ARTICLES
Induction for GP locums—how to get it right
Authors: Paula Wright
Publication date: 07 May 2005
Proper induction procedures for GP locums make for happier doctors and
safer patients, saysPaula Wright. Here she offers a practical guide to
getting it right
Most patients have a significant chance of being seen at some point by a
general practitioner (GP) who is not permanently based in their practice or
even in their PCT (primary care trust) area. This will usually be a locum,
also known as a “freelance” GP.
There is limited reserve capacity in most GP practices for covering holidays
or sickness absence. Many GPs now also pursue special interest activities
within their working week and therefore need outside locums to cover their
GP sessions. In some cases reimbursement to practices for locum cover is
only allowable on the basis that the work is carried out by doctors outside
the practice—hence the need to employ freelance GPs.
Box 1: Welcome drill for short term locum
In the surgery, show the freelance GP:
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To their room. If they have never worked with you before they will not know
where “room 6” is
Codes to any keypad operated doors that the freelance GP will need to use
(coffee room, consulting room, and so on)
Locations of panic buttons, emergency drugs, defibrillator, fire exits, toilets,
source of beverages, and where other staff can be found
In the consulting room, show the freelance GP:
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How to call patients in
How to obtain an external telephone line
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How to log in to the computer (Windows and clinical system) and how to
find the surgeries
The practice directory of phone numbers (reception, secretary, consulting
rooms, nurses and so on)
How to use the practice intranet
How to print a prescription (is there a “dummy”/“play” patient to test printer
is correctly loaded?)
Any non-phone messaging system that may be used within the practice, for
example, internal practice email, especially where this is routinely used for
communication between doctors and admin staff during surgeries.
In the consulting room, show the freelance GP where to find:
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Stationery—sick notes, FP10 pad and computer script supplies, letterhead,
envelopes, blood forms, x ray forms, etc.
Referral forms (ideally in a file)
Maps of any new estates that are not included in the commercially
available A to Z (partners will often have local council maps of these)
Essential equipment such as blood pressure machine, peak flow meter,
speculums, gloves, swabs, MSU bottles
Dictaphone and tape
Different practices
Practices vary widely in their approaches to handling workload and access,
use of IT systems, team working, chronic disease management, and so on;
they therefore need to have some means of helping freelance GPs to
become rapidly acquainted with their systems. Patients are quickly
unsettled by a consultation where a competent GP is struggling to find
essential items of equipment or forms, or lacks important information about
local services.
Preventing mistakes
Many adverse events involving patients are thought to be down to a
combination of unsafe acts (“active failures”) and unsafe systems (“latent
conditions”). [1] NHS inquiries into adverse events have consistently
recommended that action is needed in communication (between
individuals, departments, and organisations) and in staff training. Locum
induction procedures and information fall under both of these categories. A
robust induction for freelance GPs is a vital starting point for preventing
adverse events.
What is a good induction?
There are two key elements to a good induction:
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A welcome drill
An induction folder
Induction
Ideally, a GP registrar, salaried doctor, or long term locum should receive
protected paid time for induction (ranging from two sessions to one week,
depending on their needs). This is an essential investment that any practice
must make to maintain standards and should be a part of any contractual
arrangement for these doctors.
Short term locums
When the term of the locum is short (ie a few days), it is not cost effective
either for practices or for freelance GPs to finance the amount of time
mentioned above so it is crucial that induction systems are in place that can
be administered efficiently and reliably. When first working in a new
practice most freelance GPs usually plan to arrive 10-15 minutes before
starting work in order to brief themselves and check that their room is
adequately stocked. The practice should value this bonus unpaid time
offered by the freelance GP by ensuring that there is always a member of
staff free at this time to provide a short induction. This may be a time when
surgery doors are still locked and phones are “off”, so managers should
ensure freelance GPs are given a contact “bypass” phone number so they
can get into the system when they arrive. This is also relevant where
surgeries close at lunchtime.
Welcome drill
Sometimes there is one member of staff who is charged with welcoming
the freelance GP, but a clear checklist should be available for other staff
members to follow when this person is away. This checklist should be
reviewed periodically with input from GPs and practice manager. (See box
1 for drill aimed at a short term locum.)
Saying something like, “If you need anything just ask” should not be a lazy
replacement for actually checking the room with the freelance GP until they
are satisfied that they have everything they need to work. It will be
inefficient and irritating to the staff, freelance GPs, and patients to have a
surgery punctuated by phone call requests for missing items, which could
clearly have been foreseen to be required at the outset. This will also help
surgeries run to time.
The locum induction file
This file provides essential information about how the practice works, what
services are available and how different team members refer to each other
(see box 2). The National Association of Sessional GPs
(www.nasgp.org.uk/) has a model induction folder which can be completed
by each practice, and there is also a “Locum Welcome” template document
on the website for the North-East Employed and Locum GP group
(www.nelg.org.uk) developed by the author. Exemplary practices will
already have a comprehensive file with all internal protocols, referral and
other information, and may not even need to prepare such a folder for new
doctors. Whatever the original purpose of the folder it needs to be properly
indexed so items can be found easily and regularly updated.
For practices with more sophisticated IT systems, standard forms and
protocols may be found on the practice or PCT intranet and may be
demonstrated to the freelance GP as part of the welcome drill, thus
obviating the need for maintaining photocopied stocks of forms in all
doctors' rooms and the induction folder.
Conclusion
As well as ensuring a consistent level of service, proper induction makes
being at work a more satisfying experience, and indeed the two are linked.
Freelance GPs soon learn to avoid badly organised practices that do not
support them. Practices have much to gain from routinely asking freelance
GPs for feedback about their experience working there. In this way they
can be alerted to problems that give rise to risk before adverse events
occur.
Box 2: Items to include in the induction folder
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Telephone numbers: internal extensions and external numbers (for
example, social worker, child protection, Macmillan nurses, etc)
Referral forms and guidelines relating to local services including fast track
services
How to organise investigations (routine and urgent):
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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
Outside the practice—Are forms required? Is there a walk-in service, or is
an appointment needed? X rays, USS, pregnancy scans, cardiac echo,
echo, carotid, etc.
How are different services accessed (book in reception, dictate letter, or
form) and are they available within the practice (for example, counselling,
IUDs, depo contraception, implants, minor surgery, smoking cessation,
midwife, chiropody, physiotherapy, district nurse, health visitors)? How are
laboratory and other results actioned or labelled for action—electronically
or on paper? Are EMIS “practice notes” used? How are new drugs or
diagnoses in hospital letters incorporated into records? Information about
local community or hospital services that are innovative and peculiar to the
area—direct booking of hospital appointments by patient, “falls” clinic,
headache clinic, psychosexual clinic. Information on how patients are
added to disease registers and around use of READ coding with respect to
the new general medical service contract. Practice procedures/protocols:
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Repeat prescribing protocol
Appointments (does the practice have “advanced access” and if so how are
follow ups arranged?)
Internal messaging, etc
Who to report adverse or significant events to
Referral letters—is there a practice log for these to ensure they are not
missed and how are they prioritised?
There are now a number of quality frameworks that can influence the
adoption of induction procedures by practices. Interestingly, the quality
team development framework of the Royal College of General Practitioners
(www.rcgp.org.uk/), and the new general medical services' (nGMS) quality
and outcomes framework, for example, do not include locum induction as a
standard. In what has become a “points mean prizes” world, induction files
and procedures will not be taken seriously until they become a requirement
under the nGMS quality and outcomes framework. ■
References
1. Department of Health. An organisation with a memory. Report of an
expert group on learning from adverse events in the NHS. London:
The Stationery Office,
2000.http://www.dh.gov.uk/assetRoot/04/06/50/86/04065086.pdf (acc
essed 29 Oct 2004).
Paula Wright portfolio freelance general practitioner Newcastle upon
Tyne pfwright@doctors.org.uk
Cite this as BMJ Careers ; doi: