An insight into locuming in rural locations

Here, OT speaks to three locum optometrists about positives, challenges, and what others might need to know if they’re looking to book shifts out of town.

Optometrist, Raymond Ellis, locums in Inverness and the surrounding area, including at Black Isle Opticians in Avoch and at practices in Dingwall and Golspie, as well as occasionally in Northern Ireland.

His patient demographic skews older when working in rural locations when compared to cities like Glasgow, Ellis told OT.

“Inverness has a generally older demographic,” he said: “You get people who are from the area, and you also get a lot of people who retire from further south.

He added: “Sometimes, you get people setting up glamping businesses or doing various things as a new start in midlife.”

Working back in Glasgow after a period in the Highlands often leaves him asking: “Where did all these young people come from?” he shared.

Edward Ovenden is based in Lancashire, and locums in the South Lakes, including Kendall, Keswick and Ulverston.

OT asked Ovenden about the changes he finds locuming in rural locations, compared to larger towns or cities.

Ovenden noted that there are often differences in the relationships between patients and practices, with long-term relationships being more prominent in rural areas.

“Rural practices tend to know all their patients, a lot of the time on a personal level,” he said.

“They come from these communities where everybody knows everybody, and everybody is a neighbour.”

This is something that he enjoys as a practitioner, he shared.

“Patients being familiar with each other and the staff, and having patients coming back repeatedly, builds up good rapport between a practitioner and a practice, and a good clinical record, and we get longitudinal data, even outside a research or an academic capacity,” Ovenden said.

He added: “It can be helpful for how we manage patients clinically. The worst thing is seeing, for example, an unusual spot and thinking, ‘was it there last year or not?’ and not having any records to be able to compare against.

“You tend to get more of that in rural settings than you do urban settings, so I think that’s a big positive.”

Ovenden added: “In urban practices, the base patient volume is usually higher, but it is also a bit more transient. You get fewer return patients, and you get more patients who are totally out of area, who are maybe on a holiday or a business trip, who are coming in for an acute issue.

“If you blindfolded me, without any windows, and asked me if it was rural or urban, I could probably tell you after half a clinic.”

The independent practice that Ellis works at in Avoch has a strong relationship with patients in the local community, he told OT, with practice management knowing families that have lived in the area for generations well.

“It’s a bit different for me as a locum. I don’t know everything about everyone,” he acknowledged.

The longstanding patient knowledge that the practice has is useful in navigating this, however.

Locuming in the same areas over a number of years has meant that Ellis has started to recognise patients and form bonds with them too, he told OT.

Raymond Ellis

“It’s pretty often that you will pick up that there is somebody you know in common, or that the patient does an activity at a place you know about,” he said: “It’s a small world, in that sense.”

Ovenden noted that he sees patients in cities too, including nearby Preston, and that his clinical work will not change based on location, but that it might impact the advice he gives on follow-up services, treatments, or referrals.

“The signs and the anatomy of the eyes don’t change, regardless of the setting,” Ovenden said.

He explained: “However, it’s important, as a locum, to be aware of what the other local services are. For example, if I see a patient in Preston with dry eye that isn’t responding well to conventional therapies, I can recommend two or three local practices or clinics where there are good, affordable private options like IPL, along with the usual hospital route.

“In South Cumbria, nowhere really does that. So, unless the patient is able to travel quite far, I probably wouldn’t mention that, and I would just go straight into the secondary care route.”

He added: “The worst thing is to say, ‘you’ve got this problem. The best solution is this. It’s not available.’”

There can be larger structural differences when locuming in the countryside, too.

“One of the factors that come into rural healthcare is a lack of robust secondary or tertiary healthcare services, and you definitely feel that in Cumbria, and on parts of the Fylde Coast,” Ovenden said.

Ellis also noted that, when working in Inverness, his management of patients might take into account how far they have travelled, and how likely they are to see an optometrist again in the near future.

“In Inverness, you have patients coming from very rural places as well,” he told OT.

Ellis explained: “It’s how you manage them. If they’ve travelled two hours to get there, you might need to do additional tests. How do you work around that?

“A lot of patient management, even in Inverness, will be determined by where the patient lives, and how often they come down.”

He recommends knowing the geography of where you are working in advance, so that you can know straightaway whether the patient has travelled a long distance.

“It makes you look more credible whilst having conversations if you can reference local places,” Ellis added.

If you blindfolded me, without any windows, and asked me if it was rural or urban, I could probably tell you after half a clinic

Variance in referral pathways

Optometrist Jas Bahra, who locums across Kent, including in coastal areas, noted that knowing about variations in referral pathways is important from day one of locuming.

“They [referral pathways] vary slightly, but that is something that it is important that you know about,” she said, adding: “As a locum, you have got to know where you are. Even if you’re there for your first day, of all the things, you should know about referral pathways, and be given that information by the practice.”

Jas Bahra

OT asked Ovenden what local optical committees (LOCs) can do to assist those who are new to locuming in rural locations.

He advises contacting LOCs for advice on referral pathways, in the first instance – something that he initially found helpful, as he locums across four different legacy clinical commissioning group areas, with four different systems.

“If I go to a new one, I need to know about it ahead of time,” Ovenden said: “LOC websites are very useful for that, or getting in touch with a member ahead of time.”

Lancashire and Morecambe Bay LOC, where he is treasurer, has a WhatsApp group for each location, as well as a mailing list, newsletter, social media channels and a blog, Ovenden shared.

These can be good locations for locums to make people aware of their services, as well as for practices to advertise when they need locum help, he said.

“If a locum is looking to network, because they would like to know more about local optometry or just know more people, observing their local LOC meetings is a really good way of meeting a lot of good clinicians in their area,” Ovenden believes.

Sometimes, you get people setting up glamping businesses or doing various things as a new start in midlife

Ellis highlighted a challenge that he has found with locuming in predominantly rural locations: the difficulty of being able to find an independent prescribing (IP) placement.

“Working rurally, it’s harder to get things prescribed, so it’s more useful to have IP when compared to working a mile down the road from a National Treatment Centre,” he told OT.

Less capacity in smaller health boards means finding a placement can be a challenge, Ellis said.

He added: “That’s the downside with maybe having a smaller set-up here – you have to travel to other health boards, that you’re not even going to be helping with when you complete the qualification.”

Locum rates versus cost of living

When OT asked Ovenden if rates for locums vary between different locations, the answer was unequivocally yes.

He explained: “The main driving factor is demand versus supply, which is dependent on the locum presence in the area and the presence of residents in the area. You tend to get more residents in urban areas, highly popular areas, or areas near a teaching centre. The more residents there are, the less demand there is for locums, and the more competitive those locums need to be for limited clinics.”

Ovenden continued: “The inverse is true in hard to recruit for areas, which tend to be rural areas, especially in the north of the country and the islands, but even going down to Cornwall.”

Bahra believes that locum rates are a structural problem across the country.

“That’s a massive debate going on at the moment, within the locum groups. The rates are getting quite low in certain places, or working conditions might not be very good,” she told OT.

Bahra added: “It’s so mixed, in terms of rates up and down the country. In Kent, it’s probably not that bad, and I would say the structure is there. But again, it is such a mixed bag.”

She noted: “Coastal work as a locum definitely is much more needed, and the rates obviously vary according to that. Work is probably a bit more readily available, if you look at the locum apps, when compared to more central Kent.”

Ellis noted that it can be more difficult to find locums in the Highlands, so rates in general will be a higher than in cities such as Glasgow.

“Some of the companies will pay a little bit more if you’re traveling to one of their more rural practices,” he noted.

Another factor is what the locum market will tolerate, which is dependent on cost of living, Ovenden believes.

He notes that rates might be higher in the south of England or in the London commuter belt, but that this might be outweighed by higher fuel and general cost of living expenses.

“I think there’s a threshold for when, even if there’s nothing else going, an optometrist might say, ‘No, that rate is too low. I can’t accept it.’ That threshold is going to be higher for those places compared to where I live, where cost of living is comparatively cheaper,” he said.

“It’s supply versus demand, and it’s cost of living, and I think both of those factors correlate with how rural an area is.”

Lead image: Avoch Village, in the Black Isles, where optometrist Raymond Ellis works as a locum

Read more

Eye care, everywhere

From serving remote communities to certifying low vision, OT explores how the optometry workforce is adapting