Locums forgo the traditional reward of general practice, the long-term relationship that GPs develop with patients. Patients rarely choose to see a locum.

So the task is to make the 10 minutes that you and a patient spend together rewarding for both of you. You can give patients the opportunity to tell their story afresh. At least you can offer a new view of an old problem. Perhaps you will spot a missed diagnosis.

Locums are never – well, rarely – bored. Is the surgery full of patients expecting antibiotics for a cold? Perhaps you can change the culture of the practice and persuade at least some of them there is no magic bullet for viral illnesses. Struggling with a badly organised practice? Can you find an acceptable way to offer advice so that when you or a colleague next work there, things function a little better? Is the clinical care substandard, even dangerous? Dealing with colleagues’ incompetence is not easy, but it is a professional obligation and potentially saves more lives than all the statins you will ever prescribe.

Concentrate on care

Not being tied to a practice has advantages. Unlike a partner, you can walk away from a practice you never want to work in again. Managing practices in the 21st-century NHS is increasingly onerous. Locums do not have to do it – you can concentrate on patient care. Nor do locums have to negotiate holidays with three other partners with school-aged children. You are your own boss. This has its own responsibilities, but allows you to devote more time to seeing patients and you can more easily fit work around family and other commitments. Take a holiday any time you wish.

Being a locum combines well with a portfolio career. Work as a GP three days a week and as a dermatologist or a tree surgeon on the other two. Or spend six months as a full-time GP in the UK and six months with Medecins Sans Frontieres in Angola. You can even drop out to climb in the Andes, fence in the Olympics or write your novel without fractious negotiation with partners about time off. True, you will not be paid if you stop work to have a baby or study law, but if you plan your finances carefully, you can make space in your life for anything you want to do.

If you are a newly qualified GP, you may envy friends who move straight into partnership. But they miss the opportunity to broaden their experience. You may be a locum because there is nothing else available, but make the most of it. If you have spent your time so far in suburbia, try a taste of the inner city, or head for the hills to sample rural practice. You can try big and small practices, APMS practices, those designed for the homeless, practices with traditional lists and those where part-time GPs see most patients.

ADVANTAGES OF LOCUM WORK

• As a locum you are your own boss; you have flexibility about when and where you work.
• Locum work combines well with a portfolio career or with any form of double life, whether it be family, hobby or other employment.
• Locums are not directly burdened with NHS bureaucracy and managing a practice, so can concentrate on patient care.
• Locums may not have long-term relationships with their patients but there is great professional satisfaction in making every consultation matter and in helping practices out.

You can come to grips with different medical software and different ways of recording consultations. Is nurse triage as good as doctor triage? How can a practice ensure safe handover? Is treating diseases of the rich appealing, or do you prefer to confront the problems of the poor? You can try out practices to see if you would like a salaried post or partnership there. You will have a range of models to draw on in designing your career and later on, locuming can be a rewarding way to wind down to retirement.

For practices in a jam, a locum is a lifesaver. Being welcomed by a practice with a doctor off sick and a waiting room full of patients is a good start to the day, and leaving with thanks ringing in your ears is a great goodbye. It is nice to be needed and good locums always are.

Dr Harvey is a freelance GP in London

This article originally appeared on www.gponline.com

There is no immediate right or wrong to this but methinks you may be asking the wrong question. I would rather hear “Do I expect to ever work again?”

You don’t mention your age, but if you would like to earn a professional income again, and to aim towards enjoying work again, and can imagine at some point feeling well enough to do this, then what is needed now is some career guidance before any decision is made regarding the GMC.

If the answer is no to the question – and you are aged 63 and content not to work at all from now on, then it would probably make sense to de-register.

If you are up to seeking career guidance and feel a return to work would be attractive if the right work was found, the sooner you do this the better because at some point, if they haven’t already, the GMC will be questioning your accreditation.

My experience of people attempting re-registration is that it can be an uphill struggle. It would be a real shame if you seek career guidance in two years’ time, having stopped GMC registration (or they have stopped you), only to find that you are ideally suited to a post in the pharmaceutical industry three days a week, but that they want someone to be registered and would even pay for you to study the diploma of pharmaceutical medicine. I am not saying this option would suit you, but it is simply an example of what can arise with lack of forward career planning.

You say money is tight – so the programme at Medical Forum may seem expensive . If you are on PHI, we have a one-page guide on how to approach the insurer for career guidance funds. If you would be funding it yourself and you get back to work just one week sooner (and it’s more likely to be 6 months sooner) as a result of a career review, you will have covered its cost, so it is all relative.

Finally, if a radical change in career is the outcome of career guidance, there are career development loans provided by the government.

Career Mentor is by Sonia Hutton-Taylor, founder of www.medicalforum.com who provide in-depth tailored advice to GPs looking for help with their career. Ever wondered whether your career dream is worth exploring? Ever thought that a career concern you have can’t be resolved …send a 50 word summary of any career challenge you are facing to enter a competition to win one of three ‘career materials plus’ packs from Medical Forum (workbook, guide, mp3 and phonecall worth £110).

First published in the NASGP Newsletter April/May 2013

Nursing is a tough and poorly paid job. People who choose to become nurses don’t expect to find themselves ignoring patients’ needs. But when you are rushed off your feet you can’t spend time by the bedside to chat to patients. In some hospitals it appears you don’t even have time to change soiled sheets. And you can’t be kind to a sick patient while you are ticking boxes on your iPad.

Nursing can seem a long way from the image that I absorbed from Sue Barton, Student Nurse when I was young. When my elderly mother was admitted to hospital she had a named nurse we were told to speak to about our mother’s condition. Only she never seemed to be on duty when we visited and no-one else was prepared to fill the gap. Cheerful caterers put my mum’s food on her table, and then cleared it away uneaten. She couldn’t see it, and she was too weak to lift a fork. No-one was unkind, but equally no-one seemed to see what was happening, or not happening. Yet there was no glaring deficiency that would put up red flag to the Trust Board. The Department of Health’s statistics would look fine.

The public says bring back matrons. But the root of the problem isn’t the culture of nursing. It’s too few nurses, too few beds. Beds and nurses cost money. So diabetic patients are on ENT wards, ENT patients on gynaecology wards, any patient on a trolley. At Mid Staffs we have seen the consequences of managing nursing for cost rather than for care.

Doctors seem to have come better out of the Francis report. Though we know that all is not well. A patient asked a GP colleague “Why aren’t doctors like Doctor Findlay any more?” He answered “Because patients aren’t like Doctor Findlay’s patients any more.” Social changes have spelt the end of cradle to grave continuity of care. But, like nurses, doctors still look after their patients with kindness if they have the sensitivity and the time. These days more hospital doctors introduce themselves to their patients and take the trouble to listen. Evidenced-based medicine and case discussions – and legible patient records – make it easier for practice-based GPs to follow up a colleague’s patient. GP locums have become expert in the art of creating a therapeutic relationship in 10 minutes.

So whose culture is it that needs to change?

When Tony Blair introduced his reforms of the NHS, I chaired a meeting of local GPs and consultants. A consultant stood up. He and his colleagues, being employees, were increasingly constrained by their employers.”You GPs”, he said, ”still have the freedom to plead for your patients. You lose it at your peril. You lose it at your patients’ peril. You must speak out.”

Around the same time, I was sitting in the Boardroom of a local Trust at a meeting with the chief executives when the door was pushed open and a man sidled round it. Grunting and grinning and grinding his teeth, he made a dash for the boardroom table, grabbed a handful of sugar-lumps and made his exit. There is something to be said for having a Trust boardroom on the same corridor as a ward for long-stay mentally infirm patients. Too many hospital managers are isolated from patients.

Whose culture needs to change? The government pays lip-service to services for patients, but managers are judged on cost, so the only figures they see have £ signs in front of them. And whistle-blowing doctors are the messengers bearing bad news. So they were shot. Gagging clauses are now to be banned. But will they find another way to silence those who speak out? It seems that today the NHS is only a no-blame culture if you are at the very top, and kicking the cat goes all the way down the line to the nurses.

And while we’re at it, what about the culture of patronising politicians? It isn’t motivating to hear an MP saying our performance is mediocre.

What the NHS needs is managing from the bottom up. Why not ask all front-line staff for one thing they could change for the better? It doesn’t have to be big: little things mean a lot – and may generate savings too.

Until that culture change happens, it’s time for doctors to stand up and shout when patients are suffering. If we don’t, who will?

But who’s going to listen to a locum? Well, there is strength in numbers. Get together with colleagues. Speak to as many different organisations as you can. Be persistent. And use the media if you have the confidence and the contacts. We are a privileged profession and it is our duty. To the NHS, to patients, to ourselves.

Judith Harvey
judithharvey12@btinternet.com

This article first appeared in the NASGP Newsletter April/May 2013

In general practice communication has to extend to a wide range of people, so there are many opportunities for it to fail. Communication between primary, secondary, voluntary and social care should be viewed, not as a chain, but as a communication net.

As a locum GP visiting different practices, you may feel a little out of the loop with who is doing what in the practice, and understanding the part they play. Colleagues should share patient information with you to ensure good continuity of care, as long as it is balanced with the need to maintain confidentiality.

Working as a locum GP, your colleagues should provide all the relevant details of the patients for whom you are responsible. Practices should have protocols for the transfer of relevant information between doctors. However, many do not cater for the nuances of working as a locum, so you should have in place your own systems to ensure safe clinical handover.

During consultations

Good communication with patients during each consultation is important, as it is your first line of defence in warding off complaints and potential clinical negligence claims. Effective interpersonal skills are particularly important for locum GPs because you often only have one chance to make a good impression. Good Medical Practice states that to communicate effectively you must listen to patients, take account of their views, and respond honestly to their questions.

Patients who are denied the opportunity to explain their concerns, or reasons for presenting, may feel alienated, frustrated or resentful. Patients who are kept informed about their condition, and who are actively involved in deciding on the appropriate treatment, are more likely to comply with suggested treatments and are less likely to complain if things go wrong.

Tips for an effective consultation:

• Let the patient talk first. An uninterrupted history aids diagnosis
• Use non-verbal communication to encourage patients to talk, eg, nodding, making and maintaining eye contact
• Well-aimed open questions can help “lead” the consultation
• Allow patients enough time to ask questions and clarify things
• If there is a lot of information for patients to digest, use patient information leaflets or factsheets.

A new addition to Good Medical Practice states: “When you are on duty you must be readily accessible to patients and colleagues seeking information, advice or support”. You should ensure that arrangements are made, wherever possible, to meet patients’ language and communication needs. If a patient cannot understand what you are saying then this might prompt them to complain further down the line if something goes wrong.

Francis report

The GMC states: “You must be honest and trustworthy in all your communication with patients and colleagues. This means you must make clear the limits of your knowledge and carry out reasonable checks to make sure any information you give is accurate.”

If something goes wrong and an error is made, you should be open and honest with the patient involved. Following the Francis report, the government will be introducing a statutory duty of candour for providers, whereby the NHS will have a legal duty to be honest about mistakes.

Dr Stephanie Bown, Director of Policy and Communications at MPS, said: “MPS has long held the view that while you can mandate disclosure, legislation cannot deliver the attributes of high quality and open communication such as empathy, sincerity, and comprehensiveness. A culture change is what is needed.

We will be further highlighting to government that despite the understandable appeal of a legislated duty, this will not achieve the objective of effective open communication.”

Being open

Sometimes, in spite of your best efforts, patients will be unhappy with the care they have received. The GMC warns that patients who have lodged a complaint deserve a prompt, open, constructive and honest response including an explanation and, if appropriate, an apology.

Effective communication extends to telephone consultations, when using computers (giving the patient your full attention) and prescribing. Read more on this in an article in our new GP publication, Practice Matters.

This article first appeared in the NASGP Newsletter April/May 2013

Locum forms A and B will be retained – but amended . The new forms clearly distinguish between the actual fee and the pensionable pay and the employer contributions.

GMS Practices will receive an extra 0.15% funding intended to reimburse them for this additional cost; PMS practices will get nothing.

Locums will need to collect the employer contribution from the practice and MUST pay this over to the local area team succeeding the PCT along with the employee contribution. Cheques after 31st March need to be made payable to The NHS Commissioning Board (as the NHSCB is now the employing authority for GPs in England)

The funding practices receive will be based on practice list sizes, not on historical costs of locum usage. Thus some practices will win (a little) and some will lose – potentially much larger amounts.

Practices are already facing reducing incomes and increasing costs and thus in many cases they will be looking to reduce the gross costs of locums. This could lead to:

• Favouring locums who have left the scheme (such as those who have taken 24 hour retirement)
• Favouring locums who operate through limited companies (you cannot pension this income through the NHS scheme)
• Negotiating harder on rates that they are prepared to pay (market forces will determine whether this is a practical answer)
• Where locum usage is high, practices may consider taking on flexible part-time salaried doctors (paid at a much lower rate than locums)

From the locum’s point of view

The pension rules have not changed in that if you are pensioning your income you must pension all NHS income and not just the bits you choose. The rules are slightly contradictory, in that late payment of pension contributions is not allowed either, so up to now some locums have circumvented this by just not pensioning some income until it is too late for it to be accepted.

Under the new system, you will have to advise the practice whether you belong to the pension scheme or not, and then if you are, when they pay you the 14% (along with your fee), you are under a legal obligation to pay this over.

Locums will need to be very clear in their paperwork and will probably need to re-design their invoices, ensuring that they are prompt in paying pension over to make sure that they do not accidentally commit any offence.

Take care during the changeover period to treat work done prior to 1st April under the old rules and post 31st March under the new rules to make sure that the right entity bears the 14%. The normal deadline for payment for the March period has been extended to the end of April 2013, to allow GP locums to capture all their pre April 2013 work.

Be aware that tier rates have increased from 1st April, so the employee contribution will be higher too.

Do not be pressured into leaving the pension scheme without taking expert advice. Even leaving for a short while can have adverse consequences for you. Despite increases in pension contributions payable, there are only very rare cases when leaving the scheme is the best course of action.

Liz Densley is medical specialist partner with Sussex Chartered Accountants, Honey Barrett, and is secretary of AISMA (the Association of Independent Specialist Medical Accountants). Contact her at liz.densley@honeybarrett.co.uk.

This article first appeared in the NASGP Newsletter April/May 2013

It is essential that GP locums capture all their GP locum work actually performed up to 31/03/2013 on, at the very latest, their March 2013 form B taking account of the 10 week rule. They must not declare work performed up to 31/03/2013 on their April or May 2013 forms B otherwise they, and the Practice, will potentially be paying more in contributions. Therefore the normal 7 day deadline for submitting the March 2013 form B has been extended to the end of April 2013 to allow GP locums to capture all their pre April 2013 work.

By virtue that PCTs will no longer exist wef 01/04/2013 GP locums in England are advised to send their forms A & B and cheques to the local area team which (in GP pension terms) is the PCT’s successor. Their cheques must be made payable to ‘The NHS Commissioning Board’ by virtue that the NHSCB is now the NHSPS Employing Authority for GPs in England.

For more information on these changes, see the superannuation section of the NASGP website (members only).

You are probably aware of the NOACs (novel oral anticoagulants), new drugs that can be used in place of warfarin. You probably won’t be using them very often but here’s an overview to help you when faced with a patient asking to start one of them  or prescribing for the first time. There are three of them: dagigatran, rivaroxaban and apixaban and currently they have the following license/approval: 

• Stroke prevention in non-valvular atrial fibrillation (AF)
  • All 3 are licensed for this indication.
  • Apixaban is awaiting NICE/SIGN approval.
• Prevention of venous thromboembolism (VTE) after elective knee/hip replacement
  • All 3 are licensed and approved by NICE.
• Treatment of VTE
  • Only rivaroxaban is licensed & approved (NICE).

We have summarised the key information about the NOACs and compared the 3 in this table:

As a salaried GP you will be taxed under PAYE, so you will only need to complete a tax return if you have other untaxed income, or income subject to higher rates of tax that is material. You do still have a duty to notify the Revenue if PAYE has not deducted the correct amount of tax. You also need to remember to make a claim for professional subscriptions if they are not met by your employer.

For your pension you will need to complete the fairly simple Type 2 practitioner certificate at the end of each year. Often the practice manager or partnership accountant will help you with this if you are unsure.

As a partner you are self-employed, so you will need to complete a tax return each year. It is usually easier for the practice accountant to complete each partner’s return for them, but we are seeing more doctors retaining their own accountant when they join a practice. Provided the accountants can communicate on the same wavelength this isn’t a problem! You will normally complete a claim for expenses relating to the practice that you meet personally rather than the practice paying. The obvious costs here will be use of home, car running and mobile phone, but in some practices it will include professional subscriptions and training costs. It should be clear in your partnership agreement which costs are yours and which belong to the practice.

Your expenses claim, and usually your ‘outside earnings’ will be merged into the practice tax return, you cannot claim expenses separately on your own return. Thus the figures shown on your personal return will bear no obvious relationship to the profit figure shown in the practice accounts. The practice accountant should be able to show you how you get from one to the other if you ask.

NASGP members can read the rest of this article on the NASGP website.

Liz Densley is medical specialist partner with Sussex Chartered Accountants, Honey Barrett, and is secretary of AISMA (the Association of Independent Specialist Medical Accountants).

We have all heard of the Hippocratic Oath, and many patients still believe we swear it, though they, like most doctors, have hazy and often incorrect ideas about what it says. Most US students swear a professional oath on qualification and many French students sign a written one, but apparently only about 50% of UK students are required to swear. (If it’s expected of you, can you refuse, I wonder?) What is it that students are being asked to commit to, and does swearing an oath make a difference?

Professional oaths have a long history. The Hindu vaidya’s oath dates from the 15th century BC. The Hippocratic Oath was probably written, not by Hippocrates, between the 5th and 3rdcenturies BC. Oaths from Jewish philosophers, from Japan and from China, all have a long history. The Declaration of Geneva was written in 1948, after the revelations of the role of physicians in Nazi extermination camps. A recent development is the White Coat Ceremony, for students moving from the classroom to the wards for their clinical studies.

All these oaths are remarkably similar. The god they ask you to swear on may vary, but all stressthat physicians’ first duty is to their patients, that doctors must respect patient confidentiality, and that they must be loyal to their profession. And all oaths give some practical guidance on personal and professional conduct.

Contemporary versions of the oaths don’t tamper with the statements of general principle. Putting patients first and respecting their confidentiality retain their importance. Maintaining the honour of the profession is still emphasised, even if the wording of some oaths could be interpreted as an instruction to close ranks to protect colleagues, even errant colleagues.

The most contentious sections of the oaths concern what doctors should and should not do in the course of their work. Perhaps not surprisingly. Such clauses tend to reflect the issues current at the time of writing, and so may be interpreted now as meaning something rather different from what they meant to physicians practicing in, say, ancient Greece. For instance, the traditional version of the Hippocratic Oath appears to forbid abortion. In fact, abortion was legal at that time and the oath merely advises doctors not to use unsafe methods to terminate a pregnancy. Modern oaths tend to avoid such directives, but include an ever­lengthening list of people who should not be subject to prejudice – an indication of what exercises us in the twenty­first century.

What is the purpose of swearing a professional oath?

When the first oaths were written, there were no registers of those considered fit to practise, so the oath was the passport to the profession. Those who had professed the oath were called professionals. People who offered medical services without having professed were quacks. Now, the rite of passage is marked by final exams, registering with the GMC and signing on with a defence organisation.

So are the oaths any more than mission statements; meaningless because no doctor would ever espouse the opposite, for instance, that patients’ consultations should not be confidential? Are oaths now in fashion because there are concerns about unethical behavior? And if so, does swearing an oath make you a more principled doctor? Surely doctors who are indiscreet with patients or who provide substandard care are not confined to the unsworn.

However, oaths still stand for something important: the obligations that doctors feel are an essential element of their professional duty. In the twenty­first century we work in a managed health service where such principles are under threat. Can swearing a professional oath protect doctors from submitting to managers’ demands that they put an institution’s perceived needs before those of patients? Would that stand up as a defence in an industrial tribunal, a GMC hearing or the law courts?

These are unresolved questions. Meanwhile, I suggest we could revivify the oath. What if all students spent their first morning at medical school discussing the text of an oath, and then four years later, after their final exams, their last teaching session were a review of how their student experiences had changed their views? They could discuss what it means to be a professional in the twenty­first century. The oath would then become a living document.

Finally, the rite of passage from carefree student to responsible professional should be marked with a party to remember.

Originally published in the February/March 2013 NASGP Newsletter