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These are difficult times. Chronic underfunding of the NHS with escalating workload, costs and bureaucracy has caused many GPs to vote with their feet and choose to work as locums with fewer taking salaried or partnership roles. Locum GPs have long been an essential part of the GP workforce, often working in challenging circumstances while making an invaluable contribution to patient care. However, there is now concern that the increasing culture of locum working among disaffected GPs is itself contributing to the crisis in primary care.
Ultimately of course the real problem is political policy
Locums have traditionally covered periods of sick or maternity leave and occasional annual leave. With no guaranteed hours they received an enhanced pay rate to compensate for the lack of superannuation and other benefits. However, locums have now become a necessity to cover, not only the increasing hours needed by different provider companies, OOH, urgent care centres, hubs etc but also regular practice clinical sessions. The high level of pay has made locum work an increasingly attractive option with remuneration that competes with that of partners without the same stresses and without the risk of unlimited liability.
We now have a problem, a vicious cycle which has seen progressively increasing workload and declining numbers of salaried GPs and partners while the free market allows spiralling rates of locum pay. The inequity of current funding models, delivering variable and inequitable reimbursement based neither on measured workload nor population need, further exacerbates the problem, with practices better remunerated more able to budget and allow for these costs than others, particularly in inner city areas where high demand due to deprivation is currently not accounted for in GP pay. Ultimately everyone struggles as no practices are funded well enough to pick up the additional workload when neighbouring practices fail.
For me, what is even more important is the loss of what made us choose general practice – continuity of care, an unintended consequence of increasing locum engagement. The core strength of general practice is the ability to provide care to a dedicated patient list. While current trends show some groups of patients prefer to see any doctor at a time that suits them evidence does show that continuity of care is not only linked to patient satisfaction but also to improved chronic disease outcomes, lower use of antibiotics, effective wait-and-see management of self-limiting conditions, reduction of harm from unnecessary and potentially harmful medical interventions and fewer A&E attendances and admissions. I would also argue that it leads to greater job satisfaction as shared decision making is underpinned by a doctor-patient relationship built on a foundation of mutual knowledge and trust established over time.
Ultimately of course the real problem is not locums but a political policy that has created the situation of massive underfunding of the NHS destroying morale. Surveys show that the majority of young GPs and many locums want to be more permanent practice-based post. What can be done to facilitate this? A fee cap was widely rejected by the GP body at the national LMC conference in May this year but NHS England are now asking practices to say when they pay over the new locum indicative rate. NHS England says this is not a cap but a data collection exercise to enable targeted support where it is needed but the BMA have criticised this citing that it has not worked in secondary care and will worsen the workforce crisis. I hope it will allow a calibration of what is an acceptable locum rate but it is unlikely a cap will work as it will further alienate GPs.
But it isn’t just the pay. GPs who choose to work as locums often welcome the flexibility that is missing from permanent roles. Measures, such as schemes to actively retain GPs including a new enhanced retainer scheme from 2017, support for CCG/federation commissioned pools of portfolio GPs and the development of innovative posts such as salaried doctor schemes for new GPs that allow development opportunities, will help, as will support with the rising cost of indemnity.
When debate arises on whether the independent contractor status is sustainable the majority of GPs support the practice-partnership model, seeing it as a way to retain autonomy. However, this will only work if we ensure GPs remain working in practices now which can only be done with adequate remuneration and manageable workloads for salaried GPs and partners, making these posts a more attractive career option.
Dr Naureen Bhatti is a GP partner and trainer in Tower Hamlets and Vice-chair of Tower Hamlets LMC
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