As a locum, you are in a very strong position. Sitting in colleagues' rooms, reading their patients' notes and using their equipment means you see practices from the inside.
You are also in a very weak position. You are isolated. If you encounter something worrying, then wondering whether you are justified in bringing it to someone's attention can make you feel very vulnerable.
The ethical position is clear. The GMC's Good Medical Practice places a professional obligation on doctors to put the safety of patients first.
A locum has to address anything that could put a patient at risk. It might be the practice's building: fire exits blocked or unshielded electrical sockets into which toddlers could push their fingers.
Systems and equipment
It might be equipment: no fetal heart rate monitor, broken sphygmomanometers. It might be systems: no review dates for repeat medications, no security protocol for faxes.
It might be staff: doctors prescribing steroid drops for red eyes and antibiotics for everyone, receptionists issuing prescriptions without a doctor's agreement.
The responsibility can feel daunting, but you are not alone. Bad practice is not rare and so there are plenty of people and organisations to advise and support you. Plug the number of your defence organisation into your phone. Don't be afraid to ring it, however trivial the query may seem. That is why you pay that large subscription fee.
And join your local sessional GP group. Then, when you need peer support, you have people you know to turn to.
So, if you reach the end of your session with concerns about something at the practice, what steps should you take?
If you spot something minor in a generally good practice - for example, a wobbly stool, which sooner or later will tip a patient onto the floor as they climb on to the couch - a tactful word with the practice manager before you leave is probably all that is needed to ensure the problem is remedied. Check next time you work there, or ask a colleague to do so.
At the other extreme, if you think a patient's life is in danger or you suspect a criminal offence, do not delay. Ring your defence organisation before you leave the practice.
Most concerns fall between these extremes: the questionable prescription, the investigation that apparently has not been followed up. There could be an innocent explanation.
It is tempting to downplay your concerns. But remember your professional obligation. Your defence organisation will guide you through what you should do next. It can advise on how to validate your observations, whom to contact about your concern, how the practice should be informed that questions have been raised about it, whether a patient should be notified and, if so, by whom.
Is what you have noticed part of a pattern?
Your sessional GP group provides a safe, confidential discussion forum. Some colleagues may have worked at the practice and share your anxiety. Even if no one else has seen anything amiss, in future they will be alert to problems.
Remember too that LMC secretaries have a shrewd idea of the standard of local practices and want to know if colleagues' or practices' performance is giving cause for concern. The primary care organisation (PCO) is responsible for the safety of patients in its area.
Your defence organisation can advise you on involving the PCO, whom to contact and what to say. The PCO's medical director or clinical governance lead are the usual channels, but there may be more appropriate points of contact.
Resist the temptation to trawl for evidence to support your suspicions. By accepting the job you agreed to the practice's policy on use of their data, and taking a screenshot or photographing the notes puts you in the wrong. Nor do you want to have to hand over your mobile phone laden with confidential data. Once you have reported your concerns, it is not up to you to provide proof.
Blowing the whistle is never easy. If you are suffering sleepless nights, seek help. The BMA's has a confidential counselling helpline. If you are desperate, a trained counsellor is on the end of the phone 24 hours a day.
If you need peer support, the service will give you a telephone appointment with a doctor adviser. An independent colleague can be easier to talk to than someone you know.
If you ever feel tempted to persuade yourself that there was not really a problem, consider two things.
Firstly, even if the practice has provided you with out-of-date test strips, if you miss a patient's raised blood sugar and the patient suffers as a result, you are responsible.
Secondly, how would you feel if the patient was your mother?
- Dr Harvey is a freelance GP in London
- BMA Counselling: 0330 123 1245 (24-hour confidential phoneline) or https://www.bma.org.uk/advice/work-life-support/your-wellbeing
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