Big Interview: ‘The predicted August GP unemployment crisis has come to pass’

General practice is going through an unprecedented unemployment/recruitment crisis, where GPs cannot find jobs, and practices cannot afford to hire them. Harry Hetherington spoke to Dr Cheska Ball, outgoing BMA GP registrar committee co-chair, and Dr Amy Small, BMA GP sessional committee co-chair, about the situation, looking at issues of funding, part-time work, underemployment, ARRS roles, international doctors and more.

Q: Can you describe the current landscape of GP unemployment?

Dr Cheska Ball: The GP unemployment problem is still absolutely rife. We had already expressed to the Government, and other relevant stakeholders, that come August (the one just gone) we would see unemployment skyrocket because of the volume of new or ‘soon to’ qualify GP registrars then going into qualifying as GPs. August was that crunch point with thousands of individuals potentially struggling, and it is exactly, as we predicted, what we have seen. 

Q: Has the employment crisis affected either of you when looking for a role?

CB: I started my job search a few months ago, before I CCT’d, and there were essentially no GP jobs in my local area. My initial job hunt was not general practice based at all. I was looking for other clinical or other non-clinical jobs – there was literally nothing for me to grab hold of. As the weeks and months progressed, things did crop up, but it was jobs that had a lot of red flags to them; for example, practices that were owned by big companies, rather than by the practices themselves. That comes with certain risks from an employment point of view, or at least that’s what I found with my search. 

I have secured a job somewhere that I used to work, but they could only offer me two days a week. I did want more, and we tried to make it work, but it hasn’t. I’m still trying to find alternative work, to complete a ‘full-time employment’ working week. But I’m struggling. I’ve not got anything extra, even when looking outside general practice. 

That’s my experience, but I have heard more anecdotes in my local area. There were three GP registrars that applied for one role in a mortuary because they were worried they wouldn’t get GP-based jobs. I don’t think any of them got that role in the end because they were ‘too qualified’. So we’ve also reached a point where GPs are now too overqualified to actually be given other jobs – you’re almost at an increased detriment and struggling even more to get a job because you have too many qualifications for it. 

Dr Amy Small: We keep hearing about the newly qualified GPs, but mid and late career doctors are also struggling. I can give myself as an example: two years ago I was working as a regular practice locum. The accountants came in and overnight my work dried up. They just went: ‘Sorry, we can’t afford you. We can’t afford anyone.’ 

I looked for more locum work as it was what suited me and my family’s needs – but there was nothing. I got onto all the platforms, and there was just no work anywhere, and all of us were competing for the same locum jobs. The money was also being driven down because the competition was so high. I literally had to beg, borrow and scrape to get a role at a significantly lower rate than what I had previously done. 

After that, I spent a long time trying to secure a salaried role. But it was unaffordable to work for what was being offered. Then I look and see that people are earning more as SHOs in hospital roles. I’ve been qualified as a GP for 17 years. It was just shocking and really scary. You don’t know where your income is going to come from, and it makes you question, as a later-career GP: Do I go and do something else? Are we going to just haemorrhage GPs, going out in different directions? Because the work simply isn’t there.

I love being a GP. I wouldn’t voluntarily give it up for anything, but the job has become so unsustainable. You can’t do it 50 hours a week, so you end up developing other roles and other things to then try to find that balance. And that’s where a salaried role could be really good to get that work life balance in. 

Q: The Government expanded the Additional Roles Reimbursement Scheme (ARRS) last year to include GPs – have you noticed any changes or issues springing from GPs in these roles?

CB: There are issues with the ARRS roles. It’s happened time and time again where they have been funded at a really low rate of pay and don’t have that increased rate of pay. So it’s happened a few times where we as the BMA have gotten involved, or other groups have said: ‘Actually, this is too low; you need to do something about it.’ They have then uplifted it, but only with a bit of bartering initially. There are still roles going up that I have seen for £7,000 – 8,000 per session – which is a very, very low market. Also, just to point out, FTE would be lower than the rate of pay for an ST3. So you’re looking at going from training to a lower rate of pay for triple the work, triple the responsibility, triple the risk. Those are often the ARRS-funded roles, so not a great monopoly with that either.

AS: It takes us so long to qualify as GPs, and often, by the time we qualify, our other halves will be in a role somewhere else. We can’t just pick up everything and move across the country for a poorly paid role that may or may not exist in a year or two. And that’s the problem with the ARRS scheme – the unsustainable bit.

I see the GPs with ARRS jobs in my area, and they are in a different practice everyday. They don’t get that continuity or learning that I think is so valuable as a newly qualified GP – to be at one practice where you get your patients coming back to you, you get your referral letters coming back to you, your blood results coming back to you.

You don’t stop learning once you qualify; I still am learning 17 years later. In ARRS roles, you’re just not getting that opportunity. It’s very isolating and I really feel for the people having to take up those roles because there’s nothing else out there. Whilst this is a huge problem in England, it also is creeping in in Scotland. We’re seeing it certainly in south east Scotland, and there’s particular financial issues that cover Edinburgh and Lothians that mean there are 40 or 50 applicants going for the same jobs.

Q: What is the situation like for international medical graduates?

CB: The cost of any GP going through training is large. And then, we cannot get a job at the end of it and have to find an alternative means of making money in order to live. That is a colossal waste of taxpayers money, and there’s no way to fluff that. 

But that also extends to a visa and sponsorship point of view. The GP registrar committee has worked with the RCGP regarding international medical graduates (IMGs) within GP training, and whether they are struggling to access visas, sponsorship, jobs, etc. The majority of GP registrars to date are IMGs. Employers don’t want to spend more money on sponsoring an individual because it’s an added cost. There are already many, many people applying for this job role who do not need that added cost.

Consequently, this group of doctors is then really struggling to find work because they cannot get the sponsorship that they need in order to stay in the country. So what can they do? They leave, of course. They’ve got to. They need to find an alternative means of getting sponsorship. And that is also a colossal waste of taxpayers’ money. It is also obviously incredibly disheartening to the individual, but monetary-wise, we need to get the public to know this. It is ludicrous – they are throwing money away because they train us, and then they do not give us access to jobs. 

Q: What else do you wish that patients would understand about the employment situation in general practice?

AS: I speak to friends, families, non-GP colleagues and they’ll say how they can’t get an appointment with a GP, and I say: ‘I know!’ There are people sitting around unemployed who want to look after patients, but that message just hasn’t got out there. We need patients to know about this, because they need to really get behind the fact that there has to be ring-fenced funding for salary and locums. It must be ring-fenced; not coming out of partners’ pockets. 

The way funding is at the moment, partner take home income is being driven down. You’ve got partners who are being worked to the bone, who are ill, burnt out, struggling, and who cannot afford locums to support them. They’re not getting their annual leave or sick leave in an appropriate fashion, because they can’t afford the people, and because the SFE doesn’t cover enough or doesn’t start early enough. It is not in their interest to bring anyone in, and yet there are people out there who could do that work and see the patients. That’s the bit that we’ve got to sort out – that funding aspect to create employment.

CB: I also want to highlight that there are few part-time GPs who would like to be working that number of part-time hours. There are a significant number of individuals who want to be working more, but cannot get access to those hours – myself included. When patients say: ‘I can’t get access to my GP, I can’t get an appointment because they’re all part-time’ – we need to change that narrative. These GPs are not part-time because they want to be. They’re part time because they can’t get any more employment. They are unemployed for the rest of the working week.

AS: I think there’s also a problem with the definition of ‘part-time’. As an eight-session partner, I was doing 50 hours a week. As a five or six session partner, I was doing 36-40 hour weeks. So that’s the problem when we work in these sessions, and what we class as part-time; because a six-session partner or salaried GP will be classed as a part-time doctor when they absolutely aren’t,  when you look at European working time directives. So we need to be really mindful of hours worked. I think that’s part of the confusion. When people say ‘my GP only does three days a week’, that is actually a 36-hour week.

CB: And that is also a cultural issue. The expectation among GPs is to be paid for an eight-hour day, but to work for 12 hours. That is an expectation because there’s such a huge demand on primary care, and we cannot meet that demand because we are not getting the right resources or the right funding. And that is the Government’s problem.

Q: What areas do you want the Government to specifically look at?

CB: We’ve already laid out our asks to the Government quite plainly [see below]. But, essentially it is ring-fenced funding for GPs in general practice. No other fluffy stuff. We want funding directly for GPs in general practice. It should not come from partners’ pockets; it’s got to be from the Government, straight to the people that are working on the ground.

This interview has been edited for clarity and length

Dr Cheska Ball is the former BMA GP registrar committee co-chair and a nationally elected RCGP council member

Dr Amy Small is a BMA GP sessional committee co-chair and sessionals subcommittee representative for Yorkshire and the Humber