Until we tackle the relatively recent and accelerating culture of locum working which leads to high rates of pay, the GP workforce crisis will continue regardless of numbers, writes Mathew Wright

There has been much written in the media about the GP workforce crisis. During the election campaign it was touched on by all parties, with the newly re-elected David Cameron pledging 5,000 new GPs.

However, I don’t believe that simply training more GPs is the answer to the workforce crisis.

The problematic locum culture

The biggest problem I face running a practice isn’t the lack of GPs but the lack of GPs actually wanting to be GPs providing ongoing care for a registered list of patients. Until we tackle the relatively recent and accelerating culture of locum working, the GP workforce crisis will continue regardless of numbers.

Since Lord Darzi’s white paper in 2008, we have seen the opening of extra GP practices in under-doctored areas, walk in centres open 8am-8pm 7 days a week, followed by the more recent popularity of urgent care centres open all sorts of different hours and traditional general practices encouraged to open for extended hours.

The demand for GP time has never been higher.

‘Booming locum rates of pay are a result of high demand’

This fact, coupled with the fact that less GPs have been qualifying in the past few years provides the perfect market for GP locums. In the simplest of economic terms, demand has never been higher and supply is declining. The result: booming locum rates of pay.

I am a resources manager for Lea Vale Medical Group, a practice in Luton with 21,000 patients and I have been in post since April 2007. I am responsible for all HR and financial matters within the practice and as such take the lead on recruitment.

Cap locum pay

Throughout 2007 and 2008 we had three vacancies for salaried GPs. We advertised in one of the popular publications for GP recruitment and offered a salary of £65,000 whole time equivalent (WTE) plus medical indemnity.

For each position we received around 20 applications; we held open afternoons for GPs to visit informally prior to their interview; and before arranging interviews we had the forgotten task of actually having to shortlist candidates and send our apologies to the candidates not offered an interview.

All three roles were filled successfully following this process and the GPs recruited formed a successful part of our establishment for many years.

The situation now, however, is very different. We have tried on a number of occasions over the past years to recruit a salaried GP, working whatever hours they like, for a salary of £85,000 WTE plus medical indemnity, training investment in their area of special interest, collaborative working with other practices, etc. You name it and we have tried it.

‘They couldn’t afford the drop in income from their locum work’

Through four recruitment campaigns in the past two years we received a grand total of three applicants. Two ended up declining the offer of an interview as they had signed with a locum agency and were now fully booked for the next six months and the other one, after accepting an interview, being offered the role and starting work for two weeks then left as she too had joined an agency and was being offered full time hours.

Who can blame her? Our £85,000 WTE salary paled in to insignificance compared to the £170,000 WTE on offer from the agency. 

More recently we had a GP turn us down for a partnership because they could not afford the drop in income from their locum work. Agency fees quite simply have to be capped, as we are moving towards a time where they have the ability to effectively name their price and it is to the detriment of practices, trusts and to the NHS as a whole.

The trend

Traditionally, locums were used to cover periods of annual leave, sickness or times of temporarily increased demand. Locums did not have guaranteed hours and therefore mainly worked sessions outside of their contracted or partnered base practice time.

They received an enhanced rate because the cover was always temporary. Now, however, they still receive an enhanced rate but they are used as a necessity to cover the increasing hours needed by the vast array of provider companies or trusts delivering the services described above.

‘It is now possible to work as a professional full time locum’

It is now possible to work as a professional full time locum.

Hourly rates quoted from agencies do not go below £70/hr (£136,500 WTE) with the norm being closer to £90/hr (£175,500 WTE) and upwards. Who can blame GPs for wanting to work this way with the rewards on offer, compared to a life of high workload and high stress within a practice for half of the earning potential?

Bidders for alternative provider medical services (APMS) contracts have the chance to budget and allow for these costs, so they are not hit as hard as traditional general practices that have to fish in the same pool with nowhere near the same resources.

My practice happens to be one of the lowest funded practices in Luton, which makes it all the more difficult for us.

Variation in funding is a separate issue that is being addressed by PMS reviews and general medical services (GMS) minimum practice income guarantee (MPIG) are being reinvested in the global sum over the next seven years but that doesn’t help the many practices which are suffering here and now.

Novel recruitment scheme

Last year Luton Clinical Commissioning Group piloted a GP recruitment scheme for “future GP leaders”, aiming to recruit two new GPs on three year contracts. They are to be based in a general practice in Luton for 2.5 days, along with one day in medical education at the University of Bedfordshire or in commissioning with the CCG, and one day to study for a Masters degree. Both posts come with senior level mentoring in either the university or CCG depending on the role.

These are innovative posts enabled by partnership working between the CCG, Health Education East of England and Bedfordshire University, each contributing its expertise and resource to develop the clinical leaders of the future for the local health economy. They successfully recruited two very talented GPs and following last year’s success are recruiting again for 2015.

‘It shows the lengths required to achieve recruitment’

This is a fantastic, innovative scheme that is slowly bringing talent to Luton. But while it shows that recruitment is possible, it also shows the lengths required to achieve it.

CCGs have the partnership relationships and infrastructure to create this sort of package, whereas traditional general practices do not generally.

The cost factor

If my practice were to offer this package, including the masters and one day for mentorship, the package would cost similar to that of the earnings of one of our established partners. Schemes such as this are excellent when supported through CCGs, such as the case in Luton, but are not financially sustainable for practices in isolation or even in federation and would not have the desired effect of attracting talent quickly enough.

GPs are extremely well trained and highly skilled individuals who deserve to be able to maximise their earnings. However, with demand for GP time showing no signs of decreasing and with Mr Cameron planning to have GP practices open seven days per week, locum rates will continue to spiral out of control.

This poses a real threat to general practice. Mr Cameron’s proposals for having GPs open longer will actually make them close earlier unless he takes his GP recruitment plan further with one very simple, common sense solution. Quite simply, GPs must hold a contract of employment with a practice for a minimum amount of hours or be a partner in a practice to be eligible to locum.

‘A cap on fees and a revalidation criteria for GPs would be a significant step’

GPs, like all other professionals, have the right to work under any guise they wish but a fundamental and essential attribute of a practising GP is that they be trained and highly skilled in providing continuity of care to patients. This involves prevention, anticipating need, complex case management, multidisciplinary working and advanced care planning.

Locum working presents a significant risk to the ability of primary care to provide the very services which patients say they value and which evidence demonstrates makes a difference. So could the ability to demonstrate continuity of care be introduced into revalidation criteria to get GPs back in to general practice for at least a proportion of their time? 

A cap on the fees that agencies can charge practices and trusts for GPs, coupled with a revalidation requirement for GPs to spend a minimum amount of contracted or partnership time within a practice would present a significant step in the right direction for addressing the GP workforce crisis.

Under the CCG structure, general practice is the bedrock of the NHS, ensuring GPs remain working in practices is therefore essential for the sustainability and future success of the NHS.

Mathew Wright is resources manager for Lea Vale Medical Group