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Gold, incentives and meh

GPs' views: Your 'good, reliable' locum starts making basic mistakes

Three GPs share their approach to a practice problem

Three GPs share their approach to a practice problem

Case history

You have started to use a locum and initially he seems good and reliable. He is pleasant, efficient and a hard worker. But after a few weeks he starts turning up late. Then you start to get complaints that he is rude to patients, and finally you discover some elementary mistakes when reviewing his records.

When you discuss these events with him, he dismisses them, saying you've got it in for him. He says he has done nothing wrong and accuses you of racism. He becomes angry, making veiled threats to expose deficiencies in the practice if this gets out in public. In addition, he wants to be paid for the outstanding locum sessions he has agreed to do. He storms out, saying he will never return. What action should you take?

Dr Lucy Free 'These are the empty threats of an exposed man'

Good locums are worth their weight in gold, but are hard to find. All too often they have traits that make the conventional existence as a partner uncomfortable for them, and you have clearly hit the spot with this one.

Casual locums are usually employed on past experience, word of mouth and a glance at photocopies of a GMC and defence union certificate. The contract is implicit: they do the work, you pay the bill. Sometimes the rate of pay isn't even negotiated beforehand, and who would bother to check references or GMC details for just a locum? It's no wonder that occasionally things go wrong. The problem here is that it has gone sour on you, and you have become uncertain of your ground.

You have done your bit by trying to discuss the problems with him. So don't be cowed by his bluster about racism, payment and newspaper revelations ­ these are the empty threats of an exposed man. The good news is that he isn't returning. You have enough of a job identifying the damage he may have already caused.

As the employer, to a degree you were responsible for his actions, and while I would not actively contact patients whom he has seen, it should be easy enough to check things out the next time they attend. You have to decide how far to pursue this.

Do you have the evidence and inclination to go to the GMC? You can't 'report' someone just because you had an altercation, and you could easily get bogged down in paperwork, meetings and legal ramifications. The defence unions aren't going to help, and the PCT won't be interested.

It may be better to simply spread the word locally about your problems. This is a fairly powerful tool to prevent employment in the vicinity. So when he is eventually exposed as an escaped psychiatric case, at least you can say 'I told you so!'.

Lucy Free is a GP in Hurstpierpoint, West Sussex

Dr Tonia Myers 'He has left us in the lurch, so why pay him?'

Confronting employees or colleagues about problem behaviour or weak clinical areas is always unpalatable.

Most of us prefer to avoid confrontation and overlook minor deficiencies - perhaps longer than we should. I would check with the practice manager if he has signed a contract and the terms under which we, or he, can terminate the contract and what notice has to be given. We have not asked him to leave ­ he has left us in the lurch. So I can see no reason to pay him for any outstanding sessions.

Threatening to 'expose' our practice and playing the racism card are unpleasant ploys, which do not hold water in our own practice, which is a model of ethnic diversity. While designed to intimidate, it will backfire and encourage me to take the offensive.

Assuming we have logged the complaints and have documentary evidence of his poor timekeeping and other misdemeanours, our actions can be justified. If the clinical errors were major and patients were put at risk by his care, then we may be obliged to inform the PCT on whose performance list he appears.

But first I would check this out with the BMA. I hope this will not be necessary and we can just cut our losses at this stage. If we owe him anything for sessions already completed, he should be paid the outstanding money as soon as a cheque can be raised. I would send this with a letter explaining that as he did not give the agreed notice, this amount is in full and final payment.

I would not put any other grievances in writing at this stage. If, however, we have any further threats from him, or hear he has been badmouthing the practice, I would tell him that we will take matters further.

Tonia Myers is a GP in Highams Park, London

Dr Richard Stokell 'This may highlight weaknesses in our locum hiring policy'

This locum's behaviour poses problems for the practice, the locum himself and the wider medical community.

First, I would ask the practice manager where we found out about the locum, and whether we have checked that he is on the PCT performers list and that his medical registration is valid. I would then look at the cases that have come to light as causes for concern and review the notes of other patients he has seen. I would then ask my partners to meet to look at any errors found. If we felt patient safety had been put at risk we would have to contact the affected patients to reduce their clinical risk.

We also have a duty to promptly report colleagues about whom we have cause for concern. I would discuss this first with my defence organisation. Then I would talk to the chair of the relevant PCT with a view to him being investigated by the local performance committee. Not only are the errors a cause for concern, but his attitude suggests unwillingness to evaluate his own work.

I would not pay him for the locums he has not worked, and I would not lose sleep over his threats to expose the practice ­ who is he planning to expose us to? This case may highlight weakness in our policy in hiring locums. While most locums are known in the area, having been on the local training scheme, some are not.

Perhaps we should be obtaining written references before using any locums. We also need to support locums working for us. We should keep the locum pack up to date, ensure they have easy access to diagnostic equipment and emergency drugs, and try not to leave inexperienced locums alone in the surgery.

For the wider medical community, the risk of professional isolation for locums adds to the danger of poor performance. Supporting locums through appraisal is valuable.However, assessing their evidence of good medical practice is difficult unless they work regularly in one place. Non-principals groups also provide support, as does higher professional education for newly trained GPs.

Richard Stokell is a GP in Birkenhead, Merseyside

Employing locums

You should check that the locum:

  • Is on the PCT performers' list.
  • Has valid GMC registration and medical defence cover.
  • Has agreed in writing to a specific contract of fees for work to be done to prevent misunderstandings or disagreements later on.
  • Has agreed in writing to terms for invoicing, payment, cancellation by either party and the period of notice for terminating the contract.
  • Has access to all necessary resources.

Resources for locums

  • PCT
  • entry to performers' list, arranging appraisal, information on practices looking for locums
  • BMA
  • National Association of Sessional GPs
  • Locum Survival Guide Robbie Coull
  • BMA Counselling and Doctor for Doctors
  • support from a doctor-adviser or counsellor 08459 200 169
  • Local non-principal support groups

Working with colleagues

Doctors whose performance or behaviour is giving cause for concern may be stressed, unwell, or have substance abuse problems. An initial approach should usually be supportive.

An episode such as this may warrant a significant event analysis which the practice can record for QOF points and partners can include in appraisal folders.

Good Medical Practice (GMC) says doctors must:

  • Protect patients from risk of harm posed by another doctor's conduct, performance or health
  • Not undermine patients' trust in the care or treatment they receive by making malicious or unfounded criticisms of colleagues.
  • This applies to both locum and practice.

Melanie Wynne-Jones is a GP in Marple, Cheshire

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