Where a GP is absent from the practice due to sickness, practices can claim reimbursement in relation to the cost of covering their sessions.
Reimbursement for sickness cover for GPs was previously made on a discretionary basis, but following concerns at regional variations in payment it was made a mandatory scheme through amendments to the GP contract in 2017.1,2
The reimbursement is claimable for partners and salaried GPs. There are no exclusions in relation to claims for GPs with pre-existing health conditions.
In order to claim the reimbursement, the sessions should be covered by a GP. If the sessions are covered by an Advanced Nurse Practitioner or other healthcare professional then the NHS will not cover these costs.
Non-sickness absences such as jury service and compassionate leave are not covered by the reimbursement.
If the sessions are covered by a GP already working at the practice, then the amount invoiced must be reasonable and in line with locum charges the practice would expect to pay if they hired an external locum.
For each period of sickness leave, practices are unable to claim reimbursement for the first two continuous weeks of absence.
After the first two weeks, practices are then able to claim a maximum amount of £1,751.52 per week for the following 26 weeks (weeks 3 to 28) and then a maximum of £875.76 per week for the following 26 weeks (weeks 29 to 54).
So, once a GP has been off for 28 weeks the maximum amount that can be claimed for the next 26 weeks is half of the amount received for weeks 3 to 28, even if costs are being incurred in excess of this.
Any claim for locum cover for sickness in the previous 12 months will be counted toward the total 52-week claim period. In other words, if a GP has more than one episode of sickness absence in a year, the time off is aggregated and the maximum amount reimbursed for the first 26 weeks of the total aggregated time.
For example, if a practice claimed for 12 weeks of cover, the GP returned for three months and then went off sick again for 20 weeks: the first 12-week period would be covered to the higher rate, then the first 14 weeks of the second absence would be paid at the higher rate (totalling 26 weeks at the higher rate), and the last six weeks would be paid at the lower rate.
If a GP has a phased return to work, with a fit note stating that they are only able to work some of the sessions that they would normally work, then practices are still able to claim locum reimbursement for the sessions that the GP is unable to work.
So, for example, if a GP partner is absent from 3 April to 26 April, after the two-week qualification period the practice is entitled to reimbursement for the lower of actual invoiced costs or weekly maximum for the period 17 to 26 April. If after 26 April the GP partner returns to work, but with a fit note stating that he or she can work three of their regular six weekly sessions for the first four weeks, the practice is entitled to reimbursement for three sessions per week for those four weeks.
If a salaried GP returns to work on a phased return basis, reimbursement is mandatory where practices have met their statutory sick pay requirements; otherwise the allowance is discretionary.
To make the claim practices need to complete the relevant claim form and submit copies of the corresponding invoices to NHS England. If this is not done it may delay the reimbursements being received by the practice. The claim should be made within 14 days of the month end that the reimbursement is being claimed for.
In exceptional circumstances top-up payments may be made above the agreed weekly maximum. Reasons for this may include:
In these circumstances practices should always ensure that they have written confirmation of the agreed additional funding before arranging the cover.
The introduction of locum allowances for sickness absence should have reduced the practice’s requirement for separate sickness insurance policies. However, practices should carefully check that the reimbursement claimable from the NHS covers the expected cost of locum cover in their area. They may wish to consider taking out a ‘top up’ sickness insurance policy to cover any potential shortfalls.
As with locum allowances for parental leave, practices are continuing to face issues with making the claim as in some cases NHS England are still treating the reimbursement as discretionary rather than mandatory and are refusing to make the payments. Some CCGs are also using outdated list size criteria when assessing whether payment should be made.
Other practices are facing issues where they have a sickness insurance policy in place, with CCGs using the insurance as a reason to refuse reimbursements.
If practices have problems with making claims they should raise the issue with their LMC for further guidance. Note that where practices have a separate sickness insurance policy they are only able to claim the difference between the actual cost and the NHS reimbursement. They do not receive the reimbursement twice.
There can often be time differences between the practice paying for the sickness cover and the reimbursement coming through from the NHS. Practices should prepare for the effect that this may have on their cashflow.
Colin Haw is healthcare partner at BHP LLP, a member of the Association of Independent Specialist Medical Accountants
1. NHS, England. General Medical Services Statement of Financial Entitlements (Amendment) Directions 2017. Part 5; 14: Amendment of Section 16 of the principal Directions
2. NHS England. Protocol in respect of locum cover or GP performer payments for parental and sickness leave. April 207. https://www.england.nhs.uk/wp-content/uploads/2017/05/protocol-in-respect-of-locum-cover-payments-17-18.pdf
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