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Do violent patients lose right to confidentiality?

Freelance GP work has its own risks and difficulties, whether clinical or administrative, says Dr Paula Wright

All clinical work has risks. These include: delays, deaths, missed diagnoses, misunderstandings, complaints and so on. Keeping one's clinical skills and knowledge up to date, reflecting on one's performance and analysing adverse events or 'near misses' are all key to reducing these risks. This applies to any clinician. Freelance or locum GP work has specific risks and freelances need to be aware of them.

For example, it is easy to confuse the arrangements of one surgery with another, leading at best to inconvenience and at worst complaints or adverse health outcomes. Responsibilities fall on both the practice and the locum to ensure everything runs smoothly.

Practice responsibilities

The practice will be responsible for checking that the locum is a GP (ie has a JCPTGP certificate), has medical indemnity, is registered with the GMC and is on a local performers list. The requirement to have had an enhanced criminal record bureau check is also being introduced.

Practices differ widely, and locums cannot be expected to offer a good standard of service if they are not provided with essential information about how the practice operates. This means having both an induction drill and a reference induction folder. The drill should include things such as how to:

·call patients in

·obtain an external telephone line

·log in to the computer (Windows and clinical system)

·Find the practice directory of phone numbers (reception, secretary, consulting rooms, nurses and so on).

Also how messages are conveyed within the practice, for example internal practice

e-mail, especially where this is routinely used for communication between doctors and admin staff during surgeries.

The other aspect of the drill is orientation within the consulting room. That is ensuring that the consulting room has everything the locum needs and showing the locum where things are kept. This will include sicknotes, FP10 pad and computer script supplies, letterhead, envelopes, blood forms, X-ray forms, referral forms (ideally in a file), maps of any new estates not included in an A to Z, essential equipment such as BP machine, peak flow meter, speculums, gloves, swabs, MSU bottles, dictaphone and tapes.

Orientation within the practice should cover: codes to any keypad-operated doors, locations of panic buttons, emergency drugs, defibrillator, fire exits, toilets, source of beverages, and where other staff can be found.

A practice should provide an induction folder containing essential information. For practices that don't have a folder a locum might want to take a checklist of things to ask at the beginning of the first session.

Patients can become annoyed when given incorrect information by locums about, for example, how to request repeat prescriptions, how to find out results or how to book certain types of appointments.

In the absence of adequate induction information provided by the practice, the locum's surgery can be punctuated by a constant stream of telephone queries between the locum and receptionists (and other staff) which disrupts everyone's work.

For longer-term locums it is good practice to include a two-hour induction as part of the first day's work ­ this is in the interests of the practice, its patients and the locum.

Terms of work ­ locum bookings

Managing time is key, as working under pressure just compounds the risk of mistakes. Freelance GPs and the practice must be realistic about the workload that can be achieved in the time available, given the locum's unfamiliarity with the practice.

Also a newly-qualified locum will work very differently to a locum who has recently retired from 20 years in a practice. Just because other GPs see 24 patients in a surgery doesn't mean the locum can or should do this, in an unfamiliar environment.

A locum may not have the flexibility to run late if they have been booked for half-day sessions at separate surgeries morning and afternoon and therefore it is usually prudent to agree to work a defined workload.

Bookings should state clearly how many appointments and visits are included in the fee.

Flexibility can be provided by agreeing to 'consider' additional work, time permitting, for pre-agreed add-on fees. It also helps

to state a cut-off time for morning visit requests.

Points locums should consider

·Locums should be wary of signing repeat prescriptions unless they are satisfied there are robust review mechanisms for prescriptions. Usually it is best to accept these only for longer-term bookings where there is an opportunity for the locum to spend some time finding out about the practice before accepting the work.

·Locums should consider carefully whether to accept on-call duties in practices they are not familiar with. Locums should always check that there is an identified individual on call before accepting work if they do not wish to cover it themselves.

·Locums should beware of signing acute prescriptions for practice nurses if they do not know what training they have had or their protocols.

·Locums should be careful to steer clear of 'struggling' practices with no permanent clinicians to keep systems in check.

·Locums should ask to be informed about and involved in responding to any complaints received against them. The NASGP has helpful guidance on this issue.

Record keeping

Locums booked for few sessions may not be there to follow patients through, nor to explain their actions to peers if things go wrong. It is therefore especially important to document very clearly a structured contemporaneous record of the clinical encounter including any advice to patients about when to return.

Locums should always insist on having patients' records, especially for home visits in chronic patients.

Computer consultations for home visits for example should not be left till the next day. Some locums now only work in paper-light practices where all consultations are entered on computer as this means records are never 'missing' and previous consultations are always legible.

A freelance GP may not be around to sign dictated referrals, so if tapes are wiped or lost this can be very serious. Some surgeries have a system whereby GPs log referrals by entering a searchable Read code on the computer.

Secretaries can then check that there are tapes to match all entered codes. Alternatively all referrals or tapes can be logged by GPs in a secretary's book at the point when tapes are handed over.

Desk aids

Most freelance GPs expect to carry their own ENT kit, stethoscope, urine dipsticks, etc. What is often forgotten is desk aids such as peakflow charts, Snellen charts,

pregnancy calculator, BMI chart, etc. And it is surprising how many of these items can

be difficult to find in a badly organised surgery.

Freelance locum work provides practices with crucial support at times of sickness and maternity absence and increasingly as replacement for outside interests of partners.

Locum work also allows GPs to keep their hand in when they are between more permanent posts, just after qualifying or post-retirement.

Reducing risk is vital for good patient care and helps make this work more fulfilling for the doctors concerned.

Paula Wright is a freelance GP and GP tutor for non-principals, Northern deanery

1 The risks of freelance work

·Working in unfamiliar environments without adequate induction

·Potential misunderstandings about agreed terms of work, especially amount and type of work covered by the locum duty

·Working in isolation from other doctors

·Poor access to education through being excluded from mainstream locality or PCT-based educational events and mailshots

2 Essential information for induction folder

·How are tests organised within the practice: are there specific forms to complete, or are they just requested by patients at reception, is an appointment needed or are they done on spec by nurses; bloods, ECG, pregnancy test, paeds, urines, spirometry, etc?

·Tests outside the practice (is there a walk-in service for X-rays or is an appointment needed; how are the following arranged: USS, pregnancy scans, cardiac echo, echo, carotid, MRIs, etc?

·How are different services accessed (book in reception, dictate letter or form) and are they available within the practice (eg counselling, IUDs, depo contraception, implants, minor surgery, smoking cessation, midwife, chiropody, physio, district nurse, health visitors, GUM clinic, etc)?

·What are the forms used for local secondary care services, especially any fast-track services?

·How are lab and other results actioned or labelled for action ­ electronically or on paper, (are EMIS practice notes used)?

·How are tests organised within the practice: are there specific forms to complete, or are they just requested by patients at reception, is an appointment needed or are they done on spec by nurses; bloods, ECG, pregnancy test, paeds, urines, spirometry, etc?

·Tests outside the practice (is there a walk-in service for X-rays or is an appointment needed; how are the following arranged: USS, pregnancy scans, cardiac echo, echo, carotid, MRIs, etc?

·How are different services accessed (book in reception, dictate letter or form) and are they available within the practice (eg counselling, IUDs, depo contraception, implants, minor surgery, smoking cessation, midwife, chiropody, physio, district nurse, health visitors, GUM clinic, etc)?

·What are the forms used for local secondary care services, especially any fast-track services?

·How are lab and other results actioned or labelled for action ­ electronically or on paper, (are EMIS practice notes used)?

Accessing information

In the absence of a good library, and where you cannot get hold of a colleague, there are a few things worth doing:

·Carrying a few reference books in your car boot such as the Oxford handbooks of clinical medicine and of general practice.

·An ATHENS password for the National Electronic Library for Health will permit access to all sorts of excellent online resources, databases such as PUBMED, 'Clinical Evidence' and even some full text journals.

·Locums who move around a lot will miss out on the urgent public health alerts that are cascaded

via practices unless they sign up to receive

them by e-mail (request this via icdb1@doh.gsi.gov.uk).

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