How locum chambers reduce risk
Dr Richard Fieldhouse says that being linked to a locum chambers can reduce risk
Risk is made up of two elements – risk that a patient is exposed to, and risk that a GP is exposed to. In the patient’s case, it is the risk to their health, and in the case of the GP it is the risk (inter alia) to their GMC registration. In either case, it’s the GP who has ultimate responsibility for this management of risk.
It’s the GP who has ultimate responsibility for this management of risk
However, the uncomfortable bed partner of responsibility is control. GPs who run and manage a practice are in the best position to have the perfect balance of responsibility and control, having the ability to make decisions and plan services.
A salaried GP, however, who is unlikely to have anywhere near the same control as their employing GPs, and may not be party to ongoing discussions relating to patient services, still has to take on the full clinical responsibility for patients using these services.
And a conventional locum, working as a self-employed individual, in often dozens of different GP surgeries every year, is very unlikely to have any control over their working environment, yet will have to take full clinical responsibility for all their practice’s actions. It really is a situation where GP locums often find themselves in positions of ‘enforced underperformance’.
Enforced underperformance
There are many high-risk areas faced by GP locums that can expose patients to increased risk. These are listed below:
Arriving for work – Because so many locums manage their self-employed businesses themselves with little or no training, misunderstandings about what’s expected can occur, with double-bookings or missed bookings a common occurrence.
Repeat prescriptions are risky business, because locums will likely have no idea whether the practice allows its receptionists to add medications, or whether there’s a robust system of medication reviews
It is not atypical for a locum to turn up for surgery to find they are on-call, with no other GPs around, supervising a new GP registrar, there’s no nurse, with their supposed ‘duty GP’ session ending when they are meant to be an hour across town to do an on-call for a single-handed practice. Amidst all of this confusion, patients are being let down and are being exposed to risk by an exhausted and exasperated GP.
Prescribing is a minefield – There are inherent risks in relation to GP locums signing repeat scripts, and locums often feel forced into doing them. Repeat prescriptions are risky business, because locums will likely have no idea whether the practice allows its receptionists to add medications, or whether there’s a robust system of medication reviews, so that repeats are being checked with each patient.
Locums should refuse to sign these prescriptions or, even more sensibly, negotiate an allotment of time to do this, but ever mindful of not wanting to appear unhelpful, it is all too easy to simply oblige.
Acute prescribing is straightforward, with the patient sitting right in front of you, but there are still the vagaries of the IT system to negotiate, and opaque policies and procedures on alerting fellow prescribers to allergies and drugs prescribed by specialists that often don’t feature in the notes – yet are the ones most likely to cause a problem.
Archaic IT systems – Leaving aside their antiquity, they’re all different. Systems from the same software publisher have similar names, but vary significantly, and even the same version can be set up entirely differently. Then there is the travesty of the username/password.
So come flu or snow, abdominal pain, stress or depression, you’ll get locum GPs turning up for work when really they would be much better turning up as a patient
Across the board, locums are often given generic usernames and passwords. This can cause significant problems in that it may be difficult to identify the GP locum in the event of a complaint or claim. We’re told so often how important it is to keep good notes, yet if composing notes anonymously, how great is the temptation to cut corners when, chances are, no-one will know it was you?
In sickness – No-one likes being ill, and this is exacerbated by the effect that you know that an unexpected absence will have workload consequences for your colleagues. But what if you’re a locum GP, who will not only suffer the financial loss, but also the double whammy of damaging one’s reliability and being replaced by a healthy locum?
So come flu or snow, abdominal pain, stress or depression, you’ll get locum GPs turning up for work when really they would be much better turning up as a patient.
GP chambers
Many GP locums do not have the luxury to pick and choose where they work, let alone do anything about it
Not turning up to surgery again following a bad experience is not the answer, to simply not go back to a practice because you feel they’re exposing one to unnecessary risk is unacceptable. Many GP locums do not have the luxury to pick and choose where they work, let alone do anything about it – they have mortgages to pay.
It’s no better than a practice not booking a locum again because they thought they were a bad GP. But confronting a practice does not generally work in the locum’s favour. You should refuse to see more than the agreed number of patients, refuse to supervise the registrar if you’re not comfortable doing so, refuse to review urgent results because you’ve not been trained to, refuse to sign prescriptions when you have no idea of their provenance. You and many others do, but the reality is that you will never be asked back and by adopting such an approach you may compromise patient care.
So how can working as part of a locum GP chambers significantly tackle this situation and in turn reduce individual risk? Once a group of GPs have formed together as a team with its own corporate identity and trade, forming as a single undertaking (a chambers), they have a collective mandate to confront practices. It’s a professional obligation to be part of a wider clinical governance process and most practices understand this.
A collective battering ram
Chambers can collectively challenge behaviour, demand changes, take sanctions, and place themselves in a very strong negotiating position
Collectively employing staff and nominating several amongst them to be clinical directors and chambers leads, and some as ‘partners’ with a specialist portfolio (eg, prescribing), will allow for robust systems to be developed for managing significant events and sharing feedback.
This level of organisation fosters a sense of quality and reliability, such that they can work at positioning themselves as the preferred provider of locums to local surgeries. As a large body of local GPs with power, chambers can collectively challenge behaviour, demand changes, take sanctions, and place themselves in a very strong negotiating position to significantly change the clinical environment within which local locums (both chambers locums and other non-chambers locums) can practise in a safe environment.
If a chambers member has a bad time at a practice, chambers such as the one I belong to do not just walk away. Chambers can make sure that the risk that their members are exposed to is removed so that subsequent locums can practise safely in the future.
The practices that employ the locums from our chambers know that our members are unlikely to sign repeats, see more patients than are safe, or be taken for any sort of ride or exploited. By compromising this relationship the practices know that they will lose their supply – their lifeline – of good locums.
Dr Fieldhouse is the founder of the National Association of Sessional GPs (NASGP) and is Clinical Director at Pallant Medical Chambers.