• See also Robbie Coull's excellent guide to working Freelance

THE LARGEST GROUP of non-principals is GP locums. They are also the most flexible and often the most in demand. Strangely because of this perhaps, they are, by some, awarded the lowest professional status and are sometimes thought by patients, practice staff and some doctors to be some sort of failure. In fact, and of course this is far from the truth - many locums are recently qualified members of the RCGP whose only failing is to have suffered from diplomatitis and to have been workaholics since leaving medical school. Locuming provides a good opportunity to work in lots of practices, in lots of areas. You see a wide range of patients, buildings and ways of running a practice. It’s an education in itself and very useful if locuming whilst looking for a partnership. It enables one to get to know the locality and to gain vital experience.

GP locums are small businesses in themselves. It can be daunting at first but, after a while you get used to it and, it’s often fun. Dealing with the money is the trickiest part. The key is to keep a record of everything. A useful book to get is the Lloyds Bank Small Business Guide by Sara Williams. It’s often advertised for free (RRP £16) in the broadsheets as available from the Lloyds Bank Business Start Up Hotline on 0345 003377. This is presumably in the hope that you will open a Lloyds bank account but I was never asked to!

In order to locum you need to consider the following which are detailed below:

• How to get known;
• How to operate;
• When to take holidays;
• Local information to get before you start;
• Good places to locum;
• How to book work;
• How to collect the cash and what to do if the bill isn’t paid;
• How to record your income and expenses - see chapter on Business Money - Basics.

How to get known

• request a full medical (GP) list from all local health authorities or use the yellow pages;
• send a one sided CV to all local practices with a covering letter on the back. Include when you are available and your contact details;
• ask to be included on the health authority’s locum list and inform the LMC office that you are available for work;
• tell a local agency but beware: agency rates are variable and you may find it difficult working for a practice directly if you originally worked for them through the agency;
• advertise in the GP press - it's free(!);
• make yourself known at postgraduate meetings and to the centre manager - they are often asked if they know of any new locums;
• get some headed notepaper, preferably something slightly noticeable and use it for everything. Print some business cards that will help you to be remembered - perhaps something like the card below?
  
  
  
  
• invent a mission statement. It adds to the professional image. I used both “Quality Cover for Primary Care” and “Cover with Confidence” as a footer on my headed notepaper;
• join a local group and circulate members’ names and phone numbers to practices.

How to operate

• You cannot work without an answering machine. Ensure it is one that you can collect messages from remotely. This will reduce your chances of losing work. On your outgoing message ask practices to leave an evening contact number or fax number. Then you can reply to messages when you get in after surgeries have closed. You might want to add that if practices do not hear from you within 24 hours they should assume you are unavailable. It’s time-consuming, expensive to reply to dozens of messages when you are already booked up. Having said that, practice managers do like to know one way or the other, and bothering to phone back and have an apologetic chat may mean you get first refusal next time.
• A fax machine is very useful especially for responding to answer machine messages out of hours. Use it to send polite standard letters when responding to contacts that you are not available for. Use it to tell practices that you are available, what your rates are, inviting them to agree to these, and then confirming the booking in writing.
• Always confirm the dates, time, agreed length and intensity of work, and the rates of pay including pro rata payment for overrunning - see below on booking work.
• Fees - see the separate chapter on fees. Be prepared to negotiate when work is lacking and similarly, consider asking for more if you are booked at short notice. You don’t have to admit that all you are cancelling is a day in the garden. If practice managers are adverse to negotiation, encourage them to ask a principal who will often ‘ok’ a few quid more.
• Record all contacts - you can send overnight faxes or postal mailshots when you are under- worked. Overnight faxing is cheaper than stamps and envelopes and one ‘faxshot’ exercise will probably pay for the machine, let alone the calls.
• Buy the most detailed street maps of the area you can. When on visits, check the notes have the patient's phone number on them.
• Mobile phones come into their own for getting directions from the patient or the receptionists when you are lost on visits. Apart from this they are expensive and variably useful. Pagers switched to vibrate don’t interrupt consultations like phones do and with the text screens are a cheaper alternative. Soon mobile phones will do all this and be the size of a pager.
• Drugs and Equipment - see chapter on The doctor’s bag.
• Computers can be marvellous. They enable you to design your own headed paper and business cards, you can use them as fax machines and answering machines, you can record your income and expenses on spreadsheets and you can keep copies of invoices too. Home finance software can enable you to keep a good track of your finances too. The drawbacks are that they are still relatively expensive, they have an initially steep learning curve and they are not infallible. Don’t forget to back files up onto floppy discs or a tape streamer. You should be able to set at least a proportion of your capital costs against tax, depending on how much you use it for work and leisure. Palmtops such as Psion Organisers are, though expensive, great for those who like gadgets. The ability to save a diary and address book and hence protect you in times of loss cannot be underestimated. They’ve got a calculator, word processor and spreadsheet software on board, can be attached directly to a printer and additional route finding and games software can be bought for them too.

When to take holidays
Traditional holiday times are the busiest times for locums to work. The quietest times are just after Easter, November and January. These are the cheapest times to take holiday so take advantage! Christmas and Easter are traditional holidays that many doctors will have given up over the years. Consider using your non-principal flexibility to take them as holiday yourself and relax. There are perks to being a non-principal!

Local Information to get before you start

Phone numbers

• Hospital phone numbers with direct lines for admissions, A&E, GUM Clinics and pathology departments;
• Mental Health Team;
• Ambulance service local numbers for urgent admissions and outpatient transport;
• Social Services;
• Police;
• Coroner;
• Health Authority;
• Department of Public Health so you can report Notifiable Diseases;
• Private Manipulators (in the nicest sense!) Physiotherapists, Chiropractors, Osteopaths;
• Local Self Help Charities, eg Relate, Drugs and Alcohol.

Other information that you may find useful

• Hospital’s GP Handbooks - with information on consultants names and interests and services offered and direct dial phone numbers^*
• Pathology Department Handbooks - information on locally available investigations and results;
• Chief Medical Officers Urgent Communications - GP principals are now being asked to show such letters to non-principals working for them. If you have a fax you should be able to receive your own supply from your local Director of Public Health;
• BNFs - beg the health authority (Director of Primary Care) to send you one, as often as they will;
• Local Clinical Guidelines (may be available from the Director of Primary Care or Medical Audit Group Office);
• District Pharmaceutical Officer’s Newsletter (should tell you the latest on local prescribing issues);
• Local Postgraduate Centre - get on their mailing list.

^* Many hospitals now have GP liaison officers who design, distribute and update such handbooks. If not, a copy of the internal phone directory should suffice. When I moved to a new area I called the Chief Executive’s secretary of each local hospital who usually knew who could provide the information I wanted.

Good places to locum

• Single-handed practices - provide excellent experience as they force you to deal with everything.
• Maternity locums and Long Term Sickness Cover - medium to long term locums enabling you to get real in-depth experience of a practice and some continuity of care. This is good preparation for partnership especially if you are dealing with all the absent partner’s paperwork.
• Training Practices and recommended practices - Practices that are organised are much easier places to work. The irony is that their organisation reduces their need for locums. Disorganised practices can be a nightmare. If colleagues have pre-warned you about such places, consider requesting a premium payment for accepting work, if you need to accept at all.

How to book work
Decide when you are available and more importantly when you are not. If you don’t want to work, it probably isn’t diplomatic to tell practice managers you are planning to spend the day in the garden or on the beach when they have 30 demanding patients who need seeing. Just say you are booked up that day.

Respond to offers of work quickly. If you are slow, you will lose the offer and if you never phone back, practices will stop phoning you.

Know how much you want to earn for x amount of work at y practice. Have an ideal rate and a bottom line. Be prepared to decline work when practices won’t pay your bottom rate. Don’t forget the travelling time and costs if you’re going some distance from home. Consider using a standard booking form, see the example below.

Know exactly what you are being asked to do. Confirm your understanding in writing and ask the practice manager to do the same. Things to consider are:

• How long do they expect you to be doing a surgery for?
• How many patients does this include?
• How frequently are you seeing patients, 5, 7½ or 10 minute intervals? Is this reasonable?
• Will you be the only doctor on site?
• Who will be taking urgent calls/visits?
• How many visits are they expecting you to do?
• Are you being paid anything for travelling costs?
• Are you expected to sign repeat prescriptions? Are you sure they have a safe system for repeat prescribing?
• Are you expected to review results?
• Will there be a nurse on site?
• Which computer do they use? Do you know it? If not, will they train you on it? If not, is it safe to practice here?
• Do they have a locum pack? (If not and they are disorganised it will take longer to do everything)
• Are you going to make a no-cancellation agreement?

The GMC’s Duties of a Doctor guidance states “If you have formally accepted a post, you should not withdraw unless the employer will have time to make other arrangements”. Cancellation by either party at short notice causes considerable difficulties for the other party. The GMC would view that the interests of patients should come first but, if a practice cancels you, a written agreement will enable you to bill them for the lost work.

Booking Forms
The West Yorkshire Non-Principals Group’s first locum contact list included a standard booking form with suggested rates which many practices spontaneously used (see example overleaf). The rates will need updating periodically. One advantage of the form is that it commits practices to paying for a limited number of patients per hour or incurring additional pro-rata charges. It includes a fixed amount for mileage for visits, often a difficult area to discuss and, therefore, often not pushed for by the locum. It includes the statement that the booking is only considered confirmed on receipt of a completed form. This encourages practices to put something in the box about cancellation and overall it provides a written agreement which, if there are later problems, you can refer back to.

How to collect the cash

• Some practices will pay the day you do the work. If not send an invoice immediately after the work requesting payment within seven days. It is professional, efficient and effective. Practice managers like invoices as they aid their record keeping. It will also help you record your income - so keep a copy;
• You can download a free piece of software called PennyPerfect which can simplify you're billing procedures.
• Pay cheques into your account quickly. This avoids cash flow problems and will earn you small amounts of interest. But beware. If there is a transaction charge on each cheque it makes sense to wait and collect a few up. Setting up Bankers Automated Clearing System (BACS) arrangements with practices that you work for more than a few times is worthwhile, provided they use electronic banking, as many now do;
• If payment fails to appear, call the practice manager and write formally requesting payment again. Keep a copy. If payment has not arrived, say 2 months after the work, you can turn to the small claims court for assistance - see below. It may be worth contacting an officer of the LMC who may be sympathetic and try to mediate.

What to do if your bill still isn’t paid ^{Note 1}
First call the practice manager or senior partner and bring the matter to their attention. See what they have to say. If no money appears then you must write a letter to the partnership saying that if you have not received payment at the end of seven days you will have to take proceedings.

At the end of the seven days, you can start proceedings at your local county court office. At present the financial limit for proceedings in the small claims court is £3,000. If the amount owed to you is more than this figure you would be well advised to consult your solicitor - he should be able to reclaim some of the legal costs.

If however the claim is for £3000 or less, then it is unlikely to be economical to employ a solicitor as the courts rarely award costs.

If the practice has a name, you can sue it in the practice name. In this event you will describe the Defendant as, for example, “The XYZ Practice (sued as a firm)”. The effect of suing in this way is that you can enforce any judgement which you obtain against either the practice property, or against the individual property of any partner whom you can show was a partner at the time your debt was incurred.

If the partnership does not practise under any particular name, you will have to know the name of each of the partners in the practice who was a partner at the date of your debt. You will need at least two copies of your invoice for the court office and a spare copy for each extra partner whom you sue. The court will give you the necessary forms for issuing the summons and you will be required to pay a court fee. The scale of court fees varies from time to time and a telephone call to the court to find out the fee in advance will save time - you will be required to pay in cash.

The court issues a summons to the partners. Once the summons has been issued, the procedure can vary according to whether or not the Defendant takes any steps in reply to it. The court staff will advise you on procedure (but not on law) and you will find a range of leaflets at the court office giving you more information.

It is beyond the scope of this book to go into more detailed explanation. However one word of advice is that you should keep in a folder in date order copies of all documents which you submit to or receive from the court.

Note 1
The information on using the Small Claims Court relates only to England and Wales. Readers need to check details outside of England and Wales. Which? subscribers can order a factsheet (reference SCCOUR) on the small claims court in Scotland and Northern Ireland from 0645 123 580.