Improving quality in locum general practiceBMJ 1998; 317 doi: http://dx.doi.org/10.1136/bmj.317.7150.2a (Published 04 July 1998) Cite this as: BMJ 1998;317:S2a-7150
Simple actions can dramatically increase the worth of locum work for both practice and patient. Respect, information, and education underpin Shaun O'Connell's strategy to enhance the value of the locum GP to the NHS
“You can't expect him to know, Mrs Jones. He's just the locum.” The receptionist sighed sympathetically. “Look, I can squeeze you in with Dr Brown next Tuesday … he's going to be very busy when he gets back.” Such scenarios are enacted across the country every day, destroying patients' confidence in general practice and doctors' morale - principals and locums alike. The receptionist's words are probably contrary to the General Medical Council's guidance(1): “You must not make any patient doubt a colleague's knowledge or skills by making unsustainable comments about them.”
Who is to blame if locums really don't know? Amid an explosion of non-principals' self assertion and a recognition of the need for non-principals in general practice, it is essential to look at where we are going wrong. The National Association of Non-Principals has just published its Code of Good Practice.(2) This attempts, for the first time, to establish standards of behaviour for non-principals and practices. In doing so it hopes to reduce the frequency of situations such as that described above.
This is more than just a locums' charter. With the endorsement of the Council of the Royal College of General Practitioners, it aims to improve the quality of the service delivered to patients.
Many factors contribute to patients' needs not being met. Adequate qualifications to do the job should not be a problem. Most non-principals qualified recently,(3) are vocationally trained,(4, 5) and have one or more postgraduate qualifications.(4) However, experience shows that, while bogus locums are fortunately rare, practices' failure to check even GMC registration, let alone qualification to work in general practice, is distressingly common. This is despite it being a specific GMC expectation of general practitioners.(1) The NHS Executive has issued guidance to secondary care trusts, which, though not intended for general practice, provides useful advice.(6)
Pay and conditions
In most parts of the country demand for general practitioner locums is high. Market forces usually determine the cost of services, with influence from the BMA's recommendations.(7) These indicate that full time locums should receive 75% of principals' intended average net remuneration. Many practices continue to try to push down the rates, which in any case fail to adequately define the expected workload for each session. This often leads to practices imposing unreasonable workloads for “standard” rates. You get what you pay for: it is easy for a locum who feels exploited to actually do little except prescribe unnecessarily lavishly. Such perverse and naive attempts at retribution are totally unacceptable - so is exploitation. Undoubtedly, there is truth in the saying “money motivates,” and meanness certainly demeans. Revised BMA rates are awaited with anticipation. Appropriate and prompt remuneration is as important as the locums' duty to help practices claim their due fees.
Money is not everything. Non-principals in particular believe this, exchanging income for flexibility in their working lives.(2, 3) Such flexibility and adaptability are the key strengths of non-principals. As the demands on principals increase, the fluidity that non-principals provide, enabling smooth delivery of services, becomes ever more important. Flexibility is not synonymous with unreliability or acquiescence. When work is booked both parties should formally confirm their verbal agreement and recognise their reciprocal responsibilities. The GMC's Duties of a Doctor state: “You should not withdraw unless the employer will have time to make other arrangements.”(1) Guidance should also be given to medical employers. Cancellation at short notice by either side is unacceptable. Booking patients at sensible intervals is a quality issue; less than 10 minutes per consultation risks professional discomfort and patient dissatisfaction. Doctors with time will deal with problems (that is why they became doctors). Doctors who are rushed will probably not. There is no incentive to run late and work for free when a practice has no regard for you or its patients: “Here's your prescription. Come back next week, Mrs Jones. I'm sure Dr Brown will be able to help you with all the other problems.” This may seem lazy, but with a surgery of 20 patients booked at six minute intervals the job resembles fire fighting. Should locums just douse the flames until the back up arrives?
Access to information
As we approach the millennium the value of information has become apparent. Why then do practices expect a locum general practitioner, who has been in the building for all of 10 minutes to conduct a surgery at the same speed and efficiency as an established principal? There is a huge need to communicate routine information to locums, who are expected to deal reasonably with patients' problems. When such basic information is omitted quality and productivity will suffer. The National Association of Non-Principals has published a “practice pack” - a standardised information template for practices to complete so that non-principals can rapidly get answers to common questions.(8) Induction to a practice for all non-principals has also been recommended.(4) Such efforts reduce staff interruptions or doctors not bothering (“Hmm, the receptionist isn't answering the phone, Mrs Jones. You'd better come back next week to get the blood test done”).
Computers are a perennial headache. Many locums show great skill with and knowledge of the common general practice systems. What happens when they don't? How safe is it for a locum to be unable to access a patient's electronic records? When will the accidental deaths due to the interaction of itraconazole with long repeated terfenadine begin? How many patients, long established in taking mianserin, will know its name (let alone the need to check a full blood count) when they see a locum for bronchitis? How can the locum know if the patient doesn't and he or she cannot access the records? While all doctors are individually accountable, and non-principals should, when practical, participate fully in the complaints system, only principals will face the service committee hearing. Both locum and principal may have to face a coroner, the GMC, and the press-possibly all for the sake of paying for half an hour's training on the computer.
Access to information goes beyond the practice. The Standing Committee on Postgraduate Medical Education (SCOPME) reported that only 22% of non-principals had received an edition of the British National Formulary.(4) They logically recommend that non-principals should be included on mailing lists for important publications. Why do some general practitioners receive two editions of British National Formulary a year while others get none, ever? SCOPME also found that 70% of non-principals had received no careers advice in the previous five years and that most ranked “recent advances” as the area in which they needed more training. Such deficiencies, exacerbated by the lack of educational support, particularly expose these doctors to new GMC performance procedures-a situation that unsupported doctors will find all the more stressful and expensive.
May 1998 heralded the publication of two major reports on general practitioner education; the long awaited chief medical officer's Review of Continuing Professional Development in General Practice(9) and the SCOPME report, The Educational Needs of General Practitioner Non-principals.(4) While the latter is encouragingly forthright in its recommendations, the former specifically, and disappointingly, excludes “casual workers…doctor[s] working as locum[s] in several practices.” In doing so, it risks condemning them to remaining second class doctors and the patients they treat to a second class service. Such an exclusion fails to acknowledge the actual situation in general practice - the ever increasing demand for locums and the ever increasing service provided by them.
SCOPME recommends that general practitioner non-principals should be included in initiatives to help general practitioners draw up plans for personal education and development. Crucially, SCOPME echoes others(10) in recommending that mechanisms need to be devised so that non-principals have appropriate access to financial support to meet their educational needs. The chief medical officer's review introduces the concept of “practice professional development plans” as a replacement for the postgraduate education allowance. This would concentrate activity on the service needs of the practice but should also encompass individuals' career aspirations. It does not suggest how short term locums could fit into such plans. Indeed, non-principals would probably need to be in post for at least a year to participate personally and benefit from this model. It would seem that those on shorter contracts are to remain educationally out in the cold. Why should this be so? Changes proposed in the 1997 government white paper are likely to increase the need for locums.(11) Denying reality sells patients short.
If the new NHS is to be modern and dependable it must recognise the value of the doctors it has trained and who still work for it. General practitioner locums are a vital group without whom general practice could not function. For the sake of patients, the Department of Health, employing practices, and locums themselves must recognise their responsibilities and work together. Quality is not a superficial issue. Provision must be equal for all.
Standardised practice pack*
Strong plastic box
Forms section to hold all clinical forms
Space for British National Formulary
Space for a peak flow meter
Information templates include space for:
Local non-principal group
Hospital contact details
Fast track clinics
Hospital referral details
How to refer for particular conditions
Visits and out of hours supplement
Item of service record forms
*Available from National Association of Non-Principals, cost £25 (fax: 01243 536 428)