Keeping on top of practice finances has been particularly challenging over the past three years, GP partner Dr David Coleman writes.
While many practices saw GP partnership profits rise in 2020/21 (for the first time since 2005/06), this was primarily due to Covid-19 vaccination payments and support funding. That particular income stream appears to be drying up dramatically. Our attention has now shifted to rising expenses – wage uplifts, soaring energy bills and inflation. After a short-lived boost, the future looks daunting.
And yet the challenges – and the patients – keep on coming.
Contrary to popular belief, evidence suggests that use of locum GPs has remained stable over the last few years1 and is most prevalent in rural and deprived areas, which as Management in Practice and Pulse Intelligence data highlight, is often where the highest rates are found.
I would argue that the majority of practices have a workforce shortage in at least one department. Finding permanent staff is a challenge and financial uncertainty is a potential barrier. Locum doctors provide a tempting short-term solution, but those fees can start to spiral fairly quickly.
Many practices are looking at their workforce plans and pondering how to deliver the best possible service within a tight budget. This article will explore how important it is to define a clear budget for spending on locums and how best to utilise this resource.
Set your locum budget
Every practice will have its own philosophies and approaches to budgeting. At my practice, I use a GMS ready reckoner along with historical accounts and a staff wage spreadsheet to predict an income range and an expense range excluding locum costs, which is the biggest variable expense. So many of the ins and outs are relatively predictable and I find this gives me a good feel for the estimated level of partnership profit without locum costs. We then consider how much we could take out of that profit for spending on locum staff while retaining a sensible overall profit that the partnership agrees is fair balance. This requires honesty and a degree of compromise.
It is vital that actual locum spending is monitored throughout the year to ensure it doesn’t exceed the budget. If there is a need for greater locum resources, you may need to arrange another meeting to revisit the budget. Would the partnership be happy to take a cut in profit to secure additional locum support needed, for example, to cover staff sickness, or after an unexpected event? It could even be a new source of income (and therefore work) that triggers additional demand for locum services. It is a fluid situation that needs to be closely monitored and regularly reviewed.
We aim to set our budget as soon as our accounts information is available for the previous financial year. To be able to plan locum use for the first quarter before our accounts are available, we use annual trends to anticipate and estimate what budget we have.
Analyse when spend on locums is needed most so you can plan
Workload in general practice used to ebb and flow; now it’s just busy all year round. For us, the tightest pinch-point is now increasingly holiday periods rather than winter. Although we aim to distribute our spending throughout the year, there’s a strong focus on the school holiday periods. The limited locum pool is in demand at these times of year, and they have their own take holidays to take too, so get your requests in early.
Induction is invaluable
It is impossible to overstate the importance of finding time to hold a short induction for new locum GPs. In this session you can outline the practice’s ethos and make the locum aware of local nuances in referral pathways (how does physiotherapy work?, where are the two week wait referrals?, how does the practice arrange bloods, x-rays, ECGs, spirometry etc.?) I also like to discuss our approach for requesting bloods, to try to minimise the risk of over investigation.
Get the most out of locum shifts by allocating them the right work
Locally we pay in the region of £100 per hour for locum GP shifts. At 15-minute appointments, this equates to £25 per face-to-face appointment. At this price point, getting the right patients (or admin duties) into those valuable locum slots is vital. At my practice our approach is to consider the clinician skill-mix across the whole practice team each day. We usually have a diverse mix consisting of partners, salaried GPs, GP registrars, advanced nurse practitioners (ANPs), ARRS staff (physician associates, pharmacists) and locum GPs. We typically triage complex patients, frequent attenders, and patients receiving palliative care towards permanent clinicians where continuity is critical. At the other end of the complexity spectrum, we tend to triage the minor and self-limiting illness (if it needs seeing at all) to the ANPs and physician associates (PAs). Our locums tend to manage the middle ground, often seeing first presentations of moderately complex problems or patients with non-resolving conditions who have already seen the ANPs or PAs.
Think about the admin duties you would like locums to fulfil
Locums can file pathology reports, manage documents, handle prescription queries and complete referrals. Whether you feel this is a valuable use of their skills depends on the challenges facing the practice on a given day. With the exception of long-term locum staff, I prefer to restrict locum admin duties to their own referral letters, leaving the regular admin workload for staff who are used to practice processes. This is an individual choice and something to discuss with your locums.
Be reasonable and they will come back
Like all workforce markets in primary care currently, the locum market is extremely competitive. You and your locum clinicians will both benefit as your relationship develops. It is therefore worthwhile trying to make their experience a positive and inclusive one. Make the job enjoyable, invite the locum for coffee breaks, offer lunch at the same time as partners, and don’t fill their clinics with a stream of highly complex challenging patients. Include adequate admin time to ensure they can manage the work in their scheduled hours. Look after them and they will return.
Dr David Coleman is a GP partner and trainer and PCN co-clinical director in South Yorkshire
- Grigoroglou C, Walshe K, Kontopantelis E, Ferguson J, Stringer G, Ashcroft DM, Allen T. Locum doctor use in English general practice: analysis of routinely collected workforce data 2017–2020. British Journal of General Practice 2022; 72 (715): e108-e117