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Spotting the subtle signs of a poorly-run practice

Trust in your instincts when working as a locum, writes Dr Judith Harvey.

You don't have to work as a locum for long to develop a sixth sense about practices. What are those subtle signals that make you aware you need to take extra care?

There are classic red flags: being engaged at the last minute by someone who is unwilling to clarify what they wish you to do and how much they are going to pay; no locum induction pack; no nurse; no equipment, not even anywhere to wash and dry your hands. But look out for less obvious signs. Here are some hints.

1. Beware a job offer that seems to be too good to be true. If you are to be the only doctor and there will be no visits, who is responding to urgent requests for house calls? Could this be an early warning of the practice's clinical attitudes?

2. Are patients waiting in the rain because the doors aren't opened until the time of the first appointment? Are you kept waiting in the rain because staff don't arrive until the time of the first appointment?

3. Waiting rooms tell you a lot. Are the seats sagging, stained or suppurating stuffing? Are the walls covered with out-of-date information, dog-eared posters and with punitive notices more suitable for an army barracks?

Are patients sitting hunched up with an air of 'frozen watchfulness'? And can you and everyone else in the waiting room hear everything that is going on at reception: gossip, Ms Jones' test result, patients being quizzed about their symptoms?

4. Talk to the staff. Do the receptionists convey an air of energy and enthusiasm? Can they tell you where you can safely leave your bike? Can they tell you where to find the Sonicaid? Do they know if there is a Sonicaid?

Are the staff all relatives of the partners? In a family business there is always a hidden agenda.

5. Does the consulting room make your heart sink? Are there dead plants on the window sill and untidy heaps of papers on the desk?

Is the examination couch buried under unopened journals? Does the doctor collect drug company mugs and executive toys? A check of patients' notes may suggest he prefers drug reps to the DTB as a source of prescribing advice.

A rep appearing mid-morning and expecting to be ushered in to see you is another tip-off.

6. A glance into desk drawers can be revealing: a packet of chocolate HobNobs perhaps, or packets of opioids and benzodiazepines returned by patients.

If you have been consulting for four hours without a break, helping yourself to a biscuit is not a capital offence, but the drugs raise a question mark about the practice's policies around medicines storage.

7. Is the practice's IT a mean machine or a minefield? Is there anyone around can create a unique log-in for you, or do they think it's OK to use 'locum' for all visiting GPs?

8. Some GPs practise without a computer. They have the old-fashioned virtues that are in danger of being swept away by targets, but how will you fare without clinical data at the touch of a button, online reminders of drug interactions, and printed prescriptions? And do you have the skill to decipher doctors' handwriting?

9. Patients' reactions to what you consider standard good practice are revealing. Are they surprised or even irritated when you say you need to see them to assess their condition before you will issue a prescription for antibiotics or write a sick note?

Are they astonished when you ask them what they think about their symptoms, their treatment, the future management of their condition? Perhaps they have never been offered information or given a choice before.

10. Signing prescriptions you have not authorised is a high-risk activity. Do the GPs in the practice amend patients' prescriptions on the basis of hospital letters, or is it delegated to receptionists?

Does the practice have an effective system for reviewing repeats? Do staff understand that, as a locum, you can't just sign without checking notes?

Soft signs are just that: straws in the wind. Respect your instinct. If something does not seem right, consider whether it suggests poor organisation, a lack of consideration for patients and respect for staff, or low clinical and personal standards. Be on your guard. Patients' lives could be at stake, as could your career.


The NASGP is the only independent lobbying and information service for sessional GPs (locums, salaried and retainer GPs). For further information visit www.nasgp.org.uk

The NASGP does not necessarily support or endorse the opinions or information on this page.


  • Dr Harvey is a freelance GP in north London

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