing our debts does not make a surplus…
Perhaps a Healthcare System’s primary function should be to provide healthcare for patients rather than employment opportunities for doctors?
Locums disrupt continuity of care, are expensive, and whilst sometimes necessary their use is best avoided.
GP locums became increasingly greedy. Many took advantage of practices desperate to keep the show on the road. I don’t blame them.
Practices adapted and had to reduce locum use. Now locum costs have dropped. It is a sorry state. Total triage, AI and no continuity of care is the way forward.
I don’t think hospitals commissioning primary care will have much budget for locums unfortunately