Fiona Dalziel
MA(Hons) CIHM FIHM

Independent Consultant in Practice Management

Fiona is an experienced primary care trainer and facilitator. She is the national RCGP QPA Adviser and has advised on both the original and the review of the Quality and Outcomes Framework of the 2004 GP contract

Many practices use locums. Some do so regularly, not wishing or having the need to enter into a regular contract of employment but covering occasional shortfalls in availability of appointments. Most practices will need at some point to use a locum to cover the absence of a GP partner or salaried GP for maternity or sickness absence.

For practices in England, it is likely that experienced GPs in the practice will be drawn into involvement with clinical commissioning groups (CCGs) and managing the delivery of commissioning in the practice. This will, in turn, lead to an increased need for backfill in the practice by a locum.

Developing a policy
Making a decision about how the practice employs locums is better done in advance, as an agenda item, than 'on the hoof' when someone is ill and you need cover for the day after tomorrow. Consider the following:

• Does the practice want to set a minimum qualification that locums should have? You may feel that you wish to stipulate, for example, that any locum should be a current Member of the Royal College of GPs (MRCGP).
• Would the practice consider using a locum agency? Coverage of locum agencies is variable across the UK. In some areas, where locums are in short supply and word of mouth or desperately pleading emails are not generating any interest, working with an agency may be useful to explore. Look carefully at terms and conditions of the agency's agreement with the practice and undertake a cost-benefit analysis.
• What is the practice able to pay? If the manager is going to negotiate with potential locums, the GP partners should be clear in advance about what they are willing to pay. This will include defining the duration and content of a day or part-day, and may include additional payments – for, example, for doing a duty day. The British Medical Association (BMA) is no longer able to recommend pay rates, and local practices should avoid colluding with each other on what to pay because this would be in breach of competition legislation.
• What checks will be made before commencing a locum and during their employment? The elements to include in a pre-employment checklist are defined below. Additionally, the GPs may wish to check the standard of consultations including clinical decisions, prescribing, coding and other areas (eg, referrals). Agree who will do this, how they will do it and ensure that the locum is informed of this and the frequency.

Defining a pre-employment checklist

• If not employed by an agency are you satisfied that the locum is self-employed? HM Revenue and Customs provides guidance (see Resources).
• Obtain confirmation of the following in the form of a photocopy of the original:
  – The identity of the locum (confirmed by driving licence/passport).
  – General Medical Council (GMC) registration and that there are no restrictions on practice or other pending issues (see Resources).
  – That the locum is on the Performers' List.
  – That the locum has current medical defence organisation cover.
  – Criminal Records Bureau/Disclosure Scotland/Access NI checks are up-to-date.
• Ask for referees and follow this up with a written reference.
• Have a written agreement. The following is prepared with reference to the recent BMA document on locum agreements:(1)
  – How long is a session? How many appointments? How much administration time? What start and finish times? A standard session is defined in the salaried GPs' model contract as four hours and 10 minutes.
  – What hourly rate does this compromise?
  – This will be relevant if the locum is working a part-session for any reason.
  – If you want the locum to cover extended hours, what is the rate for that?
  – What will be the rate for being Duty Doctor?
  – Will you want them to undertake work in addition to the defined basics? What will the hourly rate be?
  – If the locum is to undertake non-GMS work (eg, private certificates), what is the fee arrangement?
  – If doing house calls, what is the travel reimbursement arrangement?
  – To help workload planning, and ensuring that the practice does not pay more if the locum runs late, define how this will be covered.
  – How will the locum be paid and when? Ask for an invoice for the practice's records.
  – Ensure you have the correct documentation for informing the primary care organisation of the payment the locum has received for superannuation purposes (GP Form A).
  – If you find that you need to cancel a locum, what are the terms of this arrangement?
  – What sessions do you require? On what dates?
  – If the locum works different hours on a Duty Day or has to be available on the phone, what are the arrangements for this?
  – Are routine house calls part of a session? How are these notified to the locum and by when?
  – What are the arrangements for annual leave?
  – How will the agreement terminate? Is there an agreed notice period and what happens if this is not honoured for any reason? Include a clause stating that the agreement can be terminated by either party if the terms of the agreement are breached.

Employees can be kept on successive fixed-terms contracts for up to four years. Renewal after that point makes someone a permanent employee.

Be prepared to be flexible; you may have to be, if locums are in short supply! Regardless of this, locums will have varying levels of experience, may have family commitments, may have other posts as well and will have varying tolerances of length of appointment, workload, etc. It is fair to negotiate an agreement that works for both sides. If not, you may be left feeling that the service being supplied does not meet your needs or your locum may disappear fast over the horizon.

Defining what the locum will do
Take care to define this in detail. This is likely to cover: surgeries; house calls; triage; telephone consultations; acute and repeat prescriptions; referrals and investigations (internal, such as Treatment Room, and external); and the Quality and Outcomes Framework (QOF) and other coding.

It is possible that, for longer-term locums, there will be a need to cover a wider range of duties such as terminal care patients, private certification/medicals, clinics, prescribing reviews, etc. These should also be pre-defined and agreed, and payment adjusted accordingly.

This could also include work related to additional and enhanced services such as IUDs/contraceptive implants, minor surgery or covering a nursing home. 

Attendance at meetings and participation in learning events, such as a significant event, may also be required. Appropriate payment or time-in-lieu arrangements for this should be made as far in advance as possible and documented in the agreement.

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Looking after your locum
Many locums are undertaking this work because they have recently completed their GP training. They may be seeking partnership and 'trying out' local practices to define their preferences in terms of the type of organisation to which they want to belong. They may be uncertain of their longer-term plans, using locum work to fill a career gap or they may be unable to find a suitable salaried post locally.

Whatever the reason, it is important that locums are cared for in the practice. The practice manager can have a significant role here. If you are going to be offering a salaried or partner post in the near future, looking after locums well may pay
particular dividends.

Many locums will appreciate a brief orientation visit to the practice before commencing work there. This is an opportunity to go through elements of the Welcome Pack (see Box 1) as well as the agreement and to clarify any queries the locum may have about issues like parking or the availability of community nursing locally.

Establish that you are available to answer any kind of organisational question and how the locum should access you for guidance. Ensure the locum is aware of arrangements around coffee time and lunch so that opportunities are established for interacting with other GPs and the wider team as much as possible. This will increase the practice's knowledge of the locum, as well as enhancing the locum's experience of working in the practice.

Meet with the locum informally to check progress and to have an opportunity to identify and sort out any issues.

For longer-term locums, especially those who are immediately post-MRCGP, the practice may find it useful to have an identified GP who is the clinical buddy of the locum. This does not need to be time-consuming or a formal arrangement. However, it will aid both the practice and the locum.

As suggested above, the practice will want to reassure itself of the locum's quality of clinical decision-making and issues around using the clinical system, referrals and prescribing. This will require an identified individual and is a good opportunity to establish a culture of support and quality.

Additionally, newer locums will appreciate the continuation of a mentoring relationship, even if this is less structured than the trainer/trainee relationship. 

Reference
British Medical Association. Guidance on Locum Agreements in General Practice. London: BMA; 2011.

Resources

HM Revenue and Customs – Employment Status
www.hmrc.gov.uk/paye/employees/start-leave/status.htm

General Medical Council
www.gmc-uk.org

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