Locum GPs may work in numerous varied practices and encounter many different staff in the course of their work. Whilst team working is to be welcomed, the locum GP can often feel vulnerable when an unknown member of the team asks for their assistance. Dr Rachel Birch, medicolegal adviser and sessional GP outlines two common scenarios and provides practical advice on what locums might do in such scenarios.
Case 1 – Can you just sign this X-ray form?
Dr A was doing a busy 10-minute appointment morning locum session in a practice and he received a flashy message on his screen mid-surgery. The message was from “Medical student 1” who asked him to sign a chest X-ray form for a patient. He told Dr A it was in the locum pigeon hole and asked that he give it to the patient who was in the waiting room.
Dr A was not even aware that the practice had a medical student. He telephoned reception to find out where the medical student was consulting and then knocked on his door. The medical student, Mr F told him that he was in his 4th year and had just started his GP attachment. The GP trainer, Dr B was out on a house visit. The patient had a recurrent chest infection. He just wanted to get the patient’s X-ray form signed and he told Dr A he was running late on his own consultations.
Dr A was concerned that Mr F had limited GP experience and remained unclear about the indication for CXR.
What should Dr A do?
- Dr A should consider reviewing the patient himself as he has concerns about Mr F’s assessment of the patient and the treatment plan. The patient may require antibiotics as well as a CXR.
- He may wish to invite Mr F to be present during this assessment, since this would be a teaching opportunity and he could ask Mr F to present the patient’s history, thus potentially reducing the consultation time.
- Dr A is legally responsible for any X-ray request he makes and should be satisfied that he has reviewed and examined the patient and that the X-ray is indicated.
- Since the GP trainer is out of the building, he should consider whether Mr F requires formal supervision until Dr B returns.
- If he has concerns about patient safety due to inadequate supervision of Mr F, he should raise his concerns with the GP trainer at the end of his morning surgery.
Case 2 – Can you do me a quick prescription?
It was the first day of Dr S’s fortnight locum post. She was in the middle of an afternoon surgery when she received a knock at her door. A lady in a nurse uniform but no name badge asked her to prescribe Flucloxacillin for a patient she was seeing in the treatment room. Dr S introduced herself and asked the nurse who she was, which appeared to irritate her. She asked for more clinical detail on the patient and the nurse replied curtly “the other locums don’t ask this”.
She told Dr S that the patient was an elderly lady with a leg ulcer that was slow to heal. She had taken a swab but thought it might be infected.
Dr S decided to go in with the nurse to review the patient and, after checking with the patient that she had no allergies and confirming there would be no drug interactions, prescribed the antibiotic.
Later that afternoon the same nurse asked Dr S for a prescription for a patient for Fucidin cream. The patient had left the practice and the pharmacist would deliver the medication to her tomorrow.
What should Dr S do?
- Dr S should ask the nurse to outline the patient’s clinical history, examination findings and potential diagnosis, so she can be sure of the clinical picture.
The GMC states that GPs must only prescribe drugs when they have adequate knowledge of the patient’s health and are satisfied that the drugs serve the patient’s need.
- Dr S must decide if she is happy to prescribe the medication based on the nurse’s assessment of the patient, or whether she would wish to review the patient herself.
The GMC advises if GPs are delegating part of the patient’s care to a colleague (in this situation, the assessment of the patient by the nurse), they must be satisfied that their colleague has the appropriate qualifications, skills and experience to provide safe care for the patient.
- Dr S may wish to have a longer conversation with the nurse at the end of the day, to establish her training and background, as this may help with decisions of this nature for the remainder of her locum period.
These scenarios are not uncommon and can take time and energy out of a locum’s already busy day. If locum GPs have concerns that they are being asked to work with unfamiliar staff, such as medical students and nurses, they may wish to feedback to the practice manager that it would be helpful to have a list of such staff and their qualifications and experience, as part of their induction prior to starting their post.
NASGP has developed the Standardised Practice Induction Portal (Spip) which locums may wish to highlight to practice managers as a useful tool. The benefit of this is that locums could review the practice information, including staff members, perhaps even with a photograph of such individuals, and familiarise themselves with their experience, prior to arriving at the practice. This may go some way to ensuring scenarios such as those above are easier to manage.
Rachel Birch firstname.lastname@example.org