Locum workspaces

Locums and practices need to work together, but this doesn’t always happen. Dr Judith Harvey analyses the particular problems locums face in their working environment

“I want to see a real doctor” is a typical response to the all too common receptionist’s explanation: “I’m afraid Dr Jones is on holiday; it’s only a locum today”. This is not a great start to any locum’s consultation.

A locum can feel like an oily rag. In an emergency everybody needs one to keep the wheels turning, but then it is forgotten till the next breakdown. Practices don’t get the best out of their investment in locums. Locums may be sitting in a partner’s chair, seeing a partner’s patients; they are not the partner, however, nor are they a second-rate substitute.

They are flexible, highly-trained professionals who can bring special skills and insights to practices which are disposed to take advantage of them. If locum GPs practise in an environment of “enforced underperformance”, they, the practice, and the patients will pay a high price.

The locum in a foreign land

In a consultation it is important that a patient and a doctor have an open mind about each other. It is worth remembering that patients don’t place a high value on continuity; they are happy to see anyone who is competent. And regular patients can sometimes benefit from a fresh eye which picks up problems that familiarity has rendered invisible. Some locums provide practices with a brief biography so that patients will know a bit about them before their consultation. Practices can promote this: why not ask each locum for a biography with a photograph?

Most practices claim to have a locum induction pack. Efforts are made to keep the pack up-to-date, but I’ve visited practices where the information covering the hospital pathology services over the festive period was two years out-of-date.

Practices should provide the local information that doctors need to do their job. Locums can help their fellow locums by contributing additional notes.

If the practice system is accessed using a smart card, unless a locum has this card he/she will have to practise without patient records and write paper notes. It is helpful if practices have someone on hand who can get the locum up and running without delay.

The locum computer techie

When a locum starts they immediately need to ask, and practices need to tell them, what clinical software system the practice uses. Experienced locums will be familiar with widely-used systems and new locums can familiarise themselves with the most common systems, but a practice with a homespun, off-brand system will be difficult to navigate even for the most it-literate visitor.

Gone are the days when organising a referral just meant dictating a letter. Care pathways and clinical referral systems vary widely. Partners only need to know one system on a day-to-day basis. In the course of a month’s work, locums may be dealing with four PCOs and 24 secondary care trusts.

Telling a locum that all the information and forms are “on the computer” is unhelpful. If a locum has to run searches to find documents, which can be shrouded under an uninformative alias, their time will be directed away from seeing patients.

Similarly, while any good locum will endeavour to support the practice’s work on the QOF, enhanced services and local incentive schemes, they will not always know the computer codes. Templates incorporated into the clinical software make it much easier for doctors new to a practice to contribute to practice targets – and, hopefully, to patient health.

Some practices still log in all locums as “Dr Locum”. This is unacceptable. It is a legal requirement that every consulter have his or her own username and password, so that a proper audit trail exists and no-one can falsify another doctor’s notes.

The locum archaeologist

A typical GP’s consultation room is a monument to their individuality. But this can be difficult for a locum who has to search through a desk full of papers, knickknacks and family photos, or drawers crammed with drug company freebies, spare spectacles and stale biscuits, to find a peak-flow meter or medical certificates.

Unearthing the tools of the trade can be an exercise in office archaeology. Untidiness is hard to cure, but it helps to establish a common system for where equipment and forms are kept. Providing a box of essential bits and pieces specifically for locums is very handy. In turn, locums should leave a consultation room in the state they found it; everything should be left as it was.

The locum mind-reader

GPs who know their patients very well (likely in single-handed practices) may carry a lot of information in their heads. A locum will not know if Mrs Jones usually looks that funny colour, or what “white pills” she was prescribed last week. Adequate notes are essential to maximise patient safety. All doctors need to write notes with the assumption that the patient may be a stranger to the next doctor who sees them.

The locum prescriber

Repeat prescriptions are a daily practice chore. They are also a common cause of complaints. For locums, signing repeat prescriptions is a particularly high-risk activity and some organisations advise that they should not do so. In the real world, both sides need to minimise the risks. For the locum that means checking the patients’ notes before signing for practices that means allowing the locum time to do so, and accepting that any locum is justified in refusing to sign some prescriptions. Patients on anti-hypertensive or asthma medication, who haven’t been reviewed for years, repeats for benzodiazepines, anti-rheumatoid drugs where no evidence can be found of monitoring, can all present difficulties for the locum.

The locum visitor

In a practice it is inevitable that occasionally someone will take the opportunity to scrump an unattended Apple iPhone. However careful they are, locums are vulnerable to casual theft. You can’t lock your belongings in a drawer if the drawer is already locked and the key is on the partner’s keyring. You can’t lock the consultation room door while you go and hunt for the sonicaid if no-one knows where the spare key is.

It does not foster a good relationship between a locum and practice if a locum discovers that the small print of a practice insurance policy excludes cover for their belongings. Locums and practices need to consider whether their property is protected, and indeed whether they would have cover if they were the victim of an assault.

The locum management consultant

Locums are a fresh pair of eyes, not only for the patient but for the practice. They see almost every aspect of the practice and can spot the things that go unnoticed: out-of-date test strips, a wobbly stool, outdated TFTs – any of these are a significant event waiting to happen.

Most practice managers and partners will be glad to have problems brought clearly, but diplomatically, to their attention, and will let the locum know what they have changed as a result.

The locum and the practice

Partners work in the same place, using the same systems, every day. Locums walk into an unfamiliar building to meet a team of strangers with their own way of doing things, knowing that every patient will be a “new” patient. This requires not only the standard clinical skills, but a special degree of flexibility and an ability to judge and manage risk.

Locums can only be as good as their skills and abilities, but unfortunately all too often they are not given a chance to practise at their best.

Practices owe it to their locums, and their patients, not to put locums in a position of enforced underperformance, and locums can help themselves, their colleagues, and their patients, by using their unique position to support practices.

Further information

• National Association of Sessional GPs www.nasgp.org.uk
• Haynes, K, et al Clinical Risk Management in Primary Care. Radcliffe Publishing ISBN 1 85775 869 2 (2005).