How locum staff can both make and break general practice
It's Friday afternoon. I am preparing to wind up the week, and enjoy the weekend until Jeremy Hunt,secretary of state for health,decides I shouldn't. Then an email pings in: "Hello. We are four sessions down the week after next, and need locum cover for December and January – unless anyone isn't celebrating Christmas."
I groan, and not so inwardly. It's my deputy, struggling, as always, to juggle a rota that is now taking a sizeable chunk of her full-time role. She struggles with lack of partners and salaried GPs; my partners struggle with patient continuity; I struggle with the finances. The solution to our growing demand and dwindling GP base is killing us.
Since 2007, I have been obsessively keeping count of every GP metric imaginable within general practice; for each GP, for every working day of the past 11 years, I have been tracking number of patients seen, number of calls taken, conversion ratios of calls to appointments, total number of patient access points managed etc.
The fact that we operate with named lists makes it easy (and useful) for me to track trends and performance over time. And our GPs, normally between 11 and 13 (all part time), are able to see and compare their stats if they so wish.
Then something changed. Our historically stable group of GPs started doing unpredictable and illogical things, like retiring early, going on sabbatical, becoming partners in parts of London (or England) that could pay them better, leaving to start families in places that end in "-shire". What was left was a group of tired warriors, and a small, exceptional army playing musical chairs trying to cover vacancies.
Suddenly, I was counting GP stats not for 11 doctors, but for 20, half of which were locums. Helpful, hardworking doctors that would visit us sporadically a few times each month for a few months, until they, too, returned home to Wales or Scotland or started a travel break.
The issue here was complex. We needed – and need – these doctors desperately. We cannot recruit quickly enough (or make up our minds quickly enough) to keep pace with this transient salaried GP/partner workforce. Finding a locum is a heck of a lot easier than finding a salaried GP, and the locum workforce has saved our bacon many times over the past 18 months.
However, the challenges that this growing locum base poses are, in some cases, as severe as the problems it is trying to solve, with the impact of the downsides delayed in time. The cheapest workforce in my practice are the partners. At a rate of about £190 per session, they manage on average 31 patient touch points per session, at a GP cost of £6.12 per touch point. Our salaried GPs are not far behind; at an average rate of £209 per session (on costs included), they see only slightly fewer patients per session, and it is not unheard of that it is them that switch off the light when leaving the building at night (for which we are immensely grateful).
And then there are the locums, whose presence increases in what feels to be a directly proportional way to the financial crisis in general practice. At a cost of £300 per session (pension contributions excluded), they will see and complete on average 18 patient contacts each day, at an average cost of £16.66 per contact. And then, there is the business of overtime, which makes an uptight manager like me feel like she is sitting on a time-bomb – an expensive one.
When my salaried GPs switch off the light, often much later than the end of their four-hour and 10-minute shift, the most they want is recognition, gratitude, and a satisfied patient outside the door. When many of our locums stay later than contracted (in hopes that we can perhaps switch off the light earlier), what they often (not always) want is £75 per hour. Which cripples me, and I don’t just mean financially.
While there is a side of me that understands the rationale behind being paid per hours worked, there is also a part of me that sees clinical work as largely vocational. To be remunerated, no doubt, but not for every hour or half hour worked. In such a time of crisis and demand in the NHS, it feels imperative that clinicians stand together to shoulder the burden of un-resourced demand in an equally committed way, at equal personal cost. We risk creating an unbridgeable gap between those that paradoxically work more for far less money, and those that earn more for fewer hours.
Achieving the goal
As this divide grows, our new generation of doctors would be mad to join the first and not the latter rank. I am under no illusion that general practice should be better resourced, that our clinicians should be rewarded fairer financial recognition for the crucial work they do in our society. I would, I have, and I will, continue to be vocal and march placards to achieve this purpose. Until that day, however, I think neither that this burden should be paid by some doctors more than by others, nor that it should be paid for by the patients under the form of poor access.
The argument can be made that locum work does not guarantee the same professional stability as salaried work. That it comes without holiday, without sick leave, without protection. But that argument ceases to hold its appeal once all these offers are on the table, and still the preference points to a higher hourly rate, which the system simply cannot afford at the moment. An argument has been made to say that salaried and locum costs are very similar once on-costs are taken into consideration; what this argument fails to value are the hours and hours each week that salaried staff work, unpaid, above and beyond their contractual sessions. And the difference becomes starker yet with the introduction of practice pension contributions for locums.
I recently made this case on a Facebook forum for salaried GPs, and got very mixed replies. A single locum GP agreed that "people going the extra mile for the NHS are in fact what keeps the system from imploding". But another argued that "goodwill never did the weekly shop at Tesco". And his case was largely supported by other GPs. I wondered whether my efforts to make a case for the greatest reward for clinical work being in the work itself were perhaps ill placed.
With so much thought to values and financial sustainability, there are many more that have not even been mentioned but which carry their own relevance: clinical continuity, the power of an established team, the workload generated by endless cycles of HR checks, the time spent tracking and negotiating rates and sorting invoices.
A way forward
So what's the answer to all this? If I knew that, I guess I wouldn't have a problem. In the daily running of my practice, I use a company that offers an online platform, which you can register your "own" locums on, who all have access to any sessions available, and any agency fees are charged only if none of our own registered locums are available. It's easy, it's quick, it sorts HR and payments issues automatically, and boasts nifty stats such the ability to fill80% of appointments with familiar local GPs who know the specific pathways and understand the patient population.
Long term, diversifying our skill mix is crucial. With a dwindling base of GPs of any nature, be it salaried or locum, stability and continuity in general practice are more likely to be realistically achieved through micro teams and the creative introduction of entirely new roles within our surgeries, from paramedics to physician associates to a different brand of medical administrators.
GPs sharing awareness of these issues, and of the risks inherent in not working as an equally committed collective, is also key.
My own practice employs, at the moment, a considerable number of locums. More than we’ve ever had. This type of conversation is one we do not avoid with them. We have it during our shared lunches, at the parties our locums are invited to during the year, at the time of negotiating their work with the practice. Our locum base is expensive but excellent and relatively stable, comprised of hard working doctors who truly hold the patients' best interests at heart. And the ambition, the hope, is that we might one day all sit around the same table, as equal stakeholders. The future of the NHS depends on it.
Virginia Patania, practice manager, Jubilee Street Practice.