Five years of locuming in London and what have I learnt? A basic guide for those thinking about it

In the UK, the training programme goes from August to August which means that, in a few months, there will be a new generation of new GPs who will have to navigate the working world and everything that goes with it. I’ve been locuming pretty exclusively over the last five years (bar an eight-month salaried role) and I thought I would impart a few gems that I have learnt along the way. Just to make a point, what is written here may not be the official way to do things but it is how I do things. If you know of a better way or the correct way, please let me know!!

The advantages and disadvantages of locuming

For me, the flexibility of locuming was paramount. I did have a six-session salaried role for eight months and I hated the monotony of the routine and the inflexibility. There was something about knowing where I would be every Monday, Tuesday and Friday that I struggled with and I resented being able to take only two weeks off at a time. I left after eight months because this particular clinic wasn’t really for me and I have locumed thereafter whenever I have been in the country. For those of you new to my blog, pre-Covid, I was the Chair of the RCGP Junior International Committee and I would also spend three months a year in Japan. For those of you interested in an international career, you might want to have a look at my post about what to consider when thinking before taking time out to work abroad.

However, locuming is not without its disadvantages. I’ve made a little list of my bugbears and maybe a few tips to help

  • You have to be pretty organised as there is so much admin – invoices, pensions, tax – that normally is done by your practice but now has to be done by you. I’ll cover this later.
  • There is no continuity.
    • It’s difficult to follow up your patients and a lot of your decision-making needs to tailor to the fact that all your loops need to be closed by the end of the day. You can hand over patients you’re worried about to the regular GPs who most love (patient safety and all that) but some don’t (creating extra work). You need to do what you think is safest and what will help you sleep at night. For some people, this is really anxiety-provoking so locuming is not for everyone.
    • There is less osmotic learning – patients booked with you tend to be on-the-day emergency appointments so there is quite limited clinical scope and, if you refer, you don’t get to follow up the results. Also, you don’t get invited to practice meetings so there are no extra teaching sessions. You need to be fairly motivated to keep your knowledge up-to-date.
  • There are fewer regional opportunities
    • Many CCG non-clinical jobs require that you are a salaried in the local area which means that some regional doors are closed to you whether you like it or not.
  • There is no holiday pay, no sick pay and no maternity leave (see later about income protection)
  • Appraisal
    • It’s not impossible but audits, MSFs and PSQs are easier in salaried posts. I’d completed all three during my salaried post because it made sense to get it done early and out of the way.

Finding jobs

There are several roles even within the world of locuming. Over the last year, I have been spreading my time across a rehab unit, UCC in a major London hospital, covid clinics and GP surgeries.

  • Ad hoc shifts at GP surgeries
    • After a few years of doing this, I have a few clinics that I like that have me on their books as their go-to locum. A lot of this is about relationship-building and being reliable and having a bidirectional relationship. Clinics vary hugely in how they treat their locums and I try to avoid the places that are administratively disorganised (don’t pay in a timely manner) or don’t create a safe environment for me to work (no catch-up slots and no admin time). I appreciate that you could ask them to add them in but I passively aggressively just don’t book with them again.
    • Vice versa, according to some of the clinics I work for, it seems that there are many locums who cancel last minute, who don’t write their own referrals or do their own admin, and can practise borderline dangerously. If you don’t do any of the above, you’re probably on a winning streak. These relationships were incredibly important for me during the first lockdown where jobs disappeared and many locums had to apply for Self-Employment Income Support (SEIS) from the government to survive. I know a lot of advice out there is about knowing what you’re worth and pushing back on clinics that don’t pay you enough or don’t have catch-up slots etc which I agree with but I say do it with kindness and empathy and be willing to negotiate rather than being inflexible. This is just me but I am happy to be flexible with my boundaries for a good clinic rather than work at a bad clinic and clinics will keep rebooking locums that they trust.
  • Joining bank
    • I currently am on bank for two hospitals. This essentially amounts to a zero-hour contract and the hourly rate is less than what I charge when I work for a clinic but they sort out your pension and your tax.
    • One job is a rehab unit and the other is an urgent care centre which mixes up my day and it’s nice to get to know the staff. This was really helpful during the pandemic because the major London hospital gave me my PPE training, Covid updates and my vaccines so there are other advantages to being on a bank too.
  • Maternity/long-term locums
    • This is the dream because they give you the flexibility of a locum but with the continuity of a salaried. You still have to do your own admin but it’s a good halfway house between the two

There are many ways of finding jobs. You can email the practice manager directly or ask your friends if their practice needs a locum. There are platforms, like Lantum, which are like dating sites for practices and doctors. My experience of Lantum is that they pay slightly less than working directly with the clinic but they autogenerate your pension forms and it’s a good way to get ad hoc shifts. Many regions have Whatsapp or email groups although it might take some time to find out about them. I was told about this website 999111 which you can use to sign up to your regional Whatsapp group but I can’t comment on how good they are for jobs because I didn’t hear back from them. You can also find some on recruitment websites or via agencies or social media but I don’t know much about these as I’ve never had to use them. Finally, there are organisations called Chambers which, as far as I can tell, is a group of locum GPs that share job opportunities, training and admin costs. It does look pretty good but there wasn’t one near me so it didn’t make sense for me to explore if fully. I suggest you speak to someone in the organisations (this is the link to the one in South London which is the only one I know of). One tiny note here but remember to check which computer system the practice you are locuming at uses. Generally speaking, West London uses SystemOne and the rest of London uses EMIS with a small hotspot in South London which uses Vision.

Also just to let you know, I don’t get affiliate marketing or know how to monetise my blog. All these suggestions are things I’ve picked up but writing this makes me think maybe I should be more entrepreneurial!!

Invoicing

When you do a shift, you will need to invoice the clinic for the work that you have done. I recommend using a platform like locumorganiser or mylocummanager to keep track of your shifts but also autogenerate your invoices and pension form A’s for you (see later) and keep track of your expenses. As mentioned before, I avoid clinics that don’t pay you on time but I have, on occasion, had to chase clinics for months before being paid. There’s actually one shift that I have never been paid for because they went into administration not long after I worked for them. I’m trying not to scaremonger here – most clinics are brilliant at being timely in their payments once you invoice them – but understand that being paid as a locum relies on more variables than being employed.

I know that some people ask about limited companies and I genuinely only know one person who invoices through one. My understanding is that they are good for tax purposes and especially if you’re planning to earn over 100k but for us mere mortals, individual invoicing seems sufficient and also the commonest way to practise. I say have a chat with your accountant but I’d be interested to hear other opinions on this if there are some.

Pensions

This is the worst part of locuming and I know that I am going to do a bad job explaining what I do to keep up with this. Apparently, the rule is that you need to submit the payments within eight weeks of the shift which is sometimes ridiculous if the clinic doesn’t pay you on time. However, I’ve not really had any problems with this rule and I am now in the habit of paying monthly anyway. If you don’t have an NHS pension or you don’t want to contribute, then you can ignore this section.

Step 1: When you send your invoice in, you need to send them a Form A which the practice signs. This is autogenerated if you use a locum platform. Do not forget to get this from the practice!!

Step 2: I complete a Form B which calculates how much pension contribution I need to pay to NHS England (employer’s and employee’s contribution). You can put several shifts on one Form B so I tend to do this only once a month. You also need to predict how much you think you’ll earn in the tax year to choose your own employee’s contribution.

Step 3: I upload and send this Form B and all the form A’s to NHS England via this website.

Step 4: I transfer the pension contribution online to the NHS England account being mindful of the fact that I change the unique payment reference to match my Form B for that month. Just a note here but until the Covid pandemic, you could send in a cheque rather than bank transfer which was incredibly antiquated but also quite weird sending a cheque into the ether and having a large wadge of money disappear from my account at any point over the next ensuing months. I switched to bank transfers after trying this twice.

The reason why I hate the pension admin is because Capita, who run it, have decided to pull their socks up in the last few months and flag up a few forms that I sent in four years ago and asking me to resubmit because they’re missing a few signatures here and there (I think I was getting a bit lax). Joyfully, they send you automated emails so it’s impossible to know what date this was submitted and therefore which forms which results in a few to-and-fro phone calls and emails. This is ongoing and it is a very opaque system and I will have to let you know someday what happens and whether I have lost my pension contributions. So remember to fill your forms in diligently and send the completed relevant form A’s in!

Tax

Being a locum makes you fairly financially savvy because you have to deal with financial issues and considerations that you wouldn’t have done before. My advice is to get a good accountant. You’ll need to have information on your income, your employee’s pension contributions, and your expenses. I really can’t list all the things that count as expenses or not but I’m pretty certain my accountant shifts through the detritus that I send her. I think it’s pretty standard that part of your mobile phone bill and your home bills get accounted for but I also send her my bike servicing bills, receipts for stamps and all sorts to see what I can get deducted. I have heard recently (from a reliable source) that psychological therapy is tax-deductible which is fantastic news for those who have had to offload during this covid pandemic. I’m definitely going to submit my payments for physio for my gammy neck and shoulder from poor desk posture this year although I’m yet to see if this will be ok.

Make sure you have enough money set aside to pay this tax bill which is split into two payments – one in July and one in January. The way that I do it is to put aside a third of my income (it is never this much) and then put the remainder into savings after I’ve paid off my tax bill. However, I know some people who just pay the tax bill at the end of the year without worrying about it beforehand.

I’m really enjoying the Medics Money podcast which is made by two GPs (one who was previously an accountant) who explain some of the stuff that we need to know when it comes to finances. Totally recommend!

Income protection

When you become sick whilst working for a Trust, the NHS is obliged to pay for your sick leave. As a locum, if you don’t work, you don’t get paid. I advise you to go to a financial adviser and get yourself income protection which means that if you get can’t work for whatever reason, you have an income. This has been so invaluable to a colleague of mine who got struck down by long Covid who couldn’t work because of her brain fog so don’t feel it can’t happen to you.

My current situation

After five years of locuming, I have finally taken a three-session salaried role. I appreciate that I’m by no means breaking my back with this but I am so excited about being part of a team again. The great thing about locuming is that you get to see a lot of clinics and different ways of skinning a cat and over time you start to appreciate what you like as an individual. I like smaller practices rather than super-practices. I like flat hierarchies, not just amongst doctors but amongst all the allied health professionals and admin staff. I like flexibility and people respecting my eccentricities. I definitely do not like working from home. I’ve worked for this clinic on-and-off for four years and I know that it is the best fit for me and it sounds like I am for them. We’ll have to see and I have express permission from the practice manager that if I don’t love it, well, I can just leave!

I supplement this with my two bank jobs and a couple of Monday shifts at a clinic that I really like. I am definitely over-committed at the moment which is a real locum thing because you never want to kick a gift horse in the mouth which means it’s so hard to turn good jobs down. If you don’t mind insecurity and you don’t mind not having a routine and you’re a fairly motivated individual, locuming is a great option. I hope that I’ve managed to impart some of the stuff that I’ve learnt along the way and I’m happy for you to take or leave what you want. It is, by all means, not gospel.

Addendum – student loans

I totally forgot about student loans, mainly because I managed to pay mine off which was genuinely the best day ever! You’ll need to contact the student loans company on how to pay individually. From memory, I used to pay monthly but you can also pay in one lump sum every year as long as you pay your minimum amount (which is a percentage of your earnings but your accountant should be able to tell you that).

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