LocumDeck for practices

GP locums are fully qualified GPs. They undergo the same training and have the same appraisal requirements as practice-based GPs. Usually, they are self-employed (unless they work for an agency) and provide medical services at, or for more than, one single organisation.

Clinical focus

The basic unit of currency of being a GP is consulting with patients. Many GP locums love their job because they get to work as clinicians without the other duties of running a practice. Some GPs have an aptitude for clinical leadership and practice management and that’s wonderful – especially if they are complemented by other GPs who want to focus on consultations.

Variety

GP locums work in up to 40 practices a year and up to a 100 different consulting rooms across different CCGs, federations or equivalent, using different acute hospitals.

The upside of this is that GP locums get to see lots of variation in practice processes and service provision so we can act as cross-pollinators of good practice.

The downside to this variety is that, though we come armed with the medical knowledge, we may not yet have highly localised non-clinical knowledge about how your practice works and interacts with local services.

For practice-based staff, a lot of these processes may seem automatic and you may not recognise that they are alien to newcomers. To quote one practice manager: “I’ve worked here so long, I don’t know what you need to know”.

But with some thought and preparation, you can equip all GPs working in your practice with the essential knowledge they need to run a safe, efficient consultation.

Out of the loop

GP locums can miss out on information about educational events, local referral and prescribing policies, changes in services, or anything else that a practice-based GP would receive every day (sometimes to the point of overload).

In our experience, few GP locums have an NHS email address, let alone one that appears on local service distribution lists, and so rarely receive updates.

But perhaps even more important is the professional isolation experienced by GP locums, and highlighted in an extensive piece of research by the Royal Medical Benevolent Fund that found locum GPs to be the most isolated professionals in the NHS. A central tenet of NHS appraisal is to participate in significant events and colleague feedback, as well as to reflect on the outcomes of these, all of which is much more effective if done in a supportive environment with other colleagues.

So wherever possible, including locum GPs in any opportunity to learn and reflect on their performance will no doubt help them to improve their effectiveness and safety.

Although continuity of management  via up-to-date, accurate, relevant information in the medical records is vital for patient care, there are important groups of patients in whom continuity of relationship will also be important e.g. frail patients or patients in palliative care.

But for many patients, so long as there is continuity in the medical records, seeing a different GP can be a great positive. As well as being an adequate temporary replacement, a locum can also be a fresh pair of eyes, can break a stalemate in a frequently-attending patient with unmet needs, reaffirm to the patient their own GP’s management, or allow a patient to ask about something they are embarrassed to ask their usual GP who has known them since they were born.

It’s a great job and there are a huge range of excellent GPs who opt to work as locums for different reasons:

• the newly-qualified GP scouting practices
• the multi-role portfolio GP
• the practice-based GP doing extra locum sessions
• the ‘career locum’ who values work-life balance
• the newly-retired GP.

Increasingly, we note a trend in mid-career ex-GP partners wanting to restore a more equitable balance to direct patient contact.

Who wouldn’t want to be a locum?

GP locums are a vital, flexible part of the workforce. Working alongside and in balance with practices, GP locums who are organised, engaged, and properly equipped provide invaluable support.

LocumDeck

NASGP’s LocumDeck is a new platform that enables GP locums to define every single parameter of the way they prefer to work, allowing them to then commit to being available for a booking at a certain time and date.

The system allows practice managers to book and confirm sessions instantly and gives them access to all necessary paperwork.

Independent GP locums

It can be great to have access to known, trusted locums who may rely on local reputation and word of mouth recommendations.

You have to work at maintaining an up-to-date list of contacts and be prepared to make lots of phone calls and emails to make a booking. If the GP locum manages their own bookings they will be juggle this with clinical work, which can mean that booking them can take time and booking errors may be more frequent.

Practice managers will also have to do their own employment checks on GP locums who make their bookings independently.

Locum chambers

Locum chambers have a clear fee structure, pay GP locums directly. GP locums pay a  fee to chambers to manage bookings.

Chambers function as ‘virtual practices’, where all the GP locums book all their work through the chambers. Chambers employ full-time staff to manage bookings and clinical governance.

The chamber usually carries out the necessary pre-employment checks and keeps this information on file for practices.

Read more on locum chambers.

Agencies

Some GP locums use one or more agencies to book work. The practice pays the agency for the GP locum’s work and the agency takes a cut of the session fee.

The agency usually carries out the necessary pre-employment checks and keep this information filed for practices to view.

Locum groups

In some areas, GP locums work together in informal groups.

Although they tend to focus more on providing  learning and development events, they also sometimes distribute membership directories to practices, or even arrange for practices to email members about session availability.

Online services

Services are available for practices to book GP locums through a website on a pay-as-you go basis.

Local medical committees (LMCs) and postgraduate education centres

LMCs and medical schools sometimes operate a distribution list of GP locums in their area.

Whatever level of locum cover your practice has historically used, you never know what’s around the corner and it will be to your benefit to be on good terms with trusted locums.

Some practices are a joy to work in. They may have the tough patients but GPs can cope with anything if they feel well-supported and enabled to work to their full capacity by having access to necessary equipment and essential practice-based information.

Top tips

• Treat GP locums as fellow professionals who will have the responsibility of looking after patients.
• Respect that GP locums have clinical knowledge, but not practice-specific knowledge.
• Prepare for a GP locum’s session so they can start smoothly in a suitably equipped room.
• Enable GP locums to consult safely and effectively by equipping them with easy access essential information.

There is huge variability in how different practices and locums work. It is essential for the smooth running of your practice and for your patients’ experience and safety that when engaging a locum, each party clearly understands and agrees on the work that is expected.

Properly worded T&Cs can also safeguard both practice and GP locum in terms of employment and tax law too.

The best way to ensure this is with a written agreement, negotiated and finalised in advance of the locum session.

Sessions confirmed on LocumDeck have this facility.

It is a matter of safety to ensure that all relevant staff on duty such as receptionists, practice nurses and other GPs understand the terms of the GP locum’s agreement and the work expected of them. You can then avoid either underusing the locum or overloading them with work beyond what was agreed.

There are three areas we recommend every GP locum agrees with a practice.

Appointments

• Start and finish time of surgery.
• Number of appointments.
• Length of each appointment.
• Special cases where longer appointments needed:
  • Practices will often know of patients with complex medical problems, mobility issues or mental health issues where GPs require longer appointments. In fairness to these patients, the locum should be given the same conditions.
  • Patients requiring interpreters.

Visits

• Number of visits.
• Whether visit to one nursing home to see more than one patient counts as ‘one visit’.
• Cut-off time for notification of a routine visit.
• Time required to travel to visits.

Administration

• Arranging referrals and investigations arising from patients seen by the GP locum during a session.

‘Extra work’ may seem automatic as your practice-based GPs quietly work away in the background, often late into the night. But actually these tasks are critical for safe patient management. Each time a doctor is asked to sign a prescription or deal with a phone call or a query from a nurse, they are taking on full clinical responsibility for that patient. This requires close attention, access to medical records and time. This is especially onerous to a doctor who is unfamiliar with your practice procedures.

So it is important to discuss and agree with the locum what ‘extras’ will be provided and whether this will be as an integral part of the session fee with time allocated to these tasks or whether they will be charged at an additional rate. Again the NASGP Terms and Conditions is a useful template for these discussions.

• Extra patient contact:
  • Seeing extra patients.
  • Dealing with telephone contacts with patient outside of the agreed surgery.
• Extra non-contact patient management tasks:
  • Signing repeat prescriptions.
  • Signing prescriptions on behalf of nurses.
  • Dealing with clinical letters.
  • Dealing with results.
• On call duties. Clarify times, whether on call in addition to a fully booked routine surgery or emergency appointments only.
• Nurse enquiries.
• Trainee supervision.

Any special enhanced services

• A GP locum may be able to undertake enhanced services like minor surgery, fitting contraceptive implants or offering services related to their special clinical interest.

Any important exclusions

Occasionally there are some services GPs are not able to offer. For example:

• They may not be an ‘authorised’ cervical smear taker.
• They may not have IUD training.
• They may have conscientious objections to requesting terminations.

Agreeing T&Cs is a balance between getting the best for your practice whilst also recognising that you are dealing with a professional who is going to have the responsibility of managing your patients.

Agreements need to be clear and fees need to balance the practice circumstances whilst recognising the professional running costs of a GP. GP locums have to fund their own professional costs (GMC, medical indemnity etc) CPD, appraisal, study leave, annual leave and sickness cover.

Competition law prohibits the direct publication of suggested fees for locum work by membership organisations. However the BMA together with the NASGP have issued general guidance on how to consider agreeing a fee.

Factors such as anticipated workload, the locum’s experience and what other GPs are paid may be part of the negotiation.

It is a statutory requirement, if engaging a GP locum who is paying contributions from that session in to the NHS pension scheme, to pay them the employer’s contribution. The locum invoice should clearly state the separate charge for the employers pension contribution and then the locum is obliged to hand on this employer contribution alongside their own employee contribution to the area NHS team.

Yes. It can be useful to give locums some context around you’re asking for cover. It can make a difference as to how they prepare themselves to work at your practice.

Sickness

Covering for a GP on sickness leave may mean your GP locum’s support will be even more appreciated.

The absent colleague may have been unwell for a period of time before taking leave which may have affected their performance.

Patients are often concerned when their usual GP takes sick leave and it can be useful for the locum to know what has been communicated to patients about their GP’s absence.

Shortage

If you’re short of permanent staff, your GP locum might be a potential recruit. Letting the GP locum know will also help them understand that your practice may need extra support and patient satisfaction may not be as high as your practice would normally hope.

Suspension

GP locums will appreciate being informed of any performance concerns as it offers them the chance to be extra vigilant for shortfalls in care and they will want to support you and your patients.

Using the NASGP Terms and Conditions template is of great way of agreeing and confirming terms.

Model locum Terms and Conditions template

Yes. If you have no choice but to cancel a session with a GP locum, always give as much warning as you possibly can. More than one month’s notice would be deemed fair and acceptable, but any less than this and the locum would expect compensation – usually on a sliding scale – if they couldn’t find alternative work.

Please consider the politest way to inform the locum in the circumstances. For instance, notification of a cancellation of large amounts of work at short notice may require sensitivity if you want to preserve a future working relationship with the GP locum and maintain your practice’s reputation with other local locums.

If a practice has a concern that a GP is unsuitable to practise in your practice for any clinical reason, the practice has a duty to raise this with the GP concerned and/or take further steps as appropriate (GMC: Raising and acting on concerns about patient safety (2012) Part 2: Acting on a concern). This protects patients and colleagues.

Raising concerns also gives the GP locum the chance to learn, reflect and improve and prevents the practice passing any concerns on – perceived or real – for another practice to deal with.

Give locums access to your practice induction pack. An induction process is key to ensuring your locum spends their time in the safest, most effective way possible.

Check the locum is set up with a secure logins and is familiar with your IT systems.

A properly-stocked consulting room – it may sound obvious but it is astonishing how often this doesn’t happen and there is a mad dash to find which room is free, causing stress to the staff, followed by more delays as the chosen room is unlocked and set up.

Having to interrupt a surgery to look for equipment has several implications, ranging from the inconvenient and frustrating to the unsafe:

• It delays the surgery causing frustration to patients, and then the practice when patients start to complain.
• It disrupts practice staff who have to interrupt their tasks to help locate the missing items.
• It undermines the locum in front of the patient.
• It annoys the locum who will move you down their preferred list for future bookings.

A welcome induction tour is more than just a professional courtesy. It allows the locum to be given a quick induction tour of your premises and a familiarisation with key staff on duty.

The basic welcome induction tour should include:

• Important safety features like location of emergency equipment, fire exits and panic buttons.
• A brief nod and familiarisation with other GPs, nurses and secretaries.
• Their room, navigating any locks and door codes.
• Access to toilets and refreshments.
• A final check that the computer system is accessible and the room is adequately stocked for a smooth-running surgery.
• A ‘point of contact’ for any enquiries during the session.
• Up-to-date information about your practice processes and referral pathways (ideally in an easy-to-search practice induction pack).

GP locums have to gather feedback from colleagues and patients once in every five-year revalidation cycle – just like practice-based GPs. They will need to work in co-operation with their employing practice to achieve this.

It is hoped that all practices would see GP locums as professional colleagues and members of the primary care team and support them with their revalidation requirements.

So vital is this feedback to learning and revalidation – we can’t work without it – that many locums now specify this support in their Terms & Conditions.

The NASGP has produced the following advice to locums about carrying out patient and colleague feedback surveys.

Like any GP, locums will come across patients of concern and wish to learn from the outcome of a treatment or referral. As a GP locum may not have ongoing access to your practice or medical records, they may need to do this by contacting the practice at a later date.

This is the natural behaviour of a committed, reflective professional and is the mark of a quality locum.

Different practices have different strategies for identifying a locum who makes contact in this way to ensure they are not breaching confidentiality e.g. asking for the practice record number of the patient concerned as this is a detail that is only known by someone who has had access to the practice records, having a named individual who liaises with locums and recognises them.

It would be of help if each practice could let the locum know of their practice procedures on this important matter.

Fairly-given, constructive feedback can be a great way of improving quality for your locum and your practice.

If done well, it can also win you the admiration and loyalty of a GP locum.

Many in the health service realise that we still have a long way to go before we catch up with other safety critical industries in how we perceive feedback and complaints. It’s hard to give and receive negative feedback and our natural psychological tendency as human beings is to try and simplify and individualise ‘blame’.

If something has gone wrong in a patient’s care and a GP locum was involved, it may seem easier to conclude that it must be the locum’s fault and not book them again.

In reality, mistakes rarely happen purely because of the actions of one individual.

Individualising blame misses out an opportunity for the practice and locum to learn what really happened and look at the whole system and sequence of events that led to any mistakes.

NHS Scotland has developed an excellent tool for looking at system wide problems called enhanced significant event analysis, and we recommend this approach to our members.

• • Significant events and Swiss cheese

Oh – and we mustn’t forget that feedback means positive as well as negative.

GP locums get a very intimate view of your practice. They sit in your consulting rooms, try and navigate and learn about your systems and talk very closely with your patients. And they do this in up to 40 practices a year, perhaps across different CCGs.

This gives them a unique and valuable perspective.

Some practices try and capitalise on this by soliciting locum feedback with exit feedback forms at the end of a session.

Pay in accordance with your agreed T&Cs. Late payment causes work and stress for both parties. Delayed payments can adversely affect the locum’s NHS pension contribution by breaching the scheme’s payment deadlines.

• Referral risks
• Test results
• MPS urges practice to set up confidential logins for locum GPs
• How to safely follow up a patient

GP locums are perhaps more vulnerable to complaints than other GPs. The GMC, in its pilot studies of gathering colleague and patient feedback, found that doctors who weren’t a regular part of a team tended to receive more negative feedback.

As human beings, we all have a psychological bias to simplify and individualise blame. We also find it easier to complain about someone we have only met once and won’t see regularly.

GP locums have the same medical training and appraisal requirements as practice-based GPs but may not have the 200 or so non-clinical bits of information about how your practice works and connects up with local services. And without induction and support, locums may be more susceptible to administrative errors in your practice, which can lead to lapses in patient care.

Mistakes rarely happen purely because of the actions of one individual, and individualising blame misses out on an opportunity for the practice and locum to learn what really happened and look at the whole system and sequence of events that led to any mistakes.

GP locums can act as a ‘canary in the mine’ for identifying weaknesses in your practice’s safety systems, or how you communicate practice procedures.

NHS Scotland has developed an excellent tool for looking at system-wide problems called ‘enhanced significant event analysis’, and we recommend this approach to our members.

Read more: ‘Significant events and Swiss cheese’

Yes. Please inform the GP locum of a complaint or significant event in a non-judgemental way

We all have a long way to go in giving and receiving negative feedback in a depersonalised, system based manner. Contrast this with the attitude of the aviation industry where staff who admit mistakes are feted as heroes because it allows for safety reviews.

In short, it can be devastating for a doctor to receive a complaint, especially if that doctor is working freelance, is perhaps professionally isolated and lacking in the camaraderie and support of other practice staff.