Dr Zoe Norris speech to LMC conference 2017 in full

In a powerful speech at the 2017 LMC conference in Edinburgh, GPC sessional subcommittee chair Dr Zoe Norris hit out at denigration both of sessional and female GPs and warns that the profession must stand together against attempts to 'divide and rule' it. Read her speech in full below.

Chair, conference – thank you. Today is an opportunity to tell you what the sessional subcommittee has been doing for the last year. I would love to do that, but before I do it’s important to address the elephant in the conference chamber.

General practice is collapsing. It’s failing. And it’s my fault. If there was a motion to support allocating the blame for the crisis we find ourselves in to me, it should pass overwhelmingly. Let me explain.

I am that increasing plague – I am a female GP. I’m an emotional, hormonal creature, largely fuelled by cups of tea and cake.

I am possessed by the need to work part time, and search for the holy grail of a life outside medicine. Driven by my ovaries, I have selfishly reproduced. Not once, but twice. I took time away from my patients to look after my children – I’m sorry.

I'm a locum GP

So I’m an emotionally wrecked, part time female GP with children. But conference, it gets worse. Brace yourselves – I’m a locum (dramatic gasp!).

A money grabbing locum, flitting from one practice to another to get the most money, as the veritable Simon Stevens recently described us.

And that horrific combination is what is destroying general practice apparently! It’s me, and the other lazy generation Y GPs who never really wanted to do any work as doctors, and who only went into medicine to impress our friends at school.

Where is our sense of vocation?? Why don’t we think of the patients?!!!

I can hear the politicians and NHSE screaming at me, presenting the solution: if every locum, or salaried GP took a partnership overnight, they tell us all the problems of general practice would be solved. The fact that we don’t have any funding wouldn’t be an issue.

GP workforce

The fact that even then we still wouldn’t have enough doctors can be glossed over.

We all know what locums are like – work shy and greedy; we all know that salaried doctors don’t pull their weight, only wanting to leave on time. Just like we know that all partners are fat-cat GPs, who shut every afternoon to go and play golf….don’t we?

Maybe it’s time to challenge a few of these misconceptions. Two months ago, the sessional subcommittee launched the biggest ever survey of salaried and locum GPs.

It was open to all sessional doctors across the whole UK. It included everyone from full time salaried GPs, to part time locums, to prison doctors - we wanted as many doctors working in any portfolio or sessional capacity to reply. Over 2,000 colleagues responded.

The results tell a few home truths, and with over half the respondents being locums, gives the first genuine data on what the increasing sessional workforce think and feel.  It tells us about colleagues who feel like this:

'I feel working as a locum is a good way to contribute to a bad workforce situation without my  health being compromised.'

'10 years to retirement and counting! This is no way to live. I used to love my job but workload, understaffing and financial issues mean every day is enforced underperformance. We and our patients deserve better.'

'Workload overwhelming. Partners struggling to cope pass this on. I want to see GPC really show they believe in salaried and locum doctors.'

Locum workforce

Our survey results tell us that 42% of the salaried and locum workforce used to be partners. These are not doctors coming straight out of training and making a rapid lifestyle choice.

 It tells us that lack of control over workload is the main reason why these salaried and locum GPs are choosing not to be partners now.

Many of us work in different roles throughout our career – the biggest driver to sessional working now, is the intolerable workload that partners find themselves expected to work under.

Things don’t look likely to change in the future. When asked what their career plans are for the next 5 years, most sessional doctors felt working as a portfolio GP was the route that would give them the most flexibility and control.

We think of the sessional workforce, especially locums, as younger. Usually women. The generation Y doctors. But it isn’t.

The average age of a salaried GP was 43. The average age of a locum GP was 48. For male locums this rose to 51. These are experienced GPs, who have been driven away from partnership because of the unrealistic demands, and the inadequate funding of the largest part of the NHS.

Working at scale

And if NHSE and the government imagine they can push these GPs, that make up the majority of the sessional workforce, to work in a wants over needs service, or at scale, or in a fully salaried model, to suit the political agenda, they are mistaken.

They must be pulling these GPs back by listening to the concerns of partners, and taking the collapse of general practice seriously. Do not push them.

Why? Because when the GPs we surveyed were asked what they would do if sessional work was further dis-incentivised, the top answer? Leave the profession completely.

Locums value their local practices, with over three quarters booking work directly with practices they know and have a relationship with. This relationship between locums and practices is vital – faceless booking systems where the practice has no idea who will arrive, or the quality of their work does no one any favours.  

Almost nine out of 10 locums work in no more than 3 practices during a typical month – this is not the mobile, greedy workforce some would have you believe. This is a workforce that stays in an area, that is settled with families, with colleagues in practices, with a support group and a relationship with secondary care.

Sessional work

There will always be a few GPs who are happy to travel the length and breadth of the country to work a shift – good for them, they are probably filling last minute desperate vacancies. But very few sessional GPs want to work like that.

The sessional workforce don’t necessarily want new models of care either. When asked about future working, MCPs, at scale organisation or hospital trust scored the lowest. Most salaried and locum doctors believe in general practice. They believe in GPs working as a team for the good of their community. The wheel does not need reinventing.

Salaried doctors know that practices are struggling. They can see the rising pressure every day and they feel it too. They are part of the practice, not working in a blissful bubble away from the crushing pressures we are all feeling. Locums feel this struggle. They know practices are financially stretched, and closing, which is why over 80% of locums have not increased their sessional rate since April 2016.

It simply isn’t about money – money hungry locums would take the cash and move to an under-doctored area. We are only interested in making a quick buck after all. Except 60% of sessional doctors say they would not move for any financial incentive. Schemes that have tried this approach have simply depleted the surrounding area of their locum support. It’s not about the money.

Salaried and locum doctors are often ignored and left out completely from workforce planning. I – and I am sure you – know of and work in practices with no regular GPs. These practices are staffed solely by locum doctors. If the Department of Health and NHSE continue vilifying sessional doctors, then they will leave.

GP partnerships

These practices, and the many partnerships working so hard across the country, relying on their salaried and locum colleagues will collapse overnight. The out of hours service will implode.

When GPC surveyed the whole profession earlier this year the message was the same – workload is overwhelming. You are giving us no choice.

All of us, at some point in our careers, may choose to work as partners, in salaried roles or as locums. But that is our choice based on individual circumstances.

Doctors should have this choice – no one should seek to restrict that or dictate to them. But politicians need to know, for many GPs you are giving them no other choice.

 I want to wholeheartedly support those GPs who make a positive choice to work in a salaried role. Who make a positive choice to locum, or have a portfolio career. We should all support them. Just as we should support our trainees.

But when we see GPs of all ages and genders having to choose their own health over working in the model of the independent contractor, that has served the NHS as the most efficient and cost-effective part of it since its inception 68 years ago, something has gone very, very wrong.

When partnership feels too high risk for a GP with children at home, often as the main earner; when there is no believable blueprint for the future of general practice, then no one wants to join.

Future of general practice

So what is the role if your SSC in all this? There is a huge expectation of spending your money, the money contributed by GPs across the UK. When we talk about spending GPDF money wisely, I want every LMC to be able to tell its members what we are doing. And while our focus is sessional doctors, as they are who elect us, many areas also affect practices, and LMCs. We are part of one profession. We will succeed, or fall together.

We are fighting for accurate, up to date performers lists from Capita, so you know who the salaried and locum doctors are in your Constituency, so you can contact them and represent them. We want all GPs to have their updated details automatically passed to their LMC. LMCs cannot represent the GPs in their area if trying to find out who they are requires the same computer skills that can apparently bring the NHS to its knees. Sessional doctors need to know who to turn to for help and representation. The failure of all national bodies to recognise the immeasurable issue that communicating with the sessional workforce is embarrasses us all. It must be solved and that solution must involve LMCs.

We have worked with Capita and NHSE to track down missing pension payments, and reunite them with the GPs. We have secured a commitment that no locum GP will be financially penalised due to Capita’s errors, or lose pension contributions as a result.

The 10-week deadline for pension contributions has been waived. An amnesty on type 2 practitioner forms will be announced. We have helped Capita realise that sending emails to practice managers, isn’t the way to reach locum GPs. We have politely advised them on their website content, on BACS, and on what GPs need from them – receipts of contributions, accurate and updated online pension records.

GP retainers

We have a new GP retainer scheme, which recognises that both the retained GP, and the practice must be better funded to help support them. The scheme has been extended to all ages, you can remain in your current practice, and are no longer limited in the other non-clinical work you can do. This helps to give all ages of GPs another choice about how they work, with flexibility and the same protections around CPD that the model contract provides.

We have helped salaried and locum doctors navigate the complex world of IR35 tax changes. Guidance from the BMA and GPC to both employers and self-employed GPs, as well as answering countless individual emails and queries.

We want to promote a professional, high quality sessional workforce. We will be submitting evidence to the DDRB to show how the salaried model contract is the contract for ensuring the correct balance for doctors. We want this protection extended to any GP who is employed in a new model of care, and we are working with the policy team for working at scale to produce guidance for LMCs and individuals on what a good contract looks like in this brave new world.

This isn’t just about sessional doctors. If partners chose to become employed, or to enter working at scale arrangements that moves them outside their GMS or PMS contracts, we must be able to have clear, national guidance on what they should expect. What they should accept. And empower them to say no if they need to.

We are working with GPC to produce a set of model terms and conditions for locums and practices. We are doing this for these reasons -  I am as angry to hear of a locum not turning up for work, or delaying a booking to charge a practice more, as I am when being told about practices that refuse to pay despite work being done, or cancel on the day of a booking.

Terms and conditions

By agreeing a model set of terms and conditions that protects the locum, and the practice equally, but leaving the freedom for the level of individual and personal negotiation that both sides want, we set the standard high for all the agencies, private companies and acute trusts out there to follow our example. This will not work if we only make a contract that favours locums, or that favours practices, and needs us to work together, not against each other.

We are working alongside the trainee’s subcommittee, and the Junior Doctors Committee, to help secure the future of general practice and give trainees the information and support they tell us they need. We are reaching out to the SAS doctors, to offer them support in their similar challenges.

In Northern Ireland we are supporting salaried and locum doctors with the uncertainty around undated resignations. We are working with NI GPC to ensure effective communication, so they remain part of the solution not the problem.

In Wales we have supported colleagues with the imposition of IR35 unilaterally by health boards.

In Scotland we continue to ensure sessional GPs are aware of and considered in the new GMS contract negotiations. They are a workforce solution to be included and considered.

Divide and rule

What does the negative perception of sessional GPs do? What does the divisive rhetoric do? It seeks to divide and rule, and split a profession. Setting GPs against our hospital colleagues; trainees against their trainers; locums against partners, - who wins from this because it isn’t us?  And it isn’t our patients.

General practice has always been the place that celebrated differences, that saw strengths where others didn’t, that innovated; endlessly adapted. We must listen to one another, we must respect each other’s choices, and fight for the right to have that choice.

I am not a partner, but I would never dream of criticising a colleague who chooses to be. I certainly wouldn’t put all partners in one big group and label them, as the trend seems to be with sessional doctors.

No government or organisation should be able to tell us as a profession how we work. Where is the real enemy of general practice? Not in this room.

How dare they tell us, that by speaking out about the dangerous state of our profession, that WE are to blame for the recruitment crisis? How dare they stand there and say, "if you weren’t negative all the time, more medical students would apply?"

Whatever the press and politicians may think of us, we are a profession with integrity. We are a profession with strength. We should never shirk from shining a light when patients are at risk.

'Think of the patients!!'  Yes – the people in this room think of little else. It is what keeps us awake at night. It is what makes us cry for a moment in our consulting room. It is what racks us with guilt when we are used up, and feel we fail by handing in our notice and saying "enough". We fail if we let them use us like this.

Outside the hall is a stand staffed by members of the Sessional Subcommittee and our amazing secretariat – every LMC can collect a* dedicated USB* still which has fully updated salaried and locum handbooks loaded onto it, as well as a range of other resources from us. We will keep these updated so you can download and share changes much faster than in the past; if you have a sessional GP with a question and you aren’t sure, use the handbooks. If you have a practice that needs support with their sessional colleagues, the answers are probably in there. If they aren’t? Get in touch. Details of all the regional SSC reps are * on there* too, with emails and contact numbers. Use us.

To help you represent all the GPs in your constituency, we are a resource. But we are only as good as you help us to be.

It is so easy to sit in meetings at national level, to agree to solve problems and make a difference, and assume the job is done. It is only by hearing from GPs and LMCs that we know when things are going wrong.

I never want your Sessional subcommittee to be in a position of blissful ignorance. Patting ourselves on the back for a job well done, while all you hear is of ongoing problems, achieves nothing. That level of detachment is what leads the GPs we work for to be frustrated with the structures that represent them. Help us to do better. Tell us what you want, what you need.

Talk to us, and use your regional reps as the resources they are. If you aren’t getting anywhere, come to me. I and the rest of the SSC will do the best we can, but just as we are all part of one profession, and one general practice, we must be part of one voice representing all GPs.

Conference, thank you.

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