Career Focus

Working as a deputy in general practice

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7112.2 (Published 04 October 1997) Cite this as: BMJ 1997;315:S2-7112
  1. Melvyn Jones, lecturer in general practice
  1. Royal Free Hospital School of Medicine, London NW3 2PF

    Melvyn Jones explains what it is like to work for a general practitioner deputising service


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    Deputising is often criticised,1 and most hospital messes are familiar with the euphemismÑ “ the dangerous doctor service.” But what is it like to work as a deputy and is the reputation justified?

    The prime reason for doing the job is probably to earn money, and as a night and weekend service deputising lends itself to moonlighting. The ability to pick a sessionÑusually at relatively short noticeÑmeans that extra work does not always take up a whole weekend as a hospital locum post can do. The posts are self employed, so reasonable expenses, such as milage, are tax deductible. Some GP principals do sessions to offset the costs of providing cover for their own practice.

    What does the work entail?

    The work is very like other out of hours work in general practice, except that the deputy usually consults in the patient's home and there is little continuity. Some companies have experimented with base surgeries and telephone advice with mixed success.2 Deputies are driven to the patient's house and supplied with basic details. There is, however, no record of previous contacts or history.

    Clinical difficulties may arise when patients try to manipulate the service to get second opinions or treatments, such as antibiotics, hypnotics, and controlled drugs. Some patients may be hostile, usually as a result of delays, but also because they are dissatisfied with their usual doctor or other NHS services. Some patients use emotive terms, such as meningitis or chest pain, to ensure a prompt visit.

    Most deputies manage two to three consultations an hour. During daytime at weekends and during the early evening shifts the calls are usually not urgent or serious, but as the night progresses deputies may see people who are more acutely ill. Medical emergencies should be directed to ambulance services, but some slip through. A drug bag is supplied, consisting of a range of oral medications, such as analgesics, antibiotics, anti-inflammatory drugs, which are usually new drugs being promoted, and some parenteral medication. Deputies usually provide their own diagnostic equipment. The cars usually carry oxygen, but are not equipment for medical emergencies.

    Ongoing psychiatric and chronic medical conditions pose the biggest problem. Calls often arise as support has broken downÑfor example, from social services. Frequently the only solution is to refer patients to hospital. Having wrestled with these problems, the deputy then may face hostility from hospital colleagues.

    The difficulty of maintaining clinical standards together with the low professional esteem in which deputising is sometimes held can be demoralising.

    Personal safety is a constant concern, particularly in inner city tower blocks where deputies may be separated from their driver for 20 or 30 minutes. Some companies have a policy that the car should not be left unattended, but insist that the driver accompanies the deputy or insists that a relative meets the car. Attacks on deputies are rare but have been documented.3

    Advantages

    Flexible hours allow work around other commitments

    Ability to moonlight

    Safety net income (post training,preretirement)

    Better pay than hospital locums

    Driving licence not required

    Self employed state, although salaried posts are available

    Disadvantages

    Little ability to control working style or environment

    No employment rights

    Feeling of vulnerability and professional isolation

    Antisocial working hours

    Pay often less than with cooperatives

    Pay

    The BMA recommends £104.50 for a six hour session before 10 pm (£17.41 an hour) and £139.50 afterwards. This compares poorly with the normal GP locum surgery hourly rate of £28.50-£31.50 and cooperative sessions, but compares reasonably well with the pay of junior hospital locums. Increasingly, this recommendation is not being honoured. It is worth checking rates of pay and any deductionsÑfor example, insuranceÑbefore agreeing to do sessions. There is usually no entitlement to annual leave, sick pay, or pension rights.

    Some companies offer long term salaried posts at about £48 000 a year. This will probably be for a 48 hour week and “ difficult to fill” shifts.

    Commercial deputising services

    Healthcall is the largest commercial deputising company. It is a public listed company, which has been in business since 1957. The BMA has had an arrangement with Healthcall since 1964. The association provides professional monitoring and receives a payment (reported to be 0.5% of turnover, worth £180 000 in 1993. 4BMA members also receive a discount for using the service. In return Healthcall can use the BMA's name and logo.

    This relationship has been criticised for not allowing active dialogue on quality standards, but the BMA maintains that its role is not restricted by the financial relationship. The association claims to be able to represent all deputising doctors and to negotiate on behalf of the whole profession at a national level about out of hours primary care. But the BMA's annual meeting recently resolved that the association should not renew any existing contracts with deputising services because of the potential conflict of interest. 5

    Standards and requirements

    Since 1984 deputies have had to possess the certificate of the Joint Committee on Postgraduate Training for General Practice or equivalent experience. Unlike many cooperatives there is, however, no requirement to be on a health authority's list. About 80-85% of deputies are GP principals; the remainder are non-principals, who tend to work more hours and do more of the night work. 6

    Effect of cooperatives

    The cooperatives have inevitably had an effect, but increasingly they are choosing to collaborate with deputising services, particularly over unpopular shifts. The positive effect of competition has meant the welcome arrival of minimum sessional payments for deputies and telephone advice services. The other benefit is that some cooperatives have started to employ non-principals, which opens up other employment opportunities.

    Deputising generates extra income, but it is professionally challenging, means working antisocial hours, does not pay competitive rates, and carries some risk to personal safety.

    More information

    National Association of Non Principals: PO Box 188, West Sussex PO19 2ZA Faxback 01243 536428. Website and email http://www.docnet.org.uk/nanp

    Joint Committee on Postgraduate Training for General Practice: Many GPs have failed to register their qualifications or experience as a GP. It is important for those who are not working as GP principals to do so. Acquired rights can be obtained by writing to the joint committee at the Royal College of General Practitioners at 14 Prince's Gate, London SW7 1PU.

    Overseas Doctors Association: 28-32 Princes Street, Manchester M1 4LB (0161 236 5594/580 7642).

    Regional postgraduate deans are making special allowances for continuing medical education for non-principals. Contact your local GP tutor of the National Association of GP Tutors: 0161 723 2145.

    There are specific initiatives to locate non-principals, such as the “ lost doctors” scheme. Oxfordshire region: tel 01865 226723; North Thames: fax 0171 278 0772.

    To find work

    Healthcall: Head officeÑMilton Keynes 01908 691919.

    Nestor Medical Duty Services: The second largest deputising service, which is based mainly in the north west and the midlands. There are a small number of salaried posts and there are vacancies in Birmingham, Liverpool, St Helens, Manchester, and Stoke.

    Contact Dr Gerry Coleman(medical director for Birmingham)to find out about local services: 0121 681 7800.

    Medi Call: North London within North Circular Road. Contact Mr Roach on 0181 354 3636. They use only GP principals for advice sessions, but non-principals are welcome for visiting sessions.

    National Association of GP Co-operatives: Secretary, Dr Mark Reynolds 01622 790717.

    Disclaimer: The comments in this article do not apply to any one service.

    References

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