See the excellent article on retainers published July 2001 in BMJ Classified...click here for the PDF file (external link)

THE AIMS of the doctors retainer scheme are to keep doctors within the workforce whilst they take a career break and to keep these doctors up to date with aspects of medical practice. There are currently about 600 doctors on the scheme, mainly in General Practice ^{Note 1}.

The current scheme helps doctors under the age of 55 to remain in touch with medicine so that they can return to a fuller commitment of work within the NHS when their circumstances permit. It gives them the opportunity:

• To undertake specially arranged clinical work of not less than 1 half day per month, and not more than 1 day per week (or any other clinical work);
• To attend postgraduate medical education sessions (minimum of 7 education sessions (one session equals 3 hours) per annum).

Members of the scheme must:

• Have a ‘right to practise’ (ie have a JCPTGP certificate, be exempt or have an acquired right. See chapter on vocational training and certification);
• Maintain registration with the GMC;
• Maintain membership of a medical defence organisation (or other suitable insurance);
• Take a recognised professional journal.

Ideally, members should:

• Have a short weekly “tutorial”/discussion with an educational supervisor within their practice;
• Meet the local GP tutor annually for a review of their progress, and planning of their learning needs for the forthcoming year.
• Obtain full PGEA points in the year prior to becoming a principal so that full PGEA can be earned in that year.

Poorly performing doctors/doctors who have been suspended from the GMC register are not permitted to join the retainer scheme.

Current Regulations

Payments to the Retainee

• An annual retainer (£290 in 1997/98)
• Payment as an assistant in an approved practice. The health authority makes payment as set out in the Statement of Fees and Allowances (Red Book) to GP’s employing a retainer scheme doctor (£44.10 per session in 97/8), but the terms of employment are a matter for agreement between the employing practice and the individual doctor. Though two sessions per week may be worked, the Health Authority will only reimburse towards one notional half day per week. If a retainer scheme doctor works one session per week for two different practices, both of which are in the same health authority, only one practice will be reimbursed. If the doctor works one session per week for two different practices which are in different health authority areas, both practices will be reimbursed. It is worth noting the current sessional reimbursement fee from the health authority does not now reflect current BMA suggested rates for locums.

Renewal of Membership of the scheme - the doctor
This should be made within 12 months of joining it and then reviewed annually. The rules on the maximum period that doctors can be part of the scheme vary by area. Directors of Postgraduate GP Education are able to consider cases individually. When a doctors’ circumstances enable them to take on extra work, they would be expected to leave the scheme. In some areas doctors would not be expected to continue as a retainee for longer than five years, others no longer than ten years.

Travelling expenses for educational sessions
Suitable education sessions should normally be available at a convenient distance from the member’s home. For courses that are approved under the Section 63 regulations, form ROGP1 should be completed and returned to the local health authority.

In some regions the Regional Director of Postgraduate GP Education will make small educational grants available to Retainer Scheme Doctors but this varies across the country. In the West Midlands members attending PGEA type approved courses/meetings may currently claim up to £200 per annum. Readers are advised to check local arrangements and to obtain approval before courses begin.

Taxation
Both the retainer and assistantship payments are taxable, normally under Schedule E. Admissible expenses may be claimed against tax, e.g. subscriptions to defence bodies and membership of the BMA. Both the BMA and the defence bodies give discounts to members of the retainer scheme.

Contracts of employment
The terms of employment are a matter for negotiation between the retainer doctor and the employing practice. All retainer scheme doctors are strongly advised to obtain a valid contract of employment with their employers. The BMA’s model contract for assistants can be used as the basis of the contract, but both sides can put in additions as they wish e.g. a doctor may wish to have all school holidays free and this could be written in to the contract. Retainer doctors should expect similar conditions of employment to all other practice employees with respect to paid holiday and sick leave. A contract also clarifies the employer’s obligations with respect to national insurance contributions etc.

Superannuation
Since September 1997 retainer scheme doctors have been able to join the NHS Pension Scheme. For further information on superannuation matters, contact to the NHS Pensions Agency (see chapter on Pensions).

National Insurance
If a person’s earnings are below the lower earnings limit (£62 per week in 1997/8) neither they nor their employer has to pay national insurance contributions. This has the effect of switching off entitlement to benefits for up to 3 years after the person has resumed paying Class 1 contributions. Class 3 (voluntary contributions) can be paid, but these only count towards entitlement towards a Retirement Pension. They do not count towards entitlement to sickness benefit or unemployment benefit. If a person is employed, but earns below the current earnings limit, they will not qualify for Statutory Maternity Pay or Maternity Allowance.

The assistantship payment as a retainer scheme doctor will normally be classified as employed pay and liable for Class 1 contributions by the employing practice. If because of other circumstances the classification for contributions purposes is in doubt, the local social security offices should be consulted.

The take home message is, ensure that you earn above the current lower earnings limit (and the best way for a retained doctor to do this is to work both sessions in the same practice). Earnings just above the lower earnings limit will incur the payment of Class 1 national insurance contributions which may be much lower than voluntary contributions and certainly entitle you to much more.

Doctors Wishing To Join The Retainer Scheme
You need to make contact with the local GP (or clinical) tutor (via the local postgraduate centre) who will be able to advise you on suitable practices in your area to join. In many regions only practices of training standard can have retainer scheme doctors. The retainer scheme doctors should have the opportunity of discussing their career progress and their personal learning plan with either their GP tutor or the practice based educational supervisor on an annual basis. The tutor should also be able to advise on the terms of the scheme, terms and conditions of employment. Tutors submit the potential retainer scheme doctor’s application form, with their comments as to the applicant’s suitability for the scheme, to the Director of Postgraduate General Practice Education.

Retainer Scheme doctors should ensure they are on the mailing list for their postgraduate centre so that they are kept informed of local Continuing Medical Education (CME) events which should be available free or at minimal cost.

Practice Approval Criteria
These vary from region to region. In the West Midlands region, where there is an Educational Facilitator for Non-Principals in post, it has recently been decided that any new practices wishing to appoint a retainer scheme doctor should reach the standard expected of a training practice.

Ideally, retainees should have regular meetings with one identified doctor - an educational supervisor/mentor who is familiar with the running of the practice. This doctor should set an example of enthusiasm, competence, good patient care and practice organisation. This doctor should demonstrate commitment to continuing medical education by having been on a recognised trainer’s course (or comparable course) within the last five years. He/she should demonstrate continuing commitment to training and education through having regular attendance at education centred events. He or she should be willing to help compile a video of their surgeries, should they wish to undertake the RCGP examination whilst on the retainer scheme and should be able to offer advice on courses to attend or other educational activities.

Retainers should expect to work in an efficient well organised working environment. For this there needs to be:

• good relationships and communications between all members;
• an induction programme for the retainer scheme doctor;
• good organisation, which should include ready availability of the doctors through a flexible appointments system, policies for home visiting and out of hours calls and a practice information leaflet for patients;
• adequate staff with assigned responsibilities, including nursing provision within the practice;
• a contract and job description for all employees, including the retainer doctor;
• training on practice management, finance and administration and opportunities to gain experience in GP computing and information technology;
• a written guide to the practice provided for the retainer;
• an annual report of the clinical, educational and organisational activities of the practice;
• premises: The retainer doctor must have an adequate consulting room for their surgeries;
• equipment: This should be comprehensive for a modern general practice. If the retainer doctor is to visit, a medical bag with all necessary equipment and drugs should be provided. The following should be provided for use in the surgery.
  • otoscope;
  • ophthalmoscope;
  • syphgmomanometer;
  • peak flow meter;
  • dictaphone.

Full records must be available for all patient contacts including home visits. The records:

• Must have continuation sheets, reports and letters fixed in date order;
• Must have long term drug therapy clearly discernible in the records, either by a separate card or some other justifiable system;
• Must have a summary of important events in every record.

The following criteria apply whether the records are in computerised or manual format:

• an age/sex register which is up to date and in use. Other disease registers and recall systems should be in use, such as those for identifying diabetic and epileptic patients, and calling and recalling those for identifying patients for immunisation and cervical cytology;
• an up-to-date practice library. It must contain recent reference text books and journals;
• appointment intervals that are normally not less than ten minutes.

Responsibilities of the parties involved (West Midlands Region’s guidelines)

The approved practice:

• provides one partner (or non-principal) identified as the mentor/educational supervisor for the retainer doctor, and protected time (at least 30 mins weekly) for discussion and teaching;
• notifies the health authority and GP Unit of the number of half days worked by the retainer scheme doctor per quarter, and of any changes in the retainer scheme doctor’s hours of work;
• is visited three yearly, unless approved as a training practice (If a practice has not had a retainer scheme doctor or GP Registrar for more than 3 years their approval lapses and they will need to be re-approved before taking on a new retainer scheme doctor);
• must arrange for a principal to be consulting at the same time as the retainee;
• try to ensure that an adequate case mix is seen by the retainee to maintain skill;
• ensure a system exists by which the retainee is passed all relevant clinical results and administrative information, particularly when changes are instituted.

The Educational Facilitator for Non-principals:

• is responsible for the overall running of the scheme in the region, answerable to the Director of PGGP education;
• answers telephone queries about the scheme to any interested parties;
• arranges refresher courses for retainer scheme doctors twice a year (June and December);
• encourages the development of local educational support groups for non-principals throughout the region;
• offers careers advice;
• updates the local booklet on the retainer scheme annually.

Regional Director of Post Graduate Education in General Practice:

• signs approval of a doctor’s form electing for the retainer scheme;
• notifies the practice and the health authority of a practice’s approval (if successful).

Health Authority:

• keeps up to date records of all doctors on the retainer scheme in their area;
• pays approved practices with a retainer scheme doctor in post (£44.70 1997/8) weekly or per session if the retainer scheme doctor is working less than one session a week;
• should supply all retainer scheme doctors working in their area with a new BNF, as supplied to principals.

Proposed Changes - a summary of the GMSC discussion paper on a new Retainer/Returner Scheme

The GMSC is, at the time of writing, discussing changes to the Retainer Scheme with the Department of Health. The increasing recruitment crisis has focused minds on the issue. These proposals build on the current scheme and indeed on many of the standards that have been developed by organisers of retainer schemes across the country. Incorporating a ‘return to work’ element, the proposals aim to maintain the education and skills of doctors who are unable, for well founded reasons to continue a substantial commitment to practice and to enable doctors to return to mainstream work. The significant proposals are:

• The scheme is principally educational but also seeks to promote career progression;
• Members should be supernumerary;
• There would be a time limit on participation;
• Members must give a commitment to return to work in general practice in due course;
• Practices would be approved, as training practices are;
• There should be protected time for discussion between members and a lead principal;
• The lead principal is responsible for errors and omissions;
• Members do not have restricted lists;
• The minimum number of sessions is one per week;
• The number of sessions be dictated by the length of time on the scheme and the individual’s needs;
• Practices will receive fixed costs of having a retainee/returner and an additional amount depending on the level of educational support given;
• Members will receive full reimbursement of necessary professional expenses;
• Non-vocationally trained doctors will not be eligible.

Retainers and membership of The Royal College of General Practitioners

The RCGP Treasurer Dr Tony Mathie has decided again to waive the annual subscription for those members or associate members of the College working as Retainers Scheme Doctors in 1997-8. Those retainers joining after a gap in membership will be asked to pay a nominal entrance fee of just £10. The NASGP applauds the RCGP’s decision and encourages retainers to join the RCGP.

Note 1: Much of this chapter has been prepared with the help of Dr Bitty Muller, Educational Facilitator for Non- Principals in the West Midlands Region. The West Midlands Regional GP Education Committee endorses a strategy to ensure that retainer scheme doctors are not marginalised and exploited whilst taking a career break, and that their skills and knowledge are valued and kept up to date. It is hoped that active support of retainer doctors will also have an impact on recruitment and retention of the doctor workforce in general practice in the West Midlands. Some of the details may not apply to all regions and doctors are advised to check with local arrangements. The future of the Retainer Scheme is being negotiated nationally at the time of writing and it is likely that there will be some changes in the near future - see proposals at the end of the chapter.