The hidden shelves – locum and academic GPs

Nada Khan is an Exeter-based NIHR Academic Clinical Fellow in general practice and GPST4/registrar, and an Associate Editor at the BJGP. She is on Twitter: @nadafkhan

I recently described the different ‘shelves’ contributing to the GP workforce in response to Charlie Massey’s assertion that there is no shelf with spare GPs, ready and waiting to be plucked into action.¹  There are two shelves I neglected to mention, that is, the shelf with locum GPs, and the shelf of academic GPs. What is the contribution to the GP workforce of these shelves of GPs, and how might they impact on workforce pressures in the UK?

Locum GPs

Locum GPs are an essential part of the GP workforce, often covering gaps at short notice and planned absences such as maternity leave or study leave. Why locum?  No one GP will have the same reason, but locum GPs report that having more control over how, where and when they work helps prevent burnout in an overstressed healthcare system.²  Aggregate locum GP use in England has been relatively stable from 2017 to 2020, making up around 3% of total GP full-time equivalence (FTE) workforce.³  Locum GPs have been accounting for a greater share in the GP workforce as the overall numbers of GP partners and salaried GPs has fallen since 2017.⁴  Most locums (74%) are in long-term positions, and in terms of the composition of the workforce,  locums are relatively young (median age 42 years), and a small majority are UK graduates (64%).³  Locum use is not uniform across the UK, and a recent analysis in the BJGP looking at locum use in England includes a hot and cold map demonstrating a wide geographical variation in locum use.³  Areas such as the north west of England and London, along with rural practices, had relatively high locum use, with up to 7.4% of the total GP FTE covered by locum GPs.

These analyses of locum rates use NHS digital data, which differentiates them between ‘regular’ locums with consistent and predicable working patterns and a planned and ongoing presence in the workforce, versus ‘ad-hoc’ locums who work briefly at a practice to cover short-term or unexpected absences.  These ‘ad-hoc’ locums (please note, this is NHS digital’s nomenclature and not mine) sometimes hold other roles within the workforce.  Interestingly, in their descriptions, NHS digital suggest that ad-hoc locums don’t provide an additional resource for the NHS as they are essentially a ‘cover’ for absences in the workforce, not an extra pair of hands.⁵

The GP locum workforce is complex, and it is difficult to get an actual headcount of the workforce as some GPs work solely as locums, working a varying number of sessions, while others hold other roles within the GP workforce.  My take is that it’s probably not as important to know the exact (and likely changeable number) of GPs who locum, but it might be interesting to see patterns amongst certain groups.  How many newly qualified GPs move straight into locuming without taking a salaried position, and how long before (if ever) they take on a salaried post?  And what has been the impact on locuming rates of the New to Practice Fellowship, which is only offered to newly qualified GPs who take on a substantive post?

The UK government is not keen on a locum workforce, which they describe as a symptom of the recruitment and retention crisis in general practice.  The Health and Social Care committee asserts that nobody should be ‘forced’ (again, their words and not mine) to work as a locum to ‘regain control over their working life’, and suggests that practices could encourage locum GPs back into regular employment by offering more flexible working patterns.⁶  Flexible working is not the only reason why GPs locum, and if we really treat locuming as a symptom of an overburdened NHS, then we need to reflect on the deeper challenges facing general practice and the NHS and the reasons why GPs choose to locum.

The Academic GPs shelf

GPs clinical academics include those who support and develop teaching of undergraduate and postgraduate general practice teaching, and those who work in a research role often affiliated with a university.  The Medical Schools Council estimates that there are 260 FTE senior academic GPs in the UK.⁷  Although some funded academic roles have set percentages of clinical time, not every academic GP works in this way, and it’s unclear what the FTE of academic GPs is in proportion to the overall workforce.  Some academic GPs have dual personalities as partners, salaried GPs, or locums, so it’s also unclear what other shelves they may sit on alongside their university roles.

A wide range of backgrounds and GPs ready to contribute to the workforce

Charlie Massey’s assertion that there are no spare GPs has led him to propose the use of specialty and associate speciality (SAS) doctors as a solution to the workforce crisis.  In a sense, however, locum GPs are exactly that, a cadre of GPs ready to be plucked into work, though many practices still report difficulties in getting locum cover when it is needed.⁸   Although the locum workforce has remained relatively stable, the Health and Social Care committee criticises their use as expensive, inequitable and negatively impacting on continuity, and wants to see a move away from a reliance on locum GPs in practice.  The locum workforce has been described as a ‘symptom’ of the recruitment and retention crisis in primary care, which may be misleading if we fail to count the variety of reasons why a doctor chooses to locum.  However, if we can better understand the locum workforce, and tease out the intricacies of who locums, how many GPs solely locum and why and at what stage of their career, we might be closer to understanding retention and some of the difficulties in recruiting GPs to substantive posts.

References

1. In full: Charlie Massey’s speech on SAS doctors: Pulse 2023 [Available from: https://www.pulsetoday.co.uk/special/workforce/in-full-charlie-masseys-speech-on-sas-doctors/.
2. Hall LH, Johnson J, Heyhoe J, Watt I, Anderson K, O’Connor DB. Strategies to improve general practitioner well-being: findings from a focus group study. Fam Pract. 2018;35(4):511-6.
3. Grigoroglou C, Walshe K, Kontopantelis E, Ferguson J, Stringer G, Ashcroft DM, et al. Locum doctor use in English general practice: analysis of routinely collected workforce data 2017-2020. Br J Gen Pract. 2022;72(715):e108-e17.
4. Shembavnekar NB, J.; Bazeer, N.; Kelly, E.; Beech, J.; Charlesworth, A.; McConkey, R.; Fisher, R. Projections: General practice workforce in England: The Health Foundation; 2022 [Available from: https://www.health.org.uk/publications/reports/projections-general-practice-workforce-in-england
5. General Practice Workforce, 31 October 2022 – Interpreting figures: NHS Digital; 2022 [Available from: https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/31-october-2022/using-this-publication#top.
6. The future of general practice. House of Commons Health and Social Care Committee; 2022-23.
7. Clinical academic survey: Medical Schools Council; 2022 [Available from: https://www.medschools.ac.uk/clinical-academic-survey.
8. Morgan M, McKevitt C, Hudson M. GPs’ employment of locum doctors and satisfaction with their service. Fam Pract. 2000;17(1):53-5.

Featured image: The future of general practice 2: hidden workers, by Andrew Papanikitas, 2023