For years, we've been calling for recognition that locuming involves performing in a specialised environment requiring at least a mention in formal GP training. We brought that together in a one-day GP locum masterclass with the BMJ in October 2015.
Ask any locum GP who’s worked in a few different surgeries over a period of a few weeks, and they’ll all have a similar story to tell. On top of the clinical complexity and the vast casemix that is the staple of general practice, they will also have had to negotiate finding out the ways things work in each practice, the local services that are available (and which ones aren’t), getting to know the personalities, strengths and weaknesses of staff and colleagues, and developing trust and rapport with all the new patients they’ve been caring for.
Some practices could have booked a locum because they’re off on a shared learning day to really get to grips with some great quality improvement, whereas other struggling practices may have made a booking in desperation after one of their colleagues has gone off with stress, or simply resigned, or even been suspended with a cloud over their head. Whatever the reason, how do we as locum GPs make sense of all this “soft information” to make sure we’re practising safely and effectively?
Locums need strategies to become specialists at dealing with the unfamiliar. But none of us have had any formal training on how to properly deal with this very specialised working environment. Not as a GP trainee working in specially approved training practices, or as partners or salaried GPs where we have more time at the same place to pick up most vagaries.
Which is all why, after calling for better locum GP induction and training for so many years, we were delighted to have been asked by BMJ to work with them to put together a unique day-long Masterclass specifically for GP locums to learn from and interact with experts on topics that can be challenging to GP locums, whether novices or experts themselves.
The day began with NASGP’s Richard Fieldhouse on the steps a GP locum should take to try and hit the ground running, no matter where it is you’re working that day. How can you ensure your expectations match those of the practice, how do you assess whether you're working in a well run or a disorganised practice; how safe is it to sign repeat prescriptions; what’s the best way to put a disappointed patient at ease; how do locums report ‘issues’ to the practice?
Prescribing is a whole issue on it’s own, so we asked Tony Avery, Dean of the School of Medicine at the University of Nottingham, a GP himself and Professor of Primary Health Care, to expand on the role of locums when asked to review medications or sign repeat prescriptions with no prior knowledge of a patient and limited time to review the notes. Tony looked at the unique challenges locums face in prescribing and also how to approach the issue of polypharmacy.
Fresh pair of eyes
Following on from this, John Sanfey, previous GP partner and a chambers locum GP, revalidation lead and medical adviser in NHS London, reflected on his work with the RCGP’s national cancer case studies in appraisal and relate this to how, as GP locums, we’re in a very good position - often seeing urgent cases, being a fresh pair of eyes, usually without prior knowledge of a patient - to make a cancer diagnosis. Recognising potential signs of cancer where patients may not present with the typical ‘red flags’ can be a challenge, particularly when we don’t always have the opportunity to follow these up as a locum. What do you do when you see a patient with a cluster of symptoms that you suspect may be cancer but don’t fit the typical two week wait criteria? How do you ensure follow up and safety-netting when you have a patient of concern but do not have ongoing access to their primary care records or involvement in their care?
Managing mental illness
Patients presenting with mental health problems can be a particularly tricky area for locum GPs. Mark Salter, consultant in adult general psychiatry in East London, teaches about mental illness and has published extensively on the subjects of substance misuse, schizophrenia, mental health legislation and community care. He gave a rundown on how you can make a difference without continuity of relationship. How do you gauge what is ‘normal’ for your patient when meeting them for the first time? When can seeing you provide added value, and when is it not helpful for a patient to feel like they are ‘repeating their story’? This session provided tips for assessing patient’s mental health when meeting them for the first time in a 10 minute consultation, and also approaches to help deal with chronic mental health or personality disorder as a locum.
All in 10 minutes
And finally, we held a highly interactive session where one of our speakers, Tony Burch, used three case histories, provided by a panel of locum doctors, to illustrate the importance of using a robust but flexible approach to assessing the frail elderly patient based on the Comprehensive Geriatric Assessment, a useful tool when confronted with illness, multimorbidity and social issues. He also addressed the four common acute presentations in older people: falls, confusion, incontinence and immobility. The importance of the functional assessment, together with a medical diagnosis, will help guide locums to draw up a plan of care, which will address the immediate issues, and can then be passed on to the practice or elsewhere.
It was a great day, and feedback was exceptionally positive. I really enjoyed meeting fellow NASGP members, and look forward to planning another of these events again soon.
Richard has worked as a freelance GP locum since 1995 in around 100 different practices, living and working in West Sussex and Hampshire. He founded NASGP in 1997, he is NASGP’s chairman and started the UK’s first locum chambers in 2004.
He enjoys walking, is a keen potter, reads too many books on behavioural economics and has an unhealthy obsession with his sourdough starter.