Locum experience can be invaluable for long term planning, according to Dr Philip Morgan
”You won't know; you're only the locum.” This is a common remark made to locums. But it is ironic as locums will often see a greater spread of cases and modes of management than many other doctors.
I worked as a registrar in several teaching hospitals before retraining as a general practitioner, and have worked as a locum in hospital and general practice over the past four years. I have seen many aspects of the profession and I realise that working entirely in one speciality, often in only one region, can produce tunnel vision. Yet locums are the Cinderellas of the profession who are rarely liked, badly treated, unrepresented, but always needed.
Locums tend to work either in hospital practice or in general practice, but there are an increasing number of doctors who work in both.
In general, general practice locums are financially better off than their hospital colleagues. Hospital locums are salaried, and so are paid net of income tax and national insurance. They are entitled to offset few expenses against their salaries, so there is little scope for reducing income tax and national insurance contributions.
General practice locums may also be employed through agencies with similar financial constraints as for hospital locums, but employment is more often obtained direct from general practices, in which case remuneration is received gross. Apart from the better rates that can usually be negotiated this allows locums to claim a wide range of expenses for income tax purposes. Legitimate expenses include running a car, telephone charges, printing, stationery, and accountancy fees. Accounts must be submitted annually to the Inland Revenue with whom the various expenses can be agreed. Normally once a basis is set up and agreed the same principle can be applied annually. General practice locums will need to set up their own personal pension arrangements whereas hospital locums will have this built into their salaries.
Whichever way the locum works, there are seasonal variations and an income cannot be guaranteed.
Locums have become increasingly important for hospitals wrestling to maintain round the clock services, but constrained by the new working arrangements of junior doctors. There has been a 20% increase in the use of locums between 1995 and 1996. There has even been a demand for locum consultants to cover for study leave. With this in mind, it is relatively easy to find work through an agency and the locum doctor will be paid at a significantly higher hourly rate than the incumbent doctor. The terms and conditions of service, including additional duty hours and notional half days may be different. These should, therefore, be checked prospectively.
The style of work is as variable as the locum wishes, with no previous experience or training required for many junior doctor locums. In some cases the hospital trusts employ “floating” locums who work in various departments.(1) This can relieve a manning problem for a trust and yet provide a broad view of current specialties in a short period of time. The flexibility of choice is always the locum's.
There are, however, disadvantages to being a locum. Personnel departments have been known to cancel appointments at the last minute, causing inconvenience and no compensation. If the post is confirmed the locum may find that the responsibility is beyond the job description and his or her professional ability.(2)
The incumbent staff often seem hostile, as I experienced. There was the attitude that as I was paid more I should do their work as well. But when I asked why they did not do the locum job the silence was deafening. It seems heresy to believe that doctors should work for money, as opposed to the glory of educational improvement.
Locums are often stigmatised as second class doctors, seemingly having a lack of responsibility. Even after three years as a teaching hospital registrar I have frequently been advised by junior staff on how operations should be performed. The irony is that locums often have more experience of different ways of managing conditions than incumbent doctors. But I have given up counting the number of times I have been told “we don't do that here,” even after it has been shown to be successful.
Problem of recognition
There is also the problem of recognised specialist training. There are two types of locum posts. There is the service appointment which lasts up to three months. It has no training element and cannot be used as training for a specialist registrar grade programme. And there is the training appointment. This offers training experience that may, if prospectively approved, count for specialist registrar training by the relevant college or faculty. A successful long term locum appointment can also provide useful contacts and references for the locum if he or she decides to progress in that speciality.
The majority of specialist registrar grade posts are linked within a two or three year rotation. These rotations are always in great demand and are often booked months or years in advance through the hospital tutors or regional advisers. So if the locum likes the specialty he or she will have to wait to the end of the queue or be lucky if someone drops out.
General practice locums
The potential for locum work in general practice is enormous and so is attractive to different groups of doctors. This is evident from the Department of Employment's recent figures of a three fold increase between 1990 and 1996 in assistants. Unfortunately, there are no figures for other groups of locums, although a straw poll conducted by Dr Ian Banks of the General Medical Services Committee at the 1996 National General Practice Registrars Conference indicated that no registrars were willing to go directly into a principal post after training. The general feelings of uncertainty, ignorance, and the poor perception of the general practice principal were to blame. The option of the locum is attractive as no long term commitment is necessary.
The work can include single surgery sessions, regular retainer sessions, day time and evening visiting, as well as work in cooperatives and primary care centres. Locums can work in an inner city singlehanded practice, suburban modern multi partner medical centre, or in a rural practice with access to the local cottage hospital.
Longer locum appointments-for example, to cover maternity leave or sabbaticals-allow the locum to practise a special interest and assist in the surgery's clinics of antenatal and postnatal care, child health surveillance, and minor surgery.
The major bonus to the locum is to see how each practice differs in clinical and practice management. This is important as general practice registrars are closeted in the best 10% of all practices in Britain. As a locum they get a chance to see what the other 90% of practices are like, together with other aspects of general practice, including fundholding, commissioning, dispensing, and computing.
“You are not my real doctor”
A locum will be appreciated by the staff for easing their workload and may be recommended to other practices. Some patients see locums as a nuisance and complain, “You are not my real doctor.” These patients will book to see “their” doctor when he or she has returned.(3)
But patients often try you out as a locum.You will be used as a listening post or as a “free” second opinion. Others will try to wheedle a prescription or sick note out of you, when they believe “their” own doctor will refuse, while others do not care whom they see, as long as it is today. So you may be privy to previously untold secrets, be used to get around the regular service, or be asked to provide an immediate and necessary service.
The abundance of options provides locums with the chance of a potential principal post, an assistant's post with the clinical commitment and lower level of management responsibility or a retainer post with increasing flexible working arrangements and more time to spend with their family. They can branch out and do things that are not normally part of general practice, but require medical training. These could include private and occupational health work as well as clinical assistant posts. (4)
Dr Judy Gilley, a deputy chairperson of the GMSC, says that it is not surprising that the majority of locums are women working part time as this fits into their other commitments and also provides a service to some patients who will wait for a consultation with a woman.
However, Dr Richard Fieldhouse of the National Association of Non-Principals emphasises that the disadvantages of locum work include missing continuity of care, no maternity benefit, no annual leave pay, no college recognition, no postgraduate education allowance, and limited professional camaraderie.
Locums have a reputation of being “suboptimal” in their work and there have been threats to introduce logbooks or a central register to prove their competence.(5) This is because of the notoriety of a few locums, but it is unjustified to generalise all locum doctors because of one or two. (6)
There is, however, no perfect system that can be applied to the locum workforce that should not be equally applied to the incumbent staff.
Locums are in great demand. The work is varied. The pay is good, although it is not guaranteed. The general terms and conditions can often be poor, without any national representation for support. There are, however, obvious differences between hospital and general practice locums. General practice locums have a distinct advantage over their hospital colleagues, with better appreciation from colleagues, and advantages of self employment. Furthermore, working has no effect on postgraduate training. The locums are already fully trained.
Locum work is flexible and interesting. It gives the doctor the chance to see many aspects of medicine without the requirement of a long term commitment early in a career. With the ever increasing demands for a better quality of life, part time work in an unstructured or semi structured form is possible.
Philip Morgan is a locum in hospital and general practice.