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The text below
is for historical information only - NASGP's up-to-date guidance on rates can be
found in our Rates Section.
DISCUSSING LOCUM FEES publicly guarantees raising the
hackles of someone. Locums are prone to feeling undervalued and principals are
prone to feeling locums are greedy and unreasonably expensive. Much of the
antipathy comes from the BMA’s suggested locum rates which, though the BMA
insists they are suggested and not 'recommended', are often stuck to
rigidly and uncompromisingly.
BMA Rates
Until 1990 the BMA made no suggestions. Medeconomics published figures
reflecting average rates in London. In 1990 the Private Practice &
Professional Fees Committee (PPPFC) of the BMA established a working party to
consider locum fees and since then, they have annually increased the suggested
fees by a percentage similar to that secured for Principals. The initial
starting point for comparison was the salary of Hospital Practitioners but the
figures now assume a working year equivalent to 39 full weeks and the net
intended annual remuneration of about 75% of that of the GP principal target.
Principals’ target is net, without expenses, whilst the locums’ is
gross and includes expenses.
Five locum groups met the working party in 1992 to make representations about
the absolute and relative values of weekend and other work. Partial success was
achieved but inconsistencies remained. To reduce these further, a joint working
party of the London and Exeter Groups met in 1994 with the PPPFC and GMSC.
Today the BMA suggested rates for weekends are still unsatisfactory. Taking BMA
rates for a weekend retainer and allowing the usual rate for each night results
in a derisory amount for all the daytime hours.
The out-of-hours patterns of work in General Practice have changed greatly.
This has led to the calculations resulting in locum rates being based on
assumptions which are now outdated. Because locums who wish to do out-of-hours
work are likely to have access to Deputising services and Co-operatives, the
end result is probably unimportant. A growing number of co- operatives have
decided to pay themselves well above the locum or deputy rates. Such increased
reward for increased responsibility, even if time limited, has been the only
way co-ops have managed to entice doctors to do the work. Non-principals
working out of hours for Deputising Services and Co-ops should, and usually do,
now receive the same pay as principals.
Current BMA rates suggested for deputies are intended to achieve a target
income based on a 46- week working year linked to principals. They are
calculated on the assumption that a deputising doctor will be provided with a
car, a driver and a radio (or mobile phone). Where this is not the case, an
additional payment should be made.
Locum fees are suggested and are a matter of negotiation between locums and
practices. The fees are based on a full time locum working 39 weeks in a year
achieving 75% of principals intended average net remuneration. The rates are
intended to take account of continuing education costs. The detailed rates are
published annually in the BMA Fees Guidance Schedules: Medical Cover in General
Practice (available from regional BMA offices). They are summarised every month
in Medeconomics.
Local locum groups across the country have successfully set their own rates.
Such rates vary widely and in areas of short locum supply, they are
significantly higher than the BMA rates. However in a few areas where there are
plenty of locums, practices often pay well below BMA rates. At the 1997 BMA
Annual Representatives Meeting the motion 'Principals who do not pay the
recommended locum rates are exploiting their colleagues' was passed as a
reference. This means that although it does not become BMA policy it is noted
as the opinion of the meeting.
In 1997 the PPPFC was asked by the NASGP to consider its views on locum fees and
agreed to do so. Although being split into three component committees the issue
will be high on the new Professional Fees Committee’s agenda. The first
GMSC Non-Principal Subcommittee will also ensure the subject is a high priority
and hopefully there will be significant change in 1998.
In the meantime when deciding your own rates to charge consider:
- your fees are gross income, not a simple labour
charge;
- your income will be variable;
- know the rates others are working for locally, or you may
price yourself out of the market. Getting together in a group to set local
rates helps prevent practices shopping around and empowers individuals to be
assertive;
- know the demand for locums locally;
- know what you need to live on and how hard you want to work;
remember you need to cover first:
- holidays;
- sickness insurance;
- a pension;
- your business running costs;
- postgraduate education;
- national insurance payments;
- tax;
- maternity/paternity pay;
- and then the rest you can live on.
Shaun O’Connell and Adrian
Midgley
There is an increasing move amongst locums
towards setting a minimum rate for work. This is to prevent practices booking
locums for just 2 hour surgeries, which, if expected to do little else, is
difficult to live on. The 2 hour surgery suits some non-principals and may be
just what practices require but it would be better if locums charged for their
time not for vaguely defined sessions which rarely last as long as they’re
supposed to and usually longer. An hourly charge encourages practices to be
organised, not to interrupt during consultations, nor add extra patients or
paperwork. If they do, it’s easier to charge for the extra time and you
leave feeling less bitter.
Fees - The NASGP’s view
The NASGP has detected an overwhelming tide of opinion from members and
practices throughout the UK that the "BMA rates" as they stand are
ambiguous and irrelevant to modern non-principal work. The rates do not
recognise the actual hours worked by an non-principal or the real cost of being
excluded from the NHS superannuation scheme. They underestimate the true and
necessary expenses of being a self-employed non-principal and undervalue the
worth of non-principals as providers of general medical services.
During 1997 and 1998, the NASGP has been publicising and setting the agenda of
the debate on appropriate pay for non-principal GPs. We sent a report and
recommendations to the Pay Review Body, and we were quoted in the 1998 Doctors
and Dentists’ Review Body’s (DDRB) report. We have represented
non-principals at the BMA's Private Fees Committee, and have directly
contributed to and influenced the policy of the GMSC's non-principal
subcommittee. We have written numerous articles on the subject for the GP
press. We hope that the new rates will take into account the following points:
- The advantages and disadvantages of working as a principal
or a self-employed non-principal ought to balance out. Hour for hour,
non-principals are worth as much as principals as providers of General Medical
Services (GMS).
- Non-principals work more hours than are directly remunerated
by direct patient encounter. There is administrative work arising from doing a
surgery, additional travelling time, and further work at home doing the books
and administering the business. This should be reflected in the correct
non-principal remuneration, which can only be directly quantified by the
patient- encounter time.
- Participation in the NHS superannuation scheme provides
principals with an additional 14% of their net remuneration, compared to the
contributions required for a private pension plan that match the benefits on
retirement. This "perk" is effectively delayed salary.
- "Full time" for a principal (less out of hours)
means, typically, 6 weeks’ paid annual leave, 8 days’ paid bank
holidays, half a day off per week and remuneration for collecting PGEA points.
The intended remuneration for a full time NP should allow for a similar
definition of "full time".
- A full time self-employed non-principal has more necessary
business expenditure than is generally realised. Principals' net pay is what is
left after all of their business expenses have been allowed for, and yet
principals often compare their net income with locum fees, which are gross
income, or "business charges".
- The NASGP estimate that to compare "like with
like", after adjusting for expenses and superannuation benefits, only 60%
of the locum's fee is actually net income. Even this figure excludes motoring
expenses (see below).
- Motoring expenses should be invoiced additionally, as car
use varies enormously between non-principals. Principals' intended net pay
includes £3500 in motoring expenses have been taken in to account. We
believe that mileage should be payable to the non-principal for journeys to the
practice area boundary (if living outside), all visits and journeys between
branch surgeries.
- The intended net pay of principals doesn't include achieving
higher target payments (worth around £3500 per annum), yet non-principals
contribute to achieving these targets.
- We believe that the idea of remunerating visits on a
separate scale is illogical and unfair. We believe that if the non-principal is
working, it means just that, and would include travelling time to and from
visits, and performing the visits.
- Although we believe that an hourly rate is the best way of
remunerating non-principals (and this is not the "booked" time, but
the time actually spent), non-principals should reasonably expect to be engaged
for a minimum time or fee per session.
There are two reasons for this:
- This will eliminate the temptation of a locum to cancel a
short surgery in favour of a half day somewhere else, and so act as a
protection for the practice.
- Surgeries tend to start at set times, and there is usually
only two opportunities per day for the non-principal to work. We recommend 3
hours minimum for a morning and 2.5 hours for an afternoon, but if there are
opportunities for additional sessions (e.g. as there often are in cities) or if
the non-principal genuinely prefers a short surgery, then this should be
negotiable.
At the time of writing, we are awaiting the
revised "BMA rates" for 1998 and we believe that, in name, these
rates should be broadly accepted as the benchmark for non-principal’s pay
across the UK. Our policy is to influence the rates by persuasive and
constructive argument. The NASGP is represented on a BMA’s Private Fees
Committee working group which will recommend a new rates structure in 1998.
We believe that non-principals should either be paid as self-employed
"locums" who do not have any work-related benefits or as
properly-employed staff who have full employment benefits, and that there
should be a different gross rate for each type. These rates take into account
the additional expenses of, (but also the tax advantages conferred on), being
self-employed, but which deliver exactly the same net pay for working similar
hours . We believe that there is no place for the "long term locum"
who has regular, but un-contracted commitments, has no holiday, study or sick
pay, no ability to join the NHS pension scheme and who is paid at the lower end
of the current scale. This situation is nothing short of exploitation, but the
current lack of distinction between employed and self-employed gross rates
means that the "long-term locum" is the cheapest option for employing
practices.
Employed assistants are able to contribute to the NHS pension scheme, and
should have paid holiday and study leave. With no such work-related benefits
and additional expenses, self- employed non-principals should expect a gross
fee considerably higher than that earned by employed non-principals. Such a
figure needs to take into account the loss of benefits of exclusion from the
NHS pension scheme (employer's contributions and inflation proofing of
premiums). Self-employed non-principals should recognise the value of their
unpaid availability and consider premium rates for work at short notice.
We remain optimistic that the Department of Health will allow self-employed
non-principals access to the NHS pension scheme in the near future.
If rates for self-employed non-principals become more realistic, this will only
help the current recruitment and retention problem for all GPs. Junior doctors
thinking about a career will know that it is a feasible, and indeed honourable
career option to become a GP (as opposed to becoming a principal in general
practice or a hospital doctor), and that they will earn reasonable pay whilst
finding their feet. They will know that they do not need to be pressurised into
taking the first partnership offer that comes along, and that their
professional status, security, and financial provision will be consolidated
whilst finding the right partnership.
In April 1997 Dr Ian Bogle, then Chairman of the GMSC, said £30 per hour
devalued GPs and he "would be surprised if any GPs worked for those kinds
of rates". The PPPFC and BMA Council have recommended principals charge
£108.50 (April 97-8 rate) per hour for private work.
In the light of such statements we need to ensure that non-principal work is
seen as an honourable part of GMS provision and that non-principals are
recognised as a vital, highly qualified, professional and flexible group of
independent GPs within the NHS.
Peter Harvey, NASGP East Norfolk Fees and
Superannuation Task Force.
Update from the
NASGP Webmaster May 1999
In case you hadn't noticed, the war has been won. The new revised BMA rates
of pay, now known as "Fees for Medical Cover in General Practice",
were published earlier this year, with a second increase in April in line with
the annual increase in Red Book fees. For details of the new rates and useful
background information pay a visit to the NASGP Rates web page. Oh, if you
should ever bump into Peter Harvey, shake him warmly by the hand.
Update from the NASGP Webmaster September
2002
In case you hadn't noticed, the war has been lost again. The Office of Fair
Trading decided in 1999 that the BMA's Fees Guidance Schedule may be
anti-competitive so told the BMA to cease publishing rates. Unfortunately the
BMA don't seem to have been able to change the OFT's mind. So locums and
practices are now left to calculate their own rates - or simply base them on
the DDRB's uplift for the last few years. See the
NASGP Rates web page
for more information.
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