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Increasing numbers of GP are abandoning partnership to work as locums in the hope that this will be an improvement in their work life balance however a lot of what is described about GP locums is based on anecdote. A survey I carried out last year showed that working as a locum is helping to keep GPs in general practice and that being a member of a sessional GP group is also aiding retention. It is time for us to have a better understanding of how locums operate and the challenges we/they face. With this in mind I carried out an online survey of locums in the North East earlier this year. They were contacted via the North East sessional GP group which is a support group for sessional GPs run by volunteers. Out of 402 NESG members who were invited 235 consider themselves to be locums. Of these 59 responded (25%).
The factors which influence the decision to work as a locum (rated from a fixed list) in order of importance were:
Written terms of agreement are agreed in advance 56% of the time (often 24%, nearly always 32%). Some locums found negotiating terms straightforward using standard written terms but some locums struggled to feel in control of additional unexpected work.
Written terms seemed to be welcome by some practice managers as a sign of professionalism, others felt less positive about this. There was a recurrent theme that if arrangements were not satisfactory locums would just leave and if they felt unsafe would leave at short notice.
Several locums mentioned that agencies remove the need to negotiate, which was welcomed even when the “terms” of work were defined by the agency or federation suggesting that certainty of limits on workload were for some more important than having the autonomy to define them yourself. To avoid the awkwardness of negotiation respondents said they would often tend to stick to practices they know. Some mentioned using NESG booking templates.
Locums vary in their willingness to sign repeat prescriptions depending on whether they are in short term or longer term placements: 38% versus 21%.
Locums were more willing to sign when review mechanisms were robust but were reluctant to sign repeats for problematic prescriptions like DMARDs, controlled drugs, sedatives and medications outside of review period and no monitoring. They also highlighted refusing to sign scripts for nurses and nurse practitioners without knowing what protocols they followed, and the standards of their work, unless they had allocated time to review each clinical decision themselves.
The means by which locums obtain work appears to be changing with the commonest being direct approaches from practices (85%), NESG alerts 66%, but a rising number using agencies 31%, and web platforms 12%. This is interesting given an increasing trend for practices to use intermediaries (agencies, federations, chambers) to get locums in order to avoid the burden of having to carry out pre-employment checks.
The factors which influence the choice of practice to work in order of importance (from a pre-defined list) using a rating scale from 1-10 with the most highly rated factor average being 8.7, and lowest rated factor being 6.9.
Free text comments indicated that additional factors influencing choice of practice were:
Locums felt generally excluded from CCG protected learning time out events due to lack of information or having to book via a practice, where the practice manager might be hard to get hold of or having to complete additional forms to prove they had worked in a specific practice. Locums suggested that CCGs could consider supporting them better through better access to timeouts and compulsory training, newsletters, updates on services and pathways and access to GP team net, as well as facilitating access to Occupational Health. CCGs have tended to restrict locums’ access to their events unless the locum can demonstrate that they ate “attached” to a practice to working predominantly in one CCG so we looked at working patterns and found that over one month locums work across an average of 1.3 CCGs, over 3 months its 1.52 and over 12months the average is 2.09. 41% had been in their current practice for more than 6months, 25% had worked at their current practice for 3-6 months, and 34% had worked at their practice for less than 3 months.
They were asked what LMCs could do to support locums and the recurrent issues mentioned were support with Indemnity, pensions, help with sickness insurance schemes, access to newsletters and information especially about CCG timeouts, access to mandatory training, guidance to practices about terms of engagement with locums, locum induction improvements at practice level. Some respondents indicated they did not understand the role of LMCS.
What could NESG (North east Sessional GP group) do to support your work as a locum (in addition to any support already provided)? Respondents said they valued the group highly but mentioned promoting use of the NASGPS electronic induction pack for practices, support on pension difficulties, promoting better access to time outs and encouraging involvement in LMCS. As a volunteer run support organisation NESG does not see itself having a union/BMA role beyond raising awareness of issues with outside organisations.
Locums working out of hours described the experience as isolating, focused on efficiency and throughput with an unsupportive culture and management. The indemnity was a barrier for many due to cost or concerns about the type of insurance based indemnity provided by the employer.
The survey highlights some well-known themes and potential areas for action.
GPs are moving into locum work to gain better control over workload and they vary in how successful they feel at negotiating clear boundaries around their work (for example signing scripts), so there is an opportunity to develop template booking tools to aid both locums and practices.
There is a perception that LMCs and CCGs could both improve their locum access to information about services, pathways and education especially mandatory training and that NESG and LMCs could encourage practices to have better induction processes and adopt the NASGP SPIP. I have produced a video on locum induction intended for practices.
Paula Wright is a salaried and locum GP, a North-east representative for sessional GPs and former chair of North East sessional GPs
Follow her on Twitter @PFW69
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