Senior doctors have long made arguments about the importance of defining the boundaries of our work.
In 2012, the BMA GPs committee started a successful ‘Quality first’ campaign raising awareness of the different types of work which were pushed on to primary care outside of contractual obligations and without additional remuneration. This included bureaucracy but also work passed over from secondary care such as carrying out investigations or acting on results of tests requested by specialists. Template letters were designed as part of a toolkit to deflect such work.
Many areas negotiated additional remuneration for local enhanced services to cover work which was being passed from secondary care on to primary care such as specialist drug monitoring, warfarin and DOAC initiation and post-op suture removal. This work is now costed and quantified and therefore appropriately rewarded.
More recently, consultants have also decided to draw clear lines around what they consider contractual work and extra-contractual work, with the introduction of a rate card for payment of all non-contractual work.
The problem with unpaid extracontractual work is that it remains invisible, erodes respect and goodwill and perpetuates inefficient processes with doctors absorbing administrative or bureaucratic tasks which could be delegated to others.
There is also the long-term effect on retention. What incentive is there for a practice to delegate work to other clinicians (for example, pharmacists to do medicines reconciliation) or non-clinicians (for example, administrative support to obtain the correct safeguarding referral form, and social services contacts) if the time the doctor would spend doing this is going to be in their own unpaid time?
There are simply no opportunity costs to having the salaried GP doing all these clinical and non-clinical tasks. The same can be said of the myriad reports which could be completed by other appropriately trained staff (who are less scarce than GPs) from medical records but fall to doctors whose time is simply not costed.
The need for flexibility and the desire for a good work-life balance remains the primary reason for working as a salaried or freelance GP. Practice-employed salaried GPs reported working an average of six hours and 45 minutes of unpaid time on top of their average of 6.1 contracted sessions.
That is an additional 25% of unpaid time on top of their contracted time or equivalent to 9.6 unpaid hours a week for a full-timer. This must stop. It is unfair and it is unhealthy. System pressures have undoubtedly contributed to this workload increase. However, it is crucial that in whichever setting salaried and locum GPs are working in, their contractual and workload limits are adhered to. This is a key tenet of being able to retain them within the workforce.
It is not acceptable for salaried GPs to be expected to work at an intensity where they are constantly worried about who may find flaws in their decisions: the GMC, negligence lawyers, NHS Employers, the tabloid press, the Care Quality Commission, with the perpetual cloud hanging over us of the risk to our registration if we are targeted for scrutiny.
The GMC provided assurances earlier this year that ‘in such challenging times, when you may need to depart from established procedures to care for people’ and that ‘in the unlikely event that you are referred to your professional regulator, they will consider the context you were working in at the time, including all relevant resources, guidelines or protocols’.
Such assurances have not been tested so the experience of Bawa Garba remains at the forefront of our minds, that history could repeat itself, which is why we are imploring GPs to support one another and stop this exploitation.
Aside from the fear of GMC suspension or erasure, GPs must be able to go home each day feeling they have done a good job. It is as simple as that. Working at impossible intensities, for extremely long days is not conducive to that experience. 63% of salaried GPs rank insufficient time with each patient among the top four factors that most negatively affect their commitment to a career in general practice.
What is the next step? Measuring all worked time and costing it by claiming it as unpaid overtime. Rewarding all worked time. The BMA has developed a fees calculator to cost all work that is performed in your own time. The BMA is developing its Doctor diary app to enable salaried GPs to monitor, track and report this invisible work.
We need to learn from the experience of consultants’ use of their rate card as we consider how best to claim for unpaid work. They have done the groundwork in pointing out that there need be no conflict between professionalism and fairness: ‘The clinical and professional responsibility you have for your patients does not mean that you must provide services over and above those for which you are contracted, or that you cannot give reasonable notice to cease doing such additional services.’
As well as claiming for extra-contractual work, salaried GPs may wish to explore the example of consultants in giving notice of which aspects of their work they will cease to do if they have fulfilled their contracted hours and there is still work left to do.
It may be reports, e-consults, filing letters, or student/trainee teaching. In all roles prioritisation is essential and GPC along with the Royal College of GPs insisted on prioritisation of workload during COVID. It is time salaried GPs started doing the same. Watch this space. Respect, reward, retain.