By Dr Shaun O'Connell

LOCUMS, DEPUTIES AND ASSISTANTS have been important components of the general practice workforce since the beginning of the NHS. The early 1990s saw the establishment of a new post, the Associate grade. The late 1990s will see the introduction of another group, salaried GPs. Many doctors participate in the Doctors’ Retainers Scheme, a popular but restrictive scheme, soon to be improved. Together all these doctors provide a vital flexible workforce without whom general practice could not operate.

General practice has undergone much change in the last eight years, particularly in the way principals work. An increased role in management coupled with increasing public demands and an explosion in clinical activity has ensured the old stereotype family GP is a distant, romantic memory. The change has left a generation of principals struggling to cope. All too often we see colleagues who are demoralised by under-funding, frustrated with bureaucracy, exhausted by patient demands and trapped by commitment. It is not surprising that many doctors decide to delay their entry into partnership, and others to get out early.

Many young doctors have different priorities to those of their predecessors, refusing to accept the pressurised life of a ’90s principal, not wanting to (or not able to) go from trainee to partner overnight and particularly not wanting to commit themselves and their families to one location for years. Some feel their training has not given them sufficient clinical or managerial experience and that further time with limited commitment is needed before choosing a partnership. Others put their family lives first, finding that partnerships are not sufficiently flexible to allow a quality mixture of both. Commonly, those who wish to return after having a family find their options are limited and the ability to be re-introduced, updated and supported, if only initially, is often lacking. These factors coupled with increasing demand for flexible work opportunities reflected throughout society seem to have led to an increase in the number of doctors working in general practice, but not as principals. In the absence of a better term these doctors have become collectively known as ‘non-principals’. It is ironic this has happened at a time when a serious crisis in recruitment and retention to training posts and principal posts is upon us. There is a message in this situation that politicians should not ignore.

The size of the increase is unknown as no national statistical data yet exists. It is estimated that there are some 7,500 non-principals. This represents about 20% of all General Practitioners. It is clear that the majority are women, most are locums and virtually all have lacked effective national representation.

In the mid-1990s the call for better representation grew louder culminating in the establishment of the National Association of Non-Principals in 1997. Up and down the country non-principal ‘support’ groups have been formed. Such local and national organisations have raised the profile of all non-principals.

The position of non-principals has been legitimised by the established organisations. The BMA’s General Medical Services Committee held its first non-principal conference in 1996 appointing a non-principal representative to the Committee. In 1997 it expanded this sole voice, permitting the setting up of a non-principal subcommittee with two of its members sitting on the parent committee. Many Local Medical Committees now co-opt non-principals to sit on or observe committees. Some health authorities have begun to help non-principals (and the patients they serve) with a range of local initiatives. The Royal College of General Practitioners has recognised the need to consider the needs of non-principals and the patients they treat. A number of research studies have been published and others continue, demonstrating that academics, at least, feel non-principals are worth knowing more about!

Being a non-principal enables doctors to concentrate on their generic clinical skills, almost unbound by practice paperwork, virtually uncommitted to specific locations and able to choose their working patterns depending on other commitments or preferences. Such freedom comes at a price. Non-principals are frequently disadvantaged by lack of patient continuity, professional isolation and with a widely perceived lower status. Financial reward for non-principals has always been lower than that for principals. Although this may be justified - less commitment, fewer overheads and responsibilities should attract a lower income but when looking at income we must compare like with like. Non-principals’ gross income is reduced by the additional costs they incur by being non-principals. For example, self-employed locums are currently considerably disadvantaged by the inability to contribute to the NHS pension scheme, and by the lack of any income whilst on sick, holiday, maternity or paternity leave. Many non-principals have to pay a greater proportion of their income than principals towards professional indemnity insurance, income protection insurance and general running costs. Most are not remunerated for time spent on postgraduate education and are not able to benefit from tax free property investments, private medical income or seniority payments that principals can.

The growth in the number of local groups across the United Kingdom reflects a reluctance to continue to suffer the disadvantages of being a non-principal. Some groups have formed simply to reduce professional isolation whilst others have set out to better working conditions in a more fundamental and far reaching way. The establishment of the National Association of Non- Principals (NASGP) has focused thoughts and activity for change. The writing of this Handbook is just one of the ways in which the NASGP is trying to create change. That the financial support for its writing has come from the NHS Executive demonstrates the increasing recognition of the importance of non-principals in general practice. The book contributes to the legitimisation of a group of doctors who have struggled to identify themselves.

I hope that this book will inform newcomers and be of use to ‘old hands’. It is not intended to be a detailed work but more of a guide that should aid readers and signpost them to other sources of information. I hope I have fulfilled that aim.

The book has been put together on a part time basis over just ten months, a short time scale but one in which there has been much change. The non-principal agenda is moving forward at a considerable pace and because of this it will inevitably be necessary for updates to be written as chapters become out of date. Volunteer writers, please don’t hesitate to submit updated chapters.

The book has been put together at a time when I expected to be a non-principal for some considerable time. In the event a partnership vacancy appeared sooner than anticipated and hence the book was started by a non-principal and finished by a principal. I hope my change in position has not significantly altered the text!

I encourage all non-principals to join local groups and to actively pursue local problems. Many are easily resolved. The National Association of Non-Principals needs enthusiastic and capable individuals to help its efforts to help you.

The inspiration for the book was Dr Richard Fieldhouse, founder of the NASGP. Its realisation is due to the encouragement of Professor Ruth Chambers and the enthusiasm of Mrs Marion Rogerson, Primary Care Lead, West Midlands NHS Executive. The reproduction of the book would not have been possible without the generous sponsorship of the Medical Defence Union. The NASGP and I are extremely grateful for their support.

Many of the ideas for this book have come from Adrian Midgley’s locum handbook, T(GP) 2 The Exeter Locum Handbook. I am indebted to Adrian Midgley for his help with many aspects of this handbook, for his permission to use many of his ideas and work, for his original work on computers, computerised prescribing and Read codes, and for his detailed proof reading. This book does not replace the T(GP) 2 The Exeter Locum Handbook which remains an excellent guide providing practical advice for those new to locuming.

Finally I must thank all those who have helped me with the compiling of the book. I am grateful to all those below, particularly those who contributed chapters and other large bits, who sent in details on local non-principal groups, who responded to draft chapters and those who did the proof reading. I am particularly grateful for the support of my wife, who missed many a weekend whilst I sat glued to the computer and who patiently listened to hours of detail, that she needed to know nothing about. She knows more about general practice than any other anaesthetist in the country! Feedback is encouraged (positive or negative). Please email me or write to me via the NASGP.

My thanks go to all those named below.

Shaun O’Connell
Tadcaster, North Yorkshire
April 1998

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