Doctor for hire

WHEN you finish your GP training, there are various career options to consider, from the commitment of a practice partnership to perhaps working for the armed forces. One career option that may not immediately spring to mind is locum GP work. While this role might not suit everyone, it is certainly worth considering.

I chose to work as a GP locum because I wasn’t ready to commit to a partnership at the end of my registrar training. Over the years I've met many different GP locums at various stages in their careers. Many of them are GP registrars who have not yet found a partnership but are keen to do so, while some have made a positive career choice to be a locum GP because they appreciate the flexibility which this work offers.

Others are returning to general practice work following a career break and some have left a partnership because they wanted to change their career plans. There are also retired partners who choose to locum to keep their hand in with clinical work.

Variety

Work as a GP locum can be very varied and interesting. You can work in a variety of urban and rural practices experiencing a range of different settings of general practice. In the five years I have worked as a full-time locum I have gone from doing long-term regular sessions with a limited number of practices to working in a different part of Scotland and completing ad hoc sessions with more than 40 practices over four health board (PCO) areas in six months.

At other points of my career I have had a succession of long-term maternity locums based in one practice. There are advantages to this in that you can become part of the local practice team (though this depends on the practice) and get some continuity of care with patients.

Unpredictable

It’s hard to know what you’ll come up against in a new practice. I have faced some interesting challenges, often because the individual practice units are disorganised. One year I went in to cover a single-handed practice after the Christmas break to find the computers were down, the receptionist did not have any instructions on what to do and the practice managerwas unavailable. Fortunately in this scenario I used my own expertise to get the server running again whilewaiting for IT support.

Other more rewarding challenges have included stitching up an elderly lady’s hand after she cut it filleting fish, saving her a long trip to the local emergency department, and then seeing her a few weeks later with it all nicely healed.

Pros and cons

Locum work has many advantages, including being your own boss and deciding when you want to be available for work. When you do work, you are contracting to provide a service to a practice so it is important to be professional about that and provide the kind of service they want, but in my view the flexibility of having control over when and where you decide to work outweighs any problems.

Also, you don’t have to worry about many of the management issues that partners have to deal with. This includes building maintenance, practice staff management and HR issues like poorly performing staff, absenteeism or what additional contracts the practice will agree with the board. You can work in a wide range of practices and choose not to return if you don’t like working in one place.

On the down side, unless you get a long-term locum contract you often lose out on the continuity of care that is sometimes regarded as key in general practice. You also have to deal with the variable availability of work so plan for the lean times when it is busy.

On occasions the practices you work in may not be as organised as you’d like, and you are usually unable to influence those systems. Equally, practices often don’t make clear the details of how they operate and local referral processes can be very varied, making it a challenge to know exactly how to manage patients.

Continuing professional development and not having a fixed group of peers can be a challenge as a locum, which is why it is important to be involved with your local sessional GP group. The National Association of Sessional GPs (www.nasgp.org.uk) keeps a list of local groups, though this can be out-of-date for some areas. In some regions these groups have links with the Local Medical Committee, which is a good way to get your views heard by representatives of local practices.

Medico-legal challenges

A lot of what you do as a locum is the same as any good GP should be doing – keeping accurate and contemporaneous records. But there are some areas where the lack of continuity potentially puts you at risk. If you decide to refer a patient, how do you make sure you complete the referral? Do you have a system for ensuring that referrals you dictate are completed by the practice? Can you be sure that someone will follow-up on any test that you request?

Often the answers lie in linking with existing systems for the practice you are working in, but making sure that you hand over key tasks at the end of your session is an important part of being a locum GP. I got into the habit of documenting the next step I planned in the notes so that anyone could pick up where I left off.

One of the biggest frustrations for locum GPs in the medico-legal sense is the reluctance of many practices to give you your own login to the clinical system. This is more important these days when nearly all practices rely on the computer system for notes. It is particularly frustrating for locum GPs given that the requirement for unique individual logins was part of the Scottish Information and Management Technology DES a few years ago, as well as being part of general good IT practice and also good practice from a medico-legal viewpoint. If you are unfortunate enough to be given a generic “locum” login to the clinical systems or, worse still, expected to use the login of a partner then it is important to put either your name or initials at the end of any clinical entry to identify yourself.

Tips for starting as a GP locum

• Get on the performers’ list of your local health board/PCT. Read detailed guidance from the Department of Health at www.tinyurl.com/2bo8lrd
• Join a local sessional GP group.
• Register as self-employed with HMRC and pay National Insurance contributions within 100 days of starting work or you will be fined.
• Explicitly agree with practices in advance what work is involved for what fee. The BMA are developing example terms and conditions, and some locums have published their own on the internet.
• Keep accurate records of the work you do, mileage and other expenses for your tax return.
• Consider hiring a medical accountant who understands GP locum work.
• Create a system for making invoices, recording where you have worked and what you were paid, your mileage and completing pension forms. You can use standard office software, but also check the (currently free) Locum Organiser at www.locumorganiser.com
• Be polite to practice admin staff. They are usually a mine of information when you are unsure.

Dr Ian Thompson works as a part-time GP partner and part-time GP locum in south-east Scotland. He formerly represented locum GPs on the BMA’s Scottish GP Committee and UK Sessional GPs Subcommittee