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The Locum’s Guide to UK Mental Health Trusts

Posted by Dr No on 22 August 2009

Shark_250.jpgDr Helen Bright once observed that locums are all too often asked to “swim in troubled waters”. Many locums will agree. Often the clues that the trust is in trouble can be spotted early on – provided one knows what to look for – which allows one to beat a hasty and hopefully painless retreat before the sharks come out to play.

The key is to make use of an index known as the “Coffee Stain Index” (usually abbreviated to CSI), named after one of the items in the index. The questions to ask and the scoring are available below:

Questions (circle the answer which best describes your new trust):

1. Arrival. You arrive, as you have been asked to do, at 09:00hrs, expecting to meet Dr Shark, who you have been given as the person to report to. On arrival, you find:

a. nothing. The doors are locked and nobody’s at home. Folk on the neighbouring ward can’t help. You return to your car to wait. After two hours of unanswered telephone calls you finally get through to Medical Staffing, who say, awfully sorry, they gave you the wrong address to report to.

b. clerical staff are present, and they were/are expecting someone, but it was either last week or next week, and they certainly weren’t expecting you, today. You are dumped in the waiting room. 90 minutes later the service manager arrives and says something about not knowing you were going to arrive today.

c. there’s actually a doctor present – and it is Dr Shark. He takes you into his office and starts eyeing you up as a potential snack for later on..

d. there’s not only another doctor present, but it is a locum who has survived in the trust for more than a few days. He/she takes you on one side and starts to show you round.

2. Office space. Once inside the building, the question of where your office space will be will come up sooner or later. Is the space offered you:

a. non-existent. As they weren’t expecting you, they haven’t made any space for you. Maybe they’ll get round to it sometime.

b. hot-desking. You will be able to use that desk over there when the trainee support worker isn’t using it.

c. a real desk – but that’s all. No phone, no computer, nothing (except drawers full of dodgy correspondence from the last incumbent of your post). No one has a clue about how to set up the phone/computer etc. They exude an air of it is your stupid fault for wanting such things in the first place. The previous incumbent got by without – so why can’t you? (Actually that was one of the main reasons he/she left.)

d. a desk with all you hope for on it – plus a vase with flowers in.

3. Secretarial support. You murmur something about could you meet whoever will be providing secretarial support for you. The person you have asked to introduce you:

a. bursts out laughing as if to say “Who the hell do you think you are? God or something?”

b. introduces you to an old hag who’s computer screen displays a Lord of the Rings screensaver. She sniffs, looks down her nose at you and announces she already has far too much work to do, and couldn’t possibly take on any more work. No pleasantries are exchanged.

c. takes you into a busy office. A woman stands up and says: “Here are the notes and your diary for this morning’s clinic. The first patient is already here”.

d. says “Come and meet Susan”. Susan shakes your hand, says welcome (and uses your name) and says she is looking forward to working with you.

4. Induction. All trusts will profess to have an induction policy. Does the induction:

a. never happen, despite you asking several times.

b. go on for ever, but does not include where the tea/coffee facilities and loo are.

c. consist of a wad of trust policy documents, most of which are well past their “review by” date.

d. tell you what you need to know, nothing more, nothing less.

5. Your first clinic. You attend your first clinic and:

a. all the patients DNA (known as a fiasco in the trade). They’ve long since given up.

b. most turn up, and spend ages, with the consultation ending with something along the lines “Thank God you are here now, doctor…”. (Don’t be fooled: the patient is being genuine: your predecessor was so crap they think you are God – and that wont go down well with the existing staff on the unit because they think they are God).

c. most turn up. As you review the notes, you realize your predecessor had some pretty odd practices. When the third patient asks for ECT/snake oil/to be sectioned for some trivial complaint and you murmur something about “had they thought about looking at other treatment options” you are greeted with the utmost hostility and told in no uncertain terms “Dr O’Flannel (your predecessor) always did that” and that “you’ll be hearing from them”.

d. you have a pleasant clinic.

6. Team meetings. You attend your first team meeting. You:

a. arrive on time, and everyone else is late. When they do arrive, they all get their snouts into their lunch-boxes and start an informal whinge about their patients. No one seems to have noticed you are there.

b. arrive, and everybody else is already there. One or two look as if to say you shouldn’t be here. The meeting goes on for three hours, with no one obviously in charge. No one involves you – until you stop paying attention, when Dr Shark will ask you what you think.

c. arrive to find the meeting started earlier than billed. There is some sort of semblance of a meeting, but it is evident that the team is dominated by a small number of individuals who are in some shape or form dysfunctional eg the community support worker who reckons they know a fing or two about mental health ishoos and now they have a captive audience they ain’t going to let nobody forget it.

d. arrive, and every one else arrives at much the same time. The team leader smiles, welcomes you and says we’ll do quick round of introductions, starting with me. After the brief but effective meeting, one or two of those present come over to you, re-introduce themselves and chat in a friendly manner.

7. And finally: the all important Coffee Stain Question (note: can be used on its own if an urgent emergency assessment is required): as you look round the unit at the furniture, what do you see:

a. all the chairs are vinyl/plastic, and all the desks have Formica tops – but no coffee stains because they got so bad that all the furniture was replaced with non-staining furniture.

b. the fabric on the furnishings appears to have come from the OT’s latest tie-dye therapy programme.

c. numerous stains of dubious age and even more dubious provenance.

d. remarkably few stains (there are never none…).


Scoring is simple: 0 for each (a) answer, 1 for each (b) answer, 2 for each (c) answer and 3 for each (d) answer. The total score should be interpreted as follows:

Total score 0: you are already under water, and sinking fast. Get out while you still can.

Total score 1-6: you are on borrowed time. Start planning your exit strategy - now. If you hang around, it will almost certainly damage your career.

Total score 7-11: be wary, very wary. Dr Shark will almost certainly decided which meal he is saving you for, and that old hag of a secretary will be spreading nasty gossip about you. You will already have had an (inexplicable to you) run in with a nurse on the ward. But – if needs must – such posts can be survived, if only on a short term basis.

Total score 12-16: these are the tricky ones. Superficially, things could be worse – but also they could be better. Keep your nose to the ground (and head below the parapet) and review on a weekly basis.

Total score 17-20: You have landed on your feet. Such posts are very rare but they do happen. So don’t put your foot in it.

Total score 21: You are in heaven (or on something very strong, which you should not be taking). Be ready for your colleagues to offer you formal admission under the MHA to the local PICU.

Sadly, research conducted over the last ten years has shown that most trusts score total scores of less than 15 most of the time. Locums do indeed swim in troubled waters – and so is it then any wonder that some of them end up bitten - and bitten hard?


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