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Dear Simon Stevens,
I am writing following your recent visit to a GPC conference where you expressed concern about the ‘casualisation’ of the GP workforce in response to a question about the role of GP locums. I wanted to highlight some important points about the GP locum workforce.
GP locums provide a much-needed safety net for sporadic gaps arising from sickness, maternity or outside commitments such as commissioning work. They act as vital cross-pollinators of innovation, and as a fresh pair of eyes on difficult clinical scenarios. Locums who refuse to sign repeat prescriptions are often highlighting unsafe systems which have become embedded in stagnant teams, an effect of the siloed culture of general practice.
Locum work allows GPs with caring responsibilities, and other professional portfolios, the flexibility and boundaries around clinical work which they need to remain practicing GPs. Many talented clinicians would not take on vital leadership roles without this option.
Even a small shift into locum work can destabilise localities by setting off domino practice closures – however, general practice has been heading for the rocks for some time due to underfunding and recruitment and retention problems. Perhaps this is a much-needed impetus to radical change and the adoption of new models. Locums are stimulating the shoots of regrowth through new models of working like locum chambers.
GP workload is unsustainable, pushing many to leave or retire. Sessional GP groups and locum chambers help retain GPs in the workforce. Many sessional GPs would actually increase their hours if their working conditions were better. This is an unrealised potential in our workforce which can be tapped without the need for costly retraining or overseas recruitment.
Pejorative generalisations about lack of professionalism in locums who chase the highest bid at the expense of short-notice cancellations are offensive and unfair.
Locum indemnity is costlier due to supposed lack of familiarity with patients, systems and medical records, yet salaried GPs employed in multi-partnership organisations working in the same way are not subject to the same indemnity costs.
The additional funding NHSE has agreed to provide to cover rising indemnity costs will only reach those locums who are in a position to negotiate an indemnity-related rise in their fees. Where their local market does not sustain this they will be excluded from this NHSE initiative.
Locums have to meet the same requirements for CPD, appraisal and revalidation, and yet are often excluded from mainstream education, are not funded for appraisal, and can be barred from retaining nhs.net email addresses. Again recouping the rising costs of CPD and appraisal through fees relies on negotiating fee rises in the face of the downward pressure of published indicative rates.
GMC investigations have a disproportionate impact on GPs who locum, when compared to salaried and partner GPs, as future bookings and therefore income can be adversely affected by this, even before any fault is found. Patient surveys show that a doctor considered not to be the ‘usual doctor’ is predicted to receive lower ratings. This negative perception, grounded in the absence of an ongoing relationship, disadvantages many locum GPs, making them more susceptible to complaints and claims.
Currently, thousands of pounds of locum superannuation payments remain in a state of invisible limbo, while the processes for ensuring they reach personal pension accounts are subject to the worst scandal management gone wrong that many of us can remember.
The move into locum work can offer greater control over workload and hours and a safety valve for the careers of many GPs who might otherwise leave, but also offers the risk of exploitation by platforms like Uber, Pimlico, DPD and primary care equivalents.
Unlike chambers, online locum platforms and agencies may have restrictive clauses hidden in their terms and conditions that preclude the locum from settling somewhere unless the practice pays a fine of 15% of the GP’s income for one year. Performance data held by platforms can be used for commercial gain, at the cost of fairness, with locums potentially discarded as commodities sometimes completely lost to the workforce, despite the investment of public funds in their skills.
In the US it has been argued we need a third category of worker distinct from the independent contractor and the employee, the ‘independent worker’ with some of the protections of employees like the right to collective bargaining and health benefits. For GP locums specifically we need to add to this better support for education and indemnity, inclusion in communications, better management of superannuation payments, and a robust system of workforce data collection which tracks their contribution.
A fifth of working age adults have tried to find work via ‘sharing economy’ platforms like Uber, and 11% succeeded. GPs mirror this wider societal trend: 10-25% of GPs are currently thought to work as locums. It is time to look upon this sector of the workforce with the respect they deserve. With support, locums can provide hope for general practice.
I would welcome the opportunity to meet with you to discuss further how together we can ensure locums continue to make a vital contribution to NHS primary care.
Paula Wright, North East representative for Sessional GPs
Follow Paula on Twitter @PFW69
Well said Paula!
Nice one Paula! I particularly like the NASGP stance against this too with their LocumDeck and in particular their anti Trojan Horse policy www.nasgp.org.uk/locumdeck
Thank you folks ! Paula wright
I would also add that practices, who for various reasons fail to recruit,and rely on locums,would otherwise totally fail, leaving millions of patients without care ,or with disrupted care, and many practice employees without jobs.This is particularly so in those areas of the country which have historically found recruitment most difficult, where there isn't necessarily a readily available practice with physical and personnel capacity nearby to mop up all of the displaced patients in the event of such closure.
Locums can provide valuable expertise and experience ,not just clinically but as regards to productive practices ,team engagement ,and safe systems.Many current locums have portfolio careers which make them ideally placed to innovate and assist with quality improvement.
It is time the true value of the locum workforce were appreciated.
Dr Susan Elton
Thank you Susan Elton- you make a really important point, thank you for adding it.
Failing practices can be given "temporary life support" by locums and I believe there are many GPs who are prepared to work occasionally in these practices as locums with a well defined workload (defined by themselves via their self employed T&Cs) but would not want to risk committing to them permanently whether full time or part-time.
Very well written. Our practice could not have got through the last 18 months without the support of our excellent locums.
And I should have mentioned the issue of no death in service benefit for locums, and their under representation in voting in GPC elections because of the need to actively make themselves known to LMCs unlike practice based GPs who are automatically balloted. Paula wright
Had it not been for the possibility of sessional work I would have left the profession completely and taken early retirement but it has allowed me to continue working (and improve my general work-life balance) so in some way sessional work is helping to slow the tide of early retirements and maintain GP numbers.
Excellent article Paula. Your passion and concern for the sessional workforce is obvious in this article. If I wasn't allowed to work as a sessional for last 2 years; I would have been jobless. Thankfully; during this period; I have been able to do many last minute shifts helping practices prevent block cancellations of clinics due to last minute crisis. It's time sessional GPs are given the respect they deserve. Dr Chitra Pandilwar
Well said, Paula. 'Casualisation' is an offensive term.
bit puzzled the comment about non funding of appraisals for locums. All GP's on the performers list have their appraisals funded by NHS England. if this is a reference to paid time for preparation for appraisal, I am not aware of any salaried GP who are provided with this, although this may happen in secondary care, although their appraisals are heavily driven by Trust rather than the doctors needs in appraisal.
Funding for appraisal went into the global sum a few years ago for practice based GPs. Locums were receiving a payment to recognise the time spent on appraisal itself for a few years but this also stopped a couple of years ago as well. Now only salaried GPs and partners have funding via the global sum. In scotland payment to locums for appraisals has recently been re-instituted. The salaried BMA model contract which is a requirement of GMS and PMS practices includes protected time for appraisal (funded from the global sum) but doesnt specific how long. The recent GMC (Pearson) report on appraisal and revalidation quotes the average time spent on appraisal as being 14 hours. Paula Wright
Delighted to receive a response from the office of Simon Stevens today inviting me to meet with Dr Arvind Madan, Director of Primary Care and Ros Roughton, Director of NHS Commissioning.