If something goes wrong

Significant events and complaints involving locums

Locum GPs are perhaps more vulnerable to complaints than other GPs. The GMC, in it’s 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. Why is this?

Factors to consider

  • Psychological bias as human beings to simplify and individualise blame, and people - patients and practice staff - feel more able to complain about someone they have only met once and won’t see regularly.
  • Enforced underperformance
    • Locums have the same medical training and appraisal requirements as practice-based GPs but they will not have the 200 or so non-clinical bits of information about how your practice works and connects up with local services.
    • Here is a not untypical experience of a locum session. See if you can spot the flashpoints of preventable delay and gaps in essential information provided to the locum that were stressors on patients, practice staff and the locum, culminating in a lapse in patient care and a complaint.

All in a morning's work

  • Locum arrives 30 minutes before the start time of their session and introduces themselves to receptionist. No room has been allocated and it takes a few minutes of discussion before being told “You’re in room 7”.
  • The door is locked, so the locum has to return to reception to get it unlocked.
  • The computer operating system is not switched on, and no login has been prepared. Booting up and finding a login involves discussion between 3 members of practice team and takes 15 minutes.
  • Meanwhile the locum notes there is no practice induction pack, so is trying to ascertain how to arrange common investigations and referrals.
  • The surgery starts 15 minutes late because of these delays.
  • During the surgery, the locum realises that clinical equipment is missing from the room. They do not know where to get this from. They call reception - the only internal phone number they have been given - who then tells them to go the treatment room.
  • The locum does not know their way around the building  and has to walk through the waiting room past frustrated, delayed patients, looking lost.
  • In the treatment room, one of the practice nurses asks “Can you just sign this while you’re here?”. It is a prescription for prednisolone and doxycycline. The locum does not know the training of the nurse and is put in the uncomfortable position of having to explain that they cannot take clinical responsibility without time to look into this further. The nurse is offended and angry.
  • Following the surgery, the locum completes a chest x-ray referral form and hands it to a member of the admin team, only to be told that the patient should have kept the form and been given a phone number to make their own appointment.
  • They need to dictate an urgent referral letter but have not been provided with dictation equipment - more delay as a dictaphone is found.
  • By now the locum is in a hurry to get to their next practice. The locum returns to reception where everyone is busy on the phones. They ask how this urgent referral tape should be processed and are told by a distracted receptionist to put it in the secretary’s  tray. The locum is faced with a wall of pigeon holes with people’s names but doesn’t know who the secretary is.
  • The distracted receptionist did not tell the locum that urgent referrals should be placed in a red folder to bring them to the secretary’s attention.
  • The urgent referral was therefore delayed. A letter of complaint was received from the patient, particularly singling out the role of the locum who the patient assumed was responsible.

Tips on approaching locum significant events

Think of Swiss cheese!

  • 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.
  • 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

Involve the locum

Please inform the locum in a non-judgemental way

  • Please recognise that 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.

Medical records

  • Offer them the opportunity to access any relevant medical records and discuss with your practice staff
  • It may help to work together on a copy of enhanced significant analysis, allowing the practice to find out what really happened and identify contributing factors.

If you have been involved in a serious significant event that caused harm, or had the potential to cause harm, you may find the process of enhanced significant event analysis helpful.

'Significant event analysis' here is different from a 'significant event' for the purposes of appraisal and revalidation; this is the name given to this very enlightened and useful form of incident analysis by its developers at NHS Education for Scotland and the Health Foundation.


Significant events and Swiss cheese

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Cancelling sessions through unforeseen circumstances such as illness is just one of those things. Obviously, it shouldn't be undertaken lightly as it can create an inordinate amount of inconvenience for the practice and patients. Wherever possible, if you can help ease the inconvenience by suggesting an alternative, then so much the better - but not always possible considering the precipitating circumstances.

If you make a habit of cancelling in this way, the sad reality is that the practice will think very hard about booking you again.

But cancelling work because of a change in mind, a better offer or to take a holiday is invariably professional suicide. For starters, the GMC's Good Medical Practice has something to say about this, and bad news about a locum cancelling at such short notice would (and does!) spread like wildfire to other practices. Unforeseen circumstances aside, only ever book work that you know you will not have to cancel.

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A cancellation can be devastating for a locum GP, particularly if it's last-minute. You may have put off other work in order to undertake the planned work, and of course may have dependents, a mortgage, loans. Same applies to anyone, which is why you have legal rights in this situation.

Firstly, refer to the terms and conditions that you agreed to - if you used the NASGP's model T&Cs, you will have a cancellation clause that means the practice must pay you a certain figure if cancelled within the agreed time limit.

If there is no agreement in place and the practice does not pay appropriate compensation the locum may be able to pursue a claim for breach of contract in a small claims court - have a word with your BMA or MPU Industrial Relations Officer or, if you get no joy, your local Citizens Advice Bureau should help you out.

See more in the NASGP Locum Toolkit

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If you have no choice but to cancel a 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.

Consider the implications

  • The locum may not be able to find alternative work and therefore suffer a crippling reduction in household income.
  • It's highly likely that the same locum may never accept work in your practice again.
  • There are over 100 locum groups around the UK, where locums meet up on a monthly basis to discuss clinical and work issues; it doesn't take long for the word to get around that you don't honour bookings, and therefore put your practice at risk of getting clinical cover when it's needed.
  • In booking a locum GP you have made an 'unconditional' contract of employment, and so breaking that contract could entitle the locum GP to financial compensation should they ultimately end up out-of-pocket if they can't find other work in time.

Communicate wisely

Although this goes without saying, NASGP has heard of instances where the GP has been told by text message! Notifying the GP concerned should always be done by the practice's senior manager or a partner, ideally in person or at the very least by a timely phone call, followed up by a written confirmation.

We've decided the locum is unsuitable and so we want to cancel them

If you have a concern that a GP is unsuitable to practise in your practice for any clinical reason, you have a duty (GMC: Raising and acting on concerns about patient safety (2012) Part 2: Acting on a concern) to raise this with the GP concerned and/or take further steps as appropriate. Although 'simply' cancelling the locum, or making the decision to never book them again, might be the easiest thing to do for you, it robs the locum GP of any chance to learn, reflect and improve the care that gave and simply passes those shortcomings - perceived or real - on to another practice.


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