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A lot to take in: locums and enforced underperformance

1 March 2007

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Judith Harvey
General Practitioner

A late entrant to medicine, Judith has tackled everything from teaching in a comprehensive school in Liverpool to running a volunteer programme in Papua New Guinea before she trained in medicine. She was a partner in a semirural Home Counties practice for 10 years and has been a sessional GP in inner London since 2001. Judith has contributed to the Handbook of Practice Management since 2001, and is also involved in working to help clinicians and nonclinicians find ways of involving patients that benefit both sides

Here’s a typical situation for a practice manager: one partner is on holiday; another is doing a hospital session; the third has just gone off sick. You need a locum. Locums are essential but expensive – and how much of what needs to be done can they do?

These days, locums should have adequate clinical skills (if they don’t, it is the practice’s duty to address the problem). But even the best locums – like workers anywhere – are only as effective as conditions allow. A practice is legally liable for the acts and omissions of employees, and it is in your interest to create conditions that allow locums to use their time and skills effectively for your patients.

Starting off on the right foot
Misunderstandings are common. Be explicit about your expectations, and check out theirs. A written contract is the ideal, but even if you don’t have one it is worth looking at the model drawn up by the National Association of Sessional GPs (NASGP) – see Resources. As well as hours, visits and payment, ask about clinical skills. Patients booked for a coil fitting or a joint injection with a doctor who is not trained to do these will be irritated, and time will be wasted.

Be realistic. Locums are not partners. With the best will in the world, they cannot do the same job, so no-one in the practice should expect them to. But they are not second-rate doctors either – if receptionists are telling the patients that “it’s only a locum”, then the doctor who is providing you with a locum service is set up for failure.

Practice patience
Locums may work in dozens of practices, often in different areas with different specialist services, referral pathways and forms. Each practice has its own culture and each doctor’s consulting room is his or her castle. And for a locum, each patient is a new patient. Locums have to be flexible, but the practice can help by allowing them adequate time and providing them with essential information.

Even simple consultations take longer when the doctor does not know the patient: taking the history, checking the records, negotiating a successful conclusion to the consultation. Every practice uses its computer system in its own way, so even a locum familiar with your software is likely to be a little slower entering information. And locums have to find things. Could your doctors lay their hands on the pathology forms, the pad of medical certificates, the swabs, in each others’ rooms? Pity the locum. All too often, finding even the most basic tools of the trade is an archaeological dig.

The locum’s time wasted is your time wasted. Giving locums more time than partners would need to see the same number of patients isn’t being soft, it’s an investment. Patients who have had a good consultation don’t come back needlessly; dissatisfied patients march straight to reception to book another appointment.

Good induction saves time
Rather than paying highly trained professionals to play hunt the speculum, draw up a list of items that should be in every consulting room and ask the partners to write down where they keep them. Consider standard containers for forms and stationery. Most locums guard against absence of vital tools by bringing as much as they can carry with them, but it is reasonable to expect that the practice will have a Sonicaid(®). And it is unlikely that locums will have second sight, so tell them where to find it.

Signing repeat prescriptions is a high-risk activity and defence organisations caution locums against doing so. Partners may sign them while eating lunch and talking on the phone, but if your locums are prepared to work that way you shouldn’t be employing them. Most locums will sign repeat prescriptions, but to be safe they will need time to check the patients’ notes. If locums refuse to give prescriptions for benzodiazepines or other drugs of abuse, respect their decision. It is highly unlikely that a patient will suffer medically from a 24-hour wait.

Lack of information is a major contributor to enforced underperformance. Where and when can patients have blood tests? What are the local physiotherapy, podiatry and audiology services? Does the practice have a counsellor or a smoking cessation adviser?

Locum induction packs, whether paper or online, should provide the answers. Standardised packs are available from NASGP. Someone needs to have responsibility for keeping the pack up-to-date. Information about services the primary care organisation (PCO) decommissioned last year is no use, nor is the path lab’s rota for Christmas 2004. But no pack is going to answer every question. Locums need a designated minder — a back-up human being, who won’t be irritated by a request for help.

Information transfer
IT is a great enabler if you can use it, a major cause of underperformance if you cannot. It is also another source of risk. Ensure that your locums are signed on as themselves, not as “a locum” or under some other doctor’s code. A few minutes spent demonstrating how the system works will soon be repaid by clear notes (essential for patient safety) and Quality and Outcomes Framework (QOF) codes (essential for income).

It isn’t just computers that generate technoanxiety; if you have a fiendishly clever phone system, give the poor newcomer a chance, and explain how to get an outside line and make an internal call. And supply a list of external and internal telephone numbers, including that of someone who can help with IT queries.

Think about your emergency systems. How will a locum know if a patient has collapsed in the waiting room? If the call for help is electronic but you haven’t put the locum on the system and explained its use, it is your responsibility, not the doctor’s, if the patient dies for want of prompt attention.

Another crucial, but often neglected, aspect of information transfer is a safe handover procedure, paper or electronic. It is vital to relay promptly information to a partner from the locum, who may not realise that Dr Bloggs will be away on a Caribbean cruise. Be sure too that a locum’s referral letters are promptly checked, signed and sent.

Good endings
If you have the opportunity, it is courteous to thank locums before they leave the practice (and to pay them promptly). If you think you will use them again, find out if they have any special interests you can take advantage of. Ask them if there were any problems; you may be able to make the next locum’s session more productive. Ask for any other comments on your practice. Locums see a lot of practices and they look at them with fresh and critical eyes. A good locum may give you invaluable feedback.

If you have concerns about the doctor’s performance, mentally noting that you won’t employ them again is not enough. You have an obligation to tackle poor performance: with locums, with their agency, and with their PCO.

A locum is not a self-contained plug-in-and-play unit. Locums need more support than the doctors who work in the practice every day. Invest in them. You will get better value for money, your reputation in the area will improve (locums talk to one another) and you will find it easier to engage a locum in the future. And remember: today’s locum may be tomorrow’s partner.

National Association of Sessional GPs

Clinical Risk Management in Primary Care
Haynes K, Thomas M. London: Radcliffe; 2005.