The Locum

The practice is four rooms above a pharmacy and covers a population of about eleven hundred spread over sixty square miles.

Dr Nkiru Eze has done locum work for six years, mostly urban, and took this because it was eleven days in August and she wanted to be somewhere with hills.

The regular GP is Dr Alasdair Ross, who has been there since 1994 and who is on leave.

Day one

Fourteen patients. Nine of them mention Dr Ross.

This is normal and Nkiru is used to it; every locum in every practice hears about the regular doctor, usually in the form of a complaint, occasionally as a compliment, always as a way of establishing that you are not him.

Here it is different in a way she notices by about patient six but cannot name until day three.

They are not comparing her to him. They are briefing her.

"He'd have my file up."

"He knows about the knee."

"Did he leave a note about Mum?"

Day two

He had left a note about Mum.

He had left notes about eleven of them, in the system, dated the week before he went, flagged for the locum — not clinical notes, which are all there anyway, but a short paragraph each of the kind of thing that does not have a field.

Mrs D. will not mention the breathlessness. Ask directly. She will then tell you everything.

J.H. brings his daughter to translate. She is fourteen. Do not use her for anything you would not want a fourteen-year-old to carry home.

Mr P. comes in about his back. It is not about his back.

Nkiru has done about ninety locums and has never seen this.

Day four

Mr P. came in about his back.

She had eleven minutes and a waiting room and she did the back properly, because you do not assume, and the back was fine, and then she had four minutes left and she said, "How's everything else?"

And Mr P. talked for the whole four minutes and then apologised, and she said there was nothing to apologise for, and booked him a double for the following week under a different code.

Day six

The practice manager, Fiona, who has been there twenty-two years, brought her a coffee at half twelve and said: "You're doing the doubles."

"Is that a problem?"

"No," said Fiona. "He does the doubles. He's about four hundred over on his appointment targets every quarter and he's had two letters about it."

Day seven

A woman of about eighty came in about a repeat prescription that did not need a doctor at all.

Nkiru did it in ninety seconds and then said, because she had the time, "Was there anything else?"

The woman said no.

Then she said, "He's not coming back, is he."

Nkiru said, carefully, that Dr Ross was on leave and that she did not have any information beyond that.

The woman nodded and said, "That's what he said," and left.

Day eight

She looked at the note flags again. Eleven of them.

She counted the practice list. Eleven hundred patients.

Eleven notes.

She had assumed, without examining it, that the eleven were a selection — the complicated ones, the ones he was worried about. Looking properly, they were not the complicated ones. Four of them had almost nothing in their file.

What the eleven had in common took her the whole evening to find and then was obvious.

Every one of them lived alone.

Day nine

She asked Fiona.

Fiona looked at her for a moment and then said: "He does a list."

The list is not in the clinical system. It is a piece of paper in Alasdair Ross's desk and it has, at present, thirty-one names on it, and it is people in the practice area who live alone and who nobody else is checking on.

He rings them. Not as a doctor. He rings them on a Sunday, from home, four or five a week, on a rotation, and has done since about 2003, and it is not recorded anywhere and is not billable and is, Fiona pointed out unnecessarily, probably several kinds of governance problem.

He flagged eleven of the thirty-one for the locum because eleven of them had appointments in the fortnight.

The other twenty are not being rung this month.

Day ten

Nkiru asked Fiona for the list.

Fiona said she couldn't give it to her.

Nkiru said she understood, and then sat in the car park for eleven minutes, and then went back in and said: "Can you ring them?"

Fiona said she wasn't a clinician.

Nkiru said it wasn't a clinical call.

Day eleven

Her last day. Sixteen patients, and a woman who came in at four with a child who turned out to need a hospital, which took the rest of the afternoon and which she is still thinking about.

She left at seven and did the handover note for Dr Ross, which is a standard document and which she has written ninety times.

At the bottom, under Other, she wrote four lines.

Your eleven are all seen. Mr P. is booked in on the 14th, double, he will say it is his back.

Fiona has rung nine of the other twenty. She did it in her own time and she will not tell you, so I am telling you.

You should not be doing this alone. I am not going to lecture you about it in a handover note.

If you ever want a hand with the Sundays, my number is below.