fbpx

Working as a salaried GP

Of all the correspondence we receive from members, the majority is from dissatisfied salaried GPs.

It's not that they don't like the job or the patients or the staff - it's often because, they feel they're being (for want of a better word) exploited by their employer. We're not suggesting here for one minute that their employer is necessarily wicked or greedy or nasty; it often transpires that they've just not necessarily prioritised the welfare of their salaried GP colleague; a conspiracy of ignorance, perhaps. After all, general practice isn't renowned for the cutting-edge management of its personnel.

Then again, us sessional GPs aren't necessarily renowned for our negotiating skills or for being assertive with our comrades, and the completely flat clinical hierarchy that is so important for being an independent professional licensed to practise independently can be at severe odds if the employee vs employer relationship isn't handled sensitively . So it's a wonder then that any of us ever end up with the ideal employment contract.

And that's why the NASGP is now advising any GP taking up a salaried GP post - and every practice who's employing a salaried GP - to use the Model Terms and Conditions of Service for a Salaried GP that were negotiated and ratified by the NHS Confederation and the BMA. This contract is the bare minimum within which any salaried GP should be employed, and so we advise that if you're a GP looking for a salaried post you must insist on it.

 Salaried GP FAQs

General

Salaried GPs

As an employee, probably not; it's not usual practise in any employment to charge for mileage to and from work. However, there may be an allowance in your contract for use of your car for visits, or if your practice requires you to travel to certain meetings to represent the practice.

Locum GPs

If you're a locum GP then you can charge for mileage to and from your place of work and for visits too if you want to - some locums do, some don't. When you charge for mileage, it's not just the fuel you're charging for - think of the tax, insurance, oil, servicing bills, wear-and-tear, tyres and the time taken to physically get there etc. What you [successfully] charge is entirely up to your negotiations with your employing practice.

A decision on whether or not to charge depends on how much it's actually costing you vs both the hassle of working it all out plus the 'perceived pettiness' by the practices that may ultimately lead them to booking someone else.

See also

Locum GP claims will depend on the pattern of their work. If they are ‘itinerant workers’ – so that they work at different places from day-to-day with no discernible pattern, then it should be possible to argue that the main place of work is home – the base from which the business is run. This should make all journeys to surgeries allowable.

If however there is a pattern claims will be restricted. For example:

  • Dr L is a freelance locum. He has a number of regular jobs. He covers at surgery A on Mondays, does 2 days a week at surgery B and the 4th and 5th days are totally variable. It is likely that surgery A and surgery B become ‘workplaces’ so that home to each of those premises will be a personal journey. The 4th and 5th days should fall within the itinerant rules so that home to surgery will be deductible.

Sometimes the pattern will not be obvious in advance. A short spell of locum work may develop into something more regular (at this stage there is a risk that the locum is no longer freelance in respect of that placement and may need to become salaried, but that is beyond the scope of this article).

Recently we have seen examples of HMRC asking to see locum mileage logs and refusing claims without them. So please try to keep a mileage log of all practice related journeys. It is much easier to take out what turns out not to be deductible, than to try to recreate information that wasn’t retained in the first place.

A mileage log can be a notebook kept in the car; a spreadsheet or a phone app that calculates journeys that you can annotate.

What if you have not kept a log?

For home to GP surgeries, it is easy enough to ‘google’ journeys to find the mileage. Visits are much harder if you haven’t retained records. Some surgeries’ computer systems can produce a printout of visits by doctor, from which you can then work out the mileage. This might work for salaried doctors, but the practices are likely to be less enthusiastic hunting out the information for irregular locums.

Don’t forget to include other travel in the course of work – such as for training courses. If they are not local, that can be a noticeable amount. Salaried doctors will not be able to claim it themselves; they will need to try to get reimbursement from the practice.

If the pattern of work has not changed then a sample period might be sufficient but this is only likely to work for salaried doctors’ visits – and if HMRC want to do it by the book, it still may not be enough. Locum work is unlikely to ever be settled enough for a sample period of mileage log to be representative – so doctors in that position need to get into the habit of keeping a regular log.

Self-employed doctors may usually claim a mileage rate similar to salaried GPs, but if their turnover exceeds £81k (for 2014-15) they should claim a proportion of total car running costs.

Salaried GPs may claim for journeys undertaken wholly in the performance of their duties. Where the practice reimburses a doctor for visits (pretty rare!), then salaried GP mileage reimbursements up to 45p per mile (assuming less than 10k miles pa) are tax free. Payments in excess of that (sometimes seen in payments by hospital trusts) will be treated as taxable benefits and should be shown on form P11d at the end of the year, and must be recorded on the employment pages of the tax return.

If the practice reimburses less than 45p per mile, the difference can be claimed as an expense of employment. If there is no reimbursement at all, the then full 45p per mile can be claimed as an expense of employment. Where miles exceed 10k p.a. then the reimbursement rate drops to 25p.

The above rates relate to car travel; motorcycles can be reimbursed/claimed at 24p; cycles at 20p.

Allowable journeys for salaried doctors would include patient visits, meetings (necessary ones as part of the employment), and travel between different sites, but see the caveat below.

Home to work journeys are not allowable.

Additional mileage may be claimed in restricted circumstances such as:

  • Dr D is employed by multi-site practice A to work at surgery X. If Dr D is asked to work at surgery Y for a limited time (perhaps to cover a maternity leave), then temporary travel from home to another place of work for an intended period of less than 2 years will be treated as allowable.

Note on the other hand that if Dr E was employed on a temporary basis for the maternity leave mentioned above, home to work mileage would not be allowed because surgery Y would be his main (and indeed only) workplace.

Travel between sites cannot be claimed in the following circumstance:

  • Dr D is still employed by practice A at surgery X. He lives close to surgery Y and pops in each day on his way to work to pick up post. This does not make the journey between the two surgeries a business journey.
  • Dr D is still employed by practice A. He works Mondays and Tuesday at surgery X and Wednesday and Thursday at surgery Y. These are two separate places of employment and travel between them or from home to work for either of them is not deductible.

Claiming for GP travel expenses

Salaried GPs may claim for journeys undertaken wholly in the performance of their duties. Where the practice reimburses a doctor for visits (pretty rare!), then salaried GP mileage reimbursements up to 45p per mile (assuming less than 10k miles pa) are tax free. Payments in excess of that (sometimes seen in payments by hospital trusts) will be treated as taxable benefits and should be shown on form P11d at the end of the year, and must be recorded on the employment pages of the tax return.

If the practice reimburses less than 45p per mile, the difference can be claimed as an expense of employment. If there is no reimbursement at all, the then full 45p per mile can be claimed as an expense of employment. Where miles exceed 10k p.a. then the reimbursement rate drops to 25p.

The above rates relate to car travel; motorcycles can be reimbursed/claimed at 24p; cycles at 20p.

Allowable journeys for salaried doctors would include patient visits, meetings (necessary ones as part of the employment), and travel between different sites, but see the caveat below.

Home to work journeys are not allowable.

Additional mileage may be claimed in restricted circumstances such as:

  • Dr D is employed by multi-site practice A to work at surgery X. If Dr D is asked to work at surgery Y for a limited time (perhaps to cover a maternity leave), then temporary travel from home to another place of work for an intended period of less than 2 years will be treated as allowable.

Note on the other hand that if Dr E was employed on a temporary basis for the maternity leave mentioned above, home to work mileage would not be allowed because surgery Y would be his main (and indeed only) workplace.

Travel between sites cannot be claimed in the following circumstance:

  • Dr D is still employed by practice A at surgery X. He lives close to surgery Y and pops in each day on his way to work to pick up post. This does not make the journey between the two surgeries a business journey.
  • Dr D is still employed by practice A. He works Mondays and Tuesday at surgery X and Wednesday and Thursday at surgery Y. These are two separate places of employment and travel between them or from home to work for either of them is not deductible.

A recently retired partner was becoming a salaried GP, and wrote in for some advice.

Is a ten minute appointment time the standard, or can one negotiate longer?

  • 15 minutes is standard in some places - you can certainly negotiate longer. Whatever consultation length you finally agree to, it must be one that lies within your personal competency and fits in with your professional boundaries.

Are any breaks allowed mid surgery?

  • Absolutely - it's entirely up to you what you finally accept as your contracted hours and breaks. If you settle for something that you're not going to be happy with, you won't last long there.

How long does one get to deal with admin after the surgery (referrals phone calls etc)?

  • Again, it's up to you to agree how much time you need to feel comfortable performing this work in the allotted time, within your professional boundaries.

How long should one be allowed for a visit?

  • There are no fixed rules here; if you're having to rush a visit, you'll put yourself at risk. It's up to you whether the terms fit your own safe working standards and are within your professional boundaries, only accepting what you know to be safe.

If one did a full day of two sessions, would one get a lunch break built in?

  • You are entitled to at least twenty uninterrupted minutes, although we recommend at least thirty minutes. It can be paid or unpaid, which is down to you to negotiate. If you don't take a break, your performance in the afternoon would be equivalent to having drunk a few glasses of wine - it's always in an employer's interests to ensure all staff have at least 30 minutes for lunch, and a good employer will insist on it.

If one is expected to deal with path results and referral letters just for patients seen during sessions, what time should be allowed?

  • Depends on you, and a sensible employer should be realistic about the time you'll require. Some GPs are comfortable to skip through these sorts of tasks quite quickly, others prefer a lot longer. Our experience is that a lot of salaried GPs end up being dissatisfied with their post because of mounting paperwork, and the longer you remain in post, the more the paperwork becomes, so be realistic about the time you need.
  • Our rule of thumb is that, on average, practice-based GP consultations generate five minutes of paperwork on the day, and a further five minutes over the following months. Double this if it was for a visit. So if you're seeing 18 patients in surgery in the morning and 12 in the afternoon, it would not be unusual to within a few months be working an extra five hours on top of the scheduled 5 hours you were actually contracted to work.

Salaried GP

  • This will be stated in the written contract. The private fee can either be entirely subsumed within the normal, regular work of the salaried GP, or there could be a provision for private work to be undertaken over and above the their usual work, stating how much of the fee they receive (bearing in mind the practice's overheads.

Locum GPs

For locum GPs, there is no issue as to whether or not a freelance GP can perform private work in a GP practice.

The practice and locum will need to agree beforehand whether their normal clinical caseload will contain private as well as NHS patients, with adequate time given for the private work in line with what other GPs in the practice would expect.

The practice and locum will also need to agree between them whether private work is charged at the same rate as NHS work.

NB you can now set your T&Cs online in NASGP's LocumDeck.

If you're doing any sort of locum work as part of your portfolio career, you'll definitely need your own personalised Terms and Conditions to help protect both you and the practice you're working for. NASGP's model T&Cs has been specifically developed for us by a specialist employment law firm, and allows you to not only fully adopt all its recommendations, but also to add any necessary clauses, and tailor it to suit your personal needs.

LocumDeck's T&Cs generator allows you to

  • Set your own cancellation sliding scale from 0 to 100% of your booked fee for 0 to 28 days in advance.
  • Include your 14.38% employer's pension contributions
  • Legal employment status
  • Tax status, IR35 etc
  • Duties (on-call, triage etc)
  • Private fees (HGV medical etc)
  • Cremation fees
  • Payment terms (14 days? 28 days?)
  • Plus much more.

As an NASGP member, go to your T&Cs generator, choose your settings and then save. You'll then be given a unique link "View my TCs" which will automatically be added to your automated invoices and session request emails, or you can paste the link into your own website.

As an added bonus, you can update your T&Cs as often as you like, with each change being saved in an archive accessible by your practices for extra confidence.

In our experience, if private patients are seen within the usual agreed hours then the locum would not expect to be paid any extra. But if seen outside the usual agreed hours, the locum would expect to be paid the full private fee, with any practice overheads being offset by the additional service being offered by the locum. It makes the paperwork easier too.

 

 

CCGs, GMS and PMS practices employing GPs have to use the BMA Salaried GP Model Contract (it's been illegal to otherwise do so since 1st April 2004, with PMS practices coming on board in 2015). NHS Professionals partly administer the scheme, and can turn down a practices/PCTs application if the model contract is not being used.

Although PMS practices don't have to offer the BMA Salaried GP Model Contract, don't forget that you DO NOT have to sign anything that you're not happy with.

NASGP advice remains that a salaried GP should never accept anything less than the BMA Salaried GP Model Contract.

Because amongst other things it includes:

  • An entitlement to one session of CPD per week for full time (and pro rata for part time)
  • Paid time for practice meetings
  • Whitley council pay for sick and maternity pay
  • Recognition of all previous NHS work experience as "continuous" for the purpose of these entitlements

But beware:

  • Some employers are refusing to recognise previous NHS service as continuous so you must ensure that the contract you sign has an agreed date from which you are considered to have started in the NHS (usually when you started working unless you have taken large breaks)
  • Ensure that you agree some form of annual pay rise, including seniority, as there is no provision for this in the contract and the current recommended pay range does not include a "ladder" which you can climb up automatically (unlike salaried hospital doctors).
  • Check any amendments suggested by your employer with your local BMA Industrial Relations Officer.

Training

basic life support

In its framework for appraisal and data to Responsible Officers, NHS England says that evidence of annual BLS training should be expected from GPs. This is apparently a nationally agreed item that will be flagged to the responsible officer if it is absent, but confusingly, is “not necessarily directly relevant to the doctor’s revalidation recommendation.” So our interpretation is that we all need to get BLS training annually.

Here at NASGP we've tried a few accredited online training modules, and our favourite is the one from Blue Stream Academy. We've got an exclusive offer for NASGP members for a 20% discount of not just this, but over 60 other online practice-based modules, including BLS, child and adult safeguarding too.

NASGP member login for 20% discount

 

This is something that more of us are being asked to provide proof of by practice managers. It's generally not something that's expected as part of our NHS appraisal evidence, but is something that the CQC are asking practices for proof of.

In 2011 the Dept of Health and the Information Commissioner's Office wrote to all NHS staff:

All NHS organisations (and others with access to NHS patient information) should:

ensure all staff undertake appropriate information governance training annually as identified in the NHS Information Governance Toolkit.

If you're a partner or a salaried GP, or work with a hospital or CCG etc, it's likely that you already undertake annual online training with Health and Social Care Information Centre HSCIC, and can just provide evidence of that.

If you're a locum, and are being asked for this

  • speak to a friendly local practice, or insist* on your CCG adding you to their IG training account with HSCIC.
  • and work for an agency, they will probably organise this for you.
  • and in a chambers or sessional GP group, you may be able to organise this as a talk (from your CCG's IG lead?).

If you're not being asked for this

  • If you personally feel it's a learning requirement, discuss it with your appraiser at your next appraisal.

*seriously, if it's so important that you're being required to do it, your CCG needs to put its money where its mouth is and support its GPs.

 

 

 

Whilst the CQC will certainly be interested to ensure that practices and staff know how to recognise and respond to vulnerable adults, the safeguarding adults training requirements for GPs in this area, and for now, the appraisal requirements, are less clearly defined than they currently are for safeguarding children and young people.

So what adult safeguarding training should I be doing?

In the absence of current clear guidance, you could consider translating the level 3 competencies required for child safeguarding across to safeguarding adults:

Translation of level 3 competencies to safeguarding adults

Knowledge

  • Aware of national guidance, professional duties of care
  • Aware of local adult safeguarding board arrangements
    • e.g. make it one of your appraisal supporting evidence items to study and reflect on local pathways and document this for your appraisal.
  • Importance of information sharing and confidentiality

Clinical knowledge

Skills

  • Able to contribute to, and make considered judgements about how to act to safeguard/protect a vulnerable adult.
  • Able to present safeguarding concerns verbally and in writing for professional and legal purposes as required (and as appropriate to role, including case conferences, court proceedings etc)

Other learning options

 

Safeguarding children

We all know why childhood safeguarding training is so necessary for safeguarding children: after every high profile case of child neglect and abuse over recent years, the same failures and lapses emerge; poor communication and information-sharing between professionals and agencies, inadequate training and support for staff, and a failure to listen to children. So no-one begrudges getting skilled up in this key area.

How should we get safeguarding children training, and what evidence will appraisers and practices want to see?

Thankfully, there is clear guidance in Safeguarding children and young people: roles and competences for health care staff, an Intercollegiate document from March 2014. GPs require level 3 competence. Highlighted quotes relevant to GPs from its 102 pages include:

  • Over a three-year period, professionals should receive refresher safeguarding children training equivalent to a minimum of 6 hours (for those at Level 3 core this equates to a minimum of 2 hours per annum).
  • Training in safeguarding children at level 3 will include the training required at level 1 and 2 and will negate the need to undertake refresher training at levels 1 and 2 in addition to level 3.
  • Training, education and learning opportunities should be multi-disciplinary and inter-agency, and delivered internally and externally. It should include personal reflection and scenario-based discussion, drawing on case studies, serious case reviews, lessons from research and audit, as well as communicating with children about what is happening.
  • Educational sessions could be a combination of e-learning, personal reflection and discussion in clinical meetings or attendance at internal or external outside training courses.
  • Safeguarding children training can be tailored by organisations to be delivered annually or once every 3 years and encompass a blended learning approach.

What does the CQC say?

In addition to appraisal requirements, the CQC also take a view on this:

  • The CQC reference the statutory guidance ‘Working Together to Safeguard Children’ which helps professionals understand what they need to do, and what they can expect of one another, to safeguard children. It focuses on core legal requirements and makes it clear what individuals and organisations should do to keep children safe.
  • "GPs in particular have a responsibility to ensure that all staff across their organisations have the knowledge and skills to be able to meet this requirement."

Appraisal and revalidation requirements

Note that this intercollegiate guidance is talking about minimum requirements, and there may well be variation in how appraisers in different areas apply this. Indeed, it seems that some local area teams are piloting adding Safeguarding as an item in supporting information for appraisal, which may one day become nationally agreed.

Take home messages for GPs from this guidance

  • Aim for minimum of 6 hours of refresher level 3 training over 3 years (or minimum 2 hours per year).
  • Training and education can be a combination of various forms e.g. training courses, e-learning, personal reflections on cases or having read guidelines.
  • Submit this evidence to your appraiser every year, and if working across different practices who ask for evidence from you that you satisfy the CQC's requirements, provide a signed letter from you stating that you submit this and any other relevant evidence in your annual NHS appraisal.
  • Ensure that the employing practice undertakes its responsibilities too by ensuring you have access to all its safeguarding information, ideally by giving you access to its Standardised Practice Information Portal.

So check with your appraiser. This guidance may be a useful reference if your appraiser’s requirements seem overly onerous or prescriptive.

See also

https://www.nasgp.org.uk/child-safeguarding-how-to-spot-the-signs/

Paperwork and compliance

As a freelance GP you'll need to hold all sorts of information - names and addresses of practices; other GPs; colleagues; educational centres etc.

And what do you do with this data - do you market yourself? Is it just for invoices? Do you give your data to other GPs or practices?

It is possible that, as a small business, you may have to register with the Data Protection Act.

Whether you need to all depends on what you use your data for and, needless to say, isn't straight forward. Fortunately, the Information Commissioner's Office website has a series of simple questions to ask and, depending on your answers, will tell you whether you need to register or not (and what can happen if you don't!).

As a GP working, or planning to work, in the UK, you need to go through a three-stage process.

Step 1 - join the GMC's GP register

  • If you are applying to work as a GP (general practitioner or family physician) in the UK, as well as being licensed by the GMC, you'll also need to be on the GMC's GP Register.
  • About the GMC GP register

Step 2 - join one of the four UK Performers Lists

  • If you you're not already working, state your “intent to work” on your performers list application, outlining roughly how many sessions a week you plan to work from a particular date.

Wales

England

Northern Ireland

Scotland

Step 3 - join the NHS appraisal process

  • Your Area Team will assign you to a 'designated body', who'll oversee your appraisal and subsequent revalidation.

Hepatitis B immunisationIt's now a requirement of the Care Quality Commission CQC that every member of staff working in a GP practice has an up-to-date Hepatitis B status. The MPS have prepared a summary of why this is needed, as part of the CQC's Cleanliness and infection control (Outcome 8, Regulation 12) "People are cared for in a clean environment, and are protected from acquiring infections".

If you're a chambers locum or are employed as an agency locum, they'll no doubt otherwise notify every practice on your behalf. Otherwise it's a sign of a well organised locum to provide this in advance of working.

If you're employed by a practice as a salaried GP, you'll be entitled to free immunisation status checks and boosters if they're a good employer. As a locum, unless you can persuade a friendly practice, you'll have to arrange this yourself with your own GP as a private service.

Added to this, the Green Book states:

Healthcare workers in the UK and overseas (including students and trainees): all healthcare workers who may have direct contact with patients’ blood, blood-stained body fluids or tissues, require vaccination. This includes any staff who are at risk of injury from blood contaminated sharp instruments, or of being deliberately injured or bitten by patients.

As a GP, if you're exposed to continuing risk of infection, you should have a single booster dose of vaccine, once only, around five years after primary immunisation. Measurement of anti-HBs levels is not required either before or after this dose.

Read this FAQ to find out

  • How often you need a Disclosure and Barring Service DBS check
  • Where and how to get one
  • How it works if you work for a locum agency
  • And what the CQC say about it
Read the FAQ

Practising as a GP

To receive a BNF book:

  • NASGP work with NHS England to help as many NASGP locum members in England receive one every September (not April), so please make sure that you've updated your NASGP membership with your country, GMC number and GP status. Salaried GPs should organise distribution through their practice; if you're a locum and salaried/partner, you'll receive a BNF via your practice - NHS England will only send you one if you're not otherwise listed as a partner or salaried GP. We can't guarantee that NHS England will provide one, as they have ultimate control over distribution and distribution is dependent on available supplies.
  • In Scotland, the Local Health Boards (or equivalent) distribute the BNF so please contact them.
  • If you live in Wales or Northern Ireland, your local Health Authority still has responsibility so you need to send your contact details to the chief executive of your Health Authority.

There is the online eBNF, or the BNF smartphone/tablet apps.

If I didn't receive my BNF?

  • NASGP acts as a third party by sending your details to the DH once a year, and they then cross-check our list against their own. If they see you on a different list e.g. on a previous practice (partner or salaried) they'll send it to that practice instead. If Binleys run out of BNFs, then they won't send any at all. We suggest check with your old practice (if you had one within the last 18 months), or if not contact Binleys direct.
  • NASGP submits its list in July ready for the September BNF mailing of that year. If you join the NASGP between those dates that we won't be able to submit your information until the following year.
  • NASGP can not supply BNFs if Binleys have run out, and does not guarantee that you will receive a copy. Please direct all queries about non-supply to Binleys.

Employers have a legal obligation to provide a working environment that enables their employees to work safely and to the best of their ability. Which should mean that they provide all the equipment you need, in working order.

The real world isn’t like that. It can be very hard to unearth the piece of equipment, and, when you find it, it may be broken or out of date. And even if it is working, it may be a model you aren’t familiar with. And nothing wastes time and reduces a patient’s confidence in you more than watching you hunt through drawers or fiddling with a device that you clearly don’t know how to use.

The solution is to take your own equipment. Then you you know where it is and you know it is working order (don’t you?).

But equipment can be expensive, and there is a limit to what you can carry, especially if you are on a bike. So here is a list of items contributed by locums. The nearer the top, the more people carry the item. Have a look and consider what, in your circumstances, you would not want to be without.

And if you have pet pieces of equipment you wouldn’t be without, let NASGP know and we will add them to the list.

  • stethoscope
  • sphygmomanometer (serviced regularly)
  • diagnostic set (with spare batteries)
  • patella hammer
  • tuning fork
  • thermometer
  • tongue depressors
  • peak flow meter plus mouthpieces
  • tape measure
  • obstetric wheel
  • gloves
  • lubricating jelly
  • pulse oximeter
  • dip sticks (in date)
  • glucometer (plus in-date test strips)
  • BNF (paper or electronic version)
  • favourite reference books (paper or electronic version)
  • pregnancy tests
  • vaginal speculum
  • Pinard stethoscope
  • adrenaline and means of administering it