Moonlighting
Extra shifts, extra money — and a surprising number of rules. Let's not skip the rules.
Moonlighting — taking on work outside your main training post — is one of those topics everyone asks about in hushed tones, as if whispering will make it less complicated. It isn't. But it is manageable if you know what you're doing. This page covers everything: what's allowed, what isn't, the working time rules, indemnity, and how to avoid getting yourself into trouble.
Web Resources
📚 A hand-picked mix of official and real-world resources
Because the official documents tell you the rules, but the deanery FAQs tell you what actually happens.
Official & Contractual
Indemnity & MDO
Deanery & Training Guidance
Quick Summary — If You Only Read One Thing
🚨 Read the indemnity and GP locum sections especially — these catch trainees out most often
💡 The bottom line in one sentence
Moonlighting can work — but only if you ask first, stay within your working hours, get the right indemnity, and don't let it eat into your training.
What Is Moonlighting?
Moonlighting is any work you do in addition to your main GP training post. It doesn't have to be medical work — though most trainees are thinking about clinical extra shifts. It can be paid or unpaid, NHS or private.
In UK GP training, the most common examples are picking up extra shifts in A&E or medical wards at trusts where you have previously worked — usually to supplement income or maintain skills in those environments.
The term dates from the 19th century, when labourers took on secret work by the light of the moon to avoid detection. Doctors today do it in considerably better lighting — but with significantly more paperwork.
🏥 Common Types
- Extra A&E shifts at previous hospitals
- Medical ward cover shifts
- Minor injuries unit work
- Urgent treatment centre shifts
- Non-clinical work (e.g. teaching, medical writing)
🚫 What You Cannot Do
- Work as a GP locum in a GP practice
- Work in an ARRS or enhanced access role as if qualified
- Take on private GP consulting roles
- Work in any role beyond your current competency level
The Rules — What Makes Moonlighting Permissible
According to the BMA model contract for GP trainees, you may undertake work outside your practice with your trainer's or educational supervisor's agreement. That agreement will not be unreasonably withheld — but it does need to be given.
📄 BMA Model Contract Wording
"With the agreement of your Trainer/Educational Supervisor, you may arrange to undertake any duties or professional activities outside those of the practice whether remunerated or not. Agreement will not be unreasonably withheld. Any medical duties or appointments outside the practice area must not compete with the Trainer/Educational Supervisor's practice or impinge on your contracted duties with the practice, or upon your GP vocational training… Consent does not imply any responsibility by the partners for your acts and omissions in the course of such activities. You are advised to ensure that your membership of a recognised medical defence organisation is commensurate with these activities."
The COPMeD Framework — All Nine Conditions Must Be Met
The Committee of Postgraduate Medical Deans (COPMeD) issued formal guidance setting out the conditions under which additional work during GP training is permissible. All nine must be satisfied. This is the definitive framework — not a checklist of suggestions. (Nine conditions. For context, most international visa applications require fewer.)
- Complies with the Working Time Regulations — 48-hour average over 26 weeks (or up to 56 hours if a valid opt-out is in place). All employers combined.
- Annual leave remains uninterrupted — At least 5.6 weeks (28 days) of annual leave per year must not be encroached upon by locum work.
- Not undertaken during sickness absence or study leave — Both are absolute bars. Working a locum shift whilst off sick is fraudulent and a GMC fitness-to-practise issue.
- Within the trainee's competency level — The work must be a clinical role the trainee has held within the previous 2 years. You cannot simply feel competent — the 2-year rule is the COPMeD standard.
- Approved by the Clinical/Educational Supervisor and TPD — Written approval is safest. Verbal agreement is not sufficient for ARCP scrutiny.
- Does not impact on achieving educational goals — If portfolio, WPBA, AKT/SCA preparation, or attendance at teaching is affected, approval can be withdrawn.
- Not undertaken after an unsatisfactory ARCP — Trainees in extended or remedial training following an unsatisfactory ARCP outcome should not undertake any additional work. Doing so can result in CCT delay and formal fitness-to-practise referral.
- Not undertaken by trainees training LTFT for health reasons — LTFT status granted for health reasons carries a strong presumption against additional work. Deaneries will review LTFT eligibility if regular locum work is discovered.
- Repetitive additional work prompts review — Regular, recurring moonlighting should trigger a conversation about whether LTFT training would be a more sustainable and appropriate arrangement.
📋 2016 Junior Doctors' Contract — NHS-First Obligation
Under the 2016 Junior Doctors' Terms and Conditions, before accepting any private or agency locum work, you must first offer your availability to an NHS Staff Bank (at any NHS Trust — not necessarily your own). You do not have to accept what is offered, and if the NHS declines, you are free to pursue other arrangements. However, the offer must be made and documented — keep a record (email or system submission).
Your employer must still be informed even if they decline your offer, so they can monitor overall working hours compliance.
🛡️ Guardian of Safe Working — Know Who This Is
The 2016 contract established an independent Guardian of Safe Working role in each NHS Trust. If your moonlighting (or any working pattern) is creating rest break violations or unsafe hours, you have the right to raise this with the Guardian — they are independent of your employer and their role is to act on your behalf. You can also use the exception reporting mechanism under the 2016 contract if additional work causes rest break violations; this protects you medico-legally.
💡 Insider Tip — Get It in Writing
Don't rely on a verbal nod over coffee. Email your ES/GP Trainer and TPD to confirm the arrangement is agreed. This protects you if questions are raised later, and keeps everything above board from the start.
📋 Before You Start — An 8-Step Decision Checklist
Work through this before committing to any extra work. If any step flags a concern, resolve it first.
- 1Why are you moonlighting? Financial need, experience, or maintaining skills — all valid. But be honest with yourself. If it's a sign of financial stress, are there other support options to explore first (BMA support, deanery hardship funds)?
- 2Rule out fatigue and burnout risk How is your current workload? Are you sleeping enough? Are your energy levels and mood stable? If you are already struggling, extra shifts will make things worse, not better.
- 3Check legality — Performers List, visa, contract Can you legally do this role? Are you on the Performers List for GP work (no — not yet)? Do your visa conditions permit additional paid employment? Does your employment contract require disclosure or approval?
- 4Check indemnity — before you start, not after Is the specific work covered? NHS contracted shifts: check CNST/CNSGP applies. Private, event, sports, or aesthetic work: arrange personal MDO cover. Never assume. Always verify with your MDO directly.
- 5Assess competence Is the role within your current clinical capability? Are you being asked to work at a level above your training grade? If in doubt, decline — working beyond competence is a patient safety risk and a GMC concern.
- 6Get approval and disclose Inform and obtain written agreement from: your ES/GP Trainer, your TPD, and both employers (HR). This is mandatory, not optional.
- 7Safety-net: decide your alarm bells in advance Before starting, agree with yourself: what would make you stop? (e.g. ePortfolio falling behind, trainer raising concerns, feeling burnt out, making errors). Write them down. Stick to them.
- 8Review regularly with your ES Bring it up at every supervision meeting: "How do you think my energy levels and engagement have been? Is there any change I haven't noticed myself?" Your ES sees you more objectively than you see yourself.
Working Time Regulations — The Numbers You Must Know
The European Working Time Directive was transposed into UK law as the Working Time Regulations 1998 (WTR). Post-Brexit, the UK retained these protections — they remain fully in force. The purpose is simple: to protect workers (including you) from the health and safety risks of excessive working hours.
The penalties for non-compliance are serious: Employment Tribunal proceedings, fines, and in extreme cases, employer imprisonment. This is not small print you can skip.
The Key Numbers
⚠️ Critical Point — ALL Hours Count Together
Your training hours and your moonlighting hours are added together for the 48-hour calculation. You cannot simply check your training rota is under 48 hours and assume you're fine — the extra shifts go on top. If you're regularly working 40 hours of training plus 10 hours of moonlighting, you have already exceeded the limit.
🔢 How Is the 48-Hour Average Calculated?
The average is calculated over a reference period of 26 weeks (6 months). This means:
- Add up all hours worked across both jobs over 26 weeks
- Divide by 26
- This must not exceed 48 hours per week
Example: If your training averages 40 hours/week, you can work a maximum of an additional 8 hours/week on average across the 26-week period. A few busier weeks are mathematically possible, but sustained extra work is likely to push you over.
Note: lunch breaks and travel to and from work are excluded from the calculation.
📝 What About the 48-Hour Opt-Out? (Maximum 56 hrs/week)
It is possible to sign an individual opt-out agreement to work above 48 hours on average. However:
- The maximum average even with a signed opt-out is 56 hours per week — this is an absolute ceiling
- An opt-out must be genuinely voluntary — you cannot be pressured or coerced into signing one
- An opt-out should not be a requirement of a post, nor part of any standard contract
- You can withdraw from an opt-out at any time with notice
- All rest requirements remain binding even with an opt-out — the 11-hour daily rest, 24-hour weekly rest, and 20-minute break rules cannot be opted out of
- Some deaneries (e.g. Mersey West Lancashire Lead Employer) require a formal sign-off form to activate the 56-hour maximum
Contact the BMA or your deanery if you have concerns about pressure to sign an opt-out.
🚨 What Are the Penalties for Breaking the WTR?
Non-compliance with the WTR is a serious matter. Potential consequences include:
- Employment Tribunal proceedings — against you and/or your employer
- Fines — enforced by the Health and Safety Executive
- Employer imprisonment — in extreme cases of deliberate non-compliance
- Disciplinary action — if you have not disclosed extra work and your combined hours breach the WTR
- Training consequences — concerns about fitness to practice or judgment may be raised at ARCP
If you have specific concerns, contact the BMA for advice. Their helpline is available to members.
Indemnity — The Part Nobody Tells You About
🚨 This is the section trainees most often get wrong
Your standard training indemnity does not cover moonlighting work. If you pick up extra shifts without checking your indemnity cover, you may be working unprotected — which is both dangerous and a GMC requirement violation.
What Your Training Indemnity Covers
As a GP trainee, your clinical negligence indemnity is provided automatically through:
| Post Type | Indemnity Scheme | Covers |
|---|---|---|
| Hospital posts (ST1/ST2) | CNST (NHS Clinical Negligence Scheme for Trusts) | Clinical negligence during contracted hospital training activities |
| GP practice posts | CNSGP (Clinical Negligence Scheme for General Practice) | Clinical negligence during NHS primary care training activities |
| Additional professional cover | HEE-funded bulk MDO scheme (e.g. MDDUS) or HEE-reimbursed personal cover | GMC hearings, disciplinary matters, medicolegal advice — but NOT moonlighting shifts |
⚠️ Critical: Your HEE/NHSE-Arranged MDO Scheme Does NOT Cover Locum Shifts
The bulk MDO scheme arranged and paid for by HEE/NHSE (e.g. through MDDUS or MDU) is specifically for your training programme activities. Locum shifts and moonlighting work are explicitly outside the scope of this arrangement. Severn GP Training confirmed this explicitly to their trainees: "locum shifts are not covered by our MDDUS indemnity provider."
What You Need to Do
- 1Check your existing cover Contact your MDO (MDDUS, MDU, or MPS) and ask explicitly: "Does my current cover include extra clinical shifts outside my training programme?" Most will say no.
- 2Arrange top-up cover Purchase additional personal indemnity cover for the specific type of moonlighting you plan to do. Severn Deanery noted this costs approximately £45–50 per year for hospital-grade locum work — you do not need to use the same provider as your training scheme. Always verify the scope of any cover you purchase.
- 3Check what the host hospital requires Many trusts require you to show proof of additional indemnity before letting you work extra shifts. They will ask at induction. Be prepared.
- 4Confirm your cover is in place before you start Do not assume. Do not start a shift without confirmed cover. The GMC requires all practising doctors to have appropriate indemnity at all times.
💡 Note on NHS Indemnity for Hospital Shifts
If you pick up extra shifts within an NHS Trust, NHS clinical negligence indemnity applies to those contracted activities (CNST covers all contracted NHS clinical work including additional hours). However, this covers clinical negligence only — it does not provide representation at GMC hearings, inquest support, disciplinary defence, or advice. That is why you still need MDO membership alongside NHS indemnity.
🏥 What About Private or Non-NHS Moonlighting?
If you are considering any private work (e.g. aesthetic medicine, sports medicine, private clinics), you are outside NHS indemnity entirely. You will need:
- Appropriate personal MDO membership covering the specific type of private work
- Confirmation that your MDO covers that clinical area (some roles require specialist additional cover)
- Confirmation from your ES and TPD that this work is appropriate and approved
Private work during training is unusual and carries additional complexity. Take advice from your MDO and BMA before proceeding.
Who You Must Tell — Disclosure Is Not Optional
If you are moonlighting, you must disclose this to everyone listed below. Not doing so risks being in breach of your contractual obligations — which can become a disciplinary matter if your combined hours exceed WTR limits.
- Your main employer (HR)
For hospital posts: inform your Clinical Supervisor and the HR department of the Trust. For GP posts: if employed by the Trust (the usual arrangement), inform HR. If directly employed by the practice (rare), inform GP Trainer and Practice Manager. - Your secondary employer
The hospital or employer you are picking up extra shifts with must also know you have a primary employer. Both employers need to be aware of the other for WTR compliance. - Your Training Programme Director (TPD)
Always. Without exception. Your TPD needs to be assured that your training is not being compromised. - Your Educational Supervisor (ES)
Your ES is your most immediate educational oversight. They need to be satisfied the work is appropriate and manageable alongside your training commitments. - Your GP Trainer (if in a GP post)
Your trainer sees you every day and will notice if you're tired, distracted, or behind on your portfolio. They need to know what's happening.
That is five separate conversations before you have worked a single extra shift. Extra income has rarely felt so administratively earned.
⚠️ What Happens If You Don't Disclose?
- You risk being in breach of your employment contract (working for two employers without disclosure)
- If your combined hours exceed WTR limits without a signed opt-out, this can become a formal disciplinary matter
- If something goes wrong clinically during a moonlighting shift, undisclosed work will be discovered — and it will make everything worse
- It damages trust with your supervisors, which affects ARCP outcomes and training references
Form R — You Must Declare All Additional Work
🚨 This is an AKT-testable point — and a fitness-to-practise issue if missed
All additional work requiring a licence to practise as a doctor must be declared on Form R (Part B, Section 2: Whole Scope of Practice). The GMC and deaneries have issued enforcement guidance confirming that failure to declare locum work on Form R is a potential fitness-to-practise issue — not a minor administrative oversight.
What Must Be Declared on Form R?
- All locum shifts — including NHS bank shifts at your own Trust
- Any private or cosmetic medical work
- Medical support at sports events, festivals, or any event where you are acting as a doctor
- Out-of-programme work
- Voluntary medical work (paid or unpaid, if acting as a doctor)
- Even a single bank A&E shift must be declared — there is no de minimis threshold below which declaration is not required
How to Complete the Form R Entry
- Group shifts by employer within an unbroken period — enter as a single entry per employer with dates and number of shifts
- Record: organisation name, nature of work, dates covered, number of shifts
- Complete this at the time — retrospective reconstruction at ARCP is difficult and may appear dishonest
- Keep a simple log (a spreadsheet or diary note per shift) so Form R completion is straightforward at review time
⚠️ Consequences of Non-Declaration
- Undeclared locum work discovered at ARCP review can result in an Outcome 3 or worse — not merely a conversation
- Discovery of undeclared work creates a dishonesty concern on top of the original regulatory breach
- Your ES is expected to proactively review Form R at supervision meetings — non-declaration is likely to be found
💡 Community Insight
"Your ES won't always proactively ask — you need to bring it to them first. Discovering undeclared locum work later (e.g. on Form R review at ARCP) creates much bigger problems than raising it yourself upfront."
LTFT Trainees — The Position Is Different
🚫 Most GP Schools prohibit LTFT trainees from regular additional employment
If you are training less than full time (LTFT), the position is significantly more restrictive. Most GP Schools and deaneries state that LTFT trainees are not permitted to undertake any regular employment, within or outside the NHS, in addition to their 50% or 60% timetable.
Why This Rule Exists
LTFT status was almost certainly granted to make your working life more manageable — to support a caring responsibility, a health need, or another significant personal commitment. Asking to work more hours elsewhere sits in direct tension with the reason LTFT was granted in the first place.
As one deanery puts it: if you want to increase the percentage you're working, talk to your TPD about adjusting your LTFT percentage — rather than taking on external work on the side.
It is a little like asking for a quieter table at a restaurant and then enquiring whether the kitchen could take on extra orders. The logic is not difficult to follow.
Some deaneries allow LTFT trainees to cover occasional unplanned shifts if a colleague is unexpectedly absent (e.g. sudden sickness). This is an emergency measure only — not a workaround for planned regular additional work, and not for covering planned annual leave.
Even in this scenario, disclose to your ES and TPD promptly, and ensure your indemnity covers the work.
💡 Always Check Your Local GP School Policy
Rules vary slightly between deaneries and GP Schools. Always check with your specific programme for the exact position. Your TPD is your first port of call — don't rely on what a colleague tells you their deanery allows.
Can I Work as a GP Locum?
🚫 No. GP trainees cannot work as GP locums in a GP practice.
This is one of the most commonly misunderstood points about moonlighting for GP trainees. You are only qualified and authorised to work in a hospital locum capacity at your current grade.
- Performers List restriction: To work as a GP (including as a GP locum) in NHS general practice in England, you must be on the NHS England Performers List. GP trainees are not on the Performers List as independent practitioners — your registration is specifically as a GP specialty trainee. You cannot therefore work as a locum GP.
- Indemnity gap: Even if you could logistically pick up a shift, CNSGP covers NHS contracted work — a locum GP shift in a practice while you are also a trainee creates a complex overlap that most MDOs will not cover under standard trainee schemes.
- Competence considerations: As a trainee, you work under supervision. A locum GP is expected to function with full independent clinical responsibility. These are not the same thing, and the difference matters medico-legally.
- Working as a GP locum in any GP practice — including your own training practice. Even covering your training practice is explicitly prohibited in all deaneries.
- Working during certified sickness absence — this is fraudulent and a GMC fitness-to-practise matter. There are no exceptions.
- Working during study leave — COPMeD guidance explicitly prohibits additional work during periods of study leave.
- Working after an unsatisfactory ARCP — trainees in extended or remedial training must not undertake additional work. Continuing to locum following an unsatisfactory ARCP has led to CCT delays and formal deanery referrals.
- Working above your competency level — if a locum agency offers you a consultant-grade or senior registrar shift that exceeds your actual training level, declining is the correct response. Working beyond competence is a Good Medical Practice violation.
You can pick up hospital-grade locum shifts at your current grade (e.g. as an SHO/middle-grade equivalent), but only in roles you have held within the previous 2 years. This is the COPMeD competency standard — not just a matter of feeling confident.
- Emergency departments — if you have worked in ED within the last 2 years
- Medical assessment units — if acute medicine is within your recent experience
- Acute wards in specialties you have held in the last 2 years
- Any hospital-based setting appropriate to your grade and 2-year competency record
If you are an ST3 whose last hospital post was 18 months ago, that still qualifies. If you left paediatrics 3 years ago and have not worked in it since, it does not.
💡 After CCT — It Changes
Once you have received your CCT and are registered on the Performers List as a qualified GP, you can then work as a GP locum. Until that point, GP practice locum work is not an option.
Moonlighting & Your Training — The Real Talk
There is a documented association between significant outside commitments during GP training and difficulties completing the scheme successfully. This doesn't mean moonlighting inevitably damages training — it means it needs to be managed with care.
- Occasional one-off shifts (once or twice a month at most)
- A specialty you know well — minimal cognitive load
- ePortfolio is up to date and in good shape
- You're sleeping well, energy levels are good
- Your trainer notices no change in your performance
- You've had a frank conversation with your ES and they're supportive
- ePortfolio falling behind — CbDs not done, reflections missed
- Arriving at consultations tired or distracted
- Tutorial preparation has slipped
- You're not fully present in teaching sessions
- Your trainer raises concerns about your performance
- You feel resentful about training demands — a sign of fatigue
💡 Insider Tip — The ePortfolio Test
A good informal test: is your ePortfolio in better shape than most of your peers, or worse? If worse, moonlighting is likely a contributing factor. The ePortfolio doesn't do itself — and the time you spend on shifts elsewhere is time not spent on reflections, learning entries, and WPBA prep.
📊 The Evidence Base — Fatigue Is Not Just a Wellbeing Issue
The HSSIB 2025 report confirmed that NHS staff fatigue contributes directly and indirectly to patient harm, yet is rarely captured in incident reporting. An MDU survey found that 35% of doctors stated tiredness had impaired their ability to treat patients, and 34% said tiredness may have played a part in a clinical error.
Fatigue is therefore not merely a wellbeing concern — it is a patient safety issue and a medico-legal exposure. Trainees should understand that working beyond safe hours creates personal liability even if the employer failed to monitor it. A 2024 BMA survey of nearly 3,200 GP registrars found that almost 73% reported burnout and stress from their clinical posting alone — before any moonlighting was factored in.
💡 Real-World Community Insight — Timing Matters
Most experienced GP registrars advise not starting regular locum work until ST3 is well established and AKT/SCA exams are either passed or in a clear preparation plan. A common and avoidable pattern: trainees begin regular locum shifts in ST2, find exam preparation becomes compromised, and fail the AKT as a result. Occasional ED or MAU shifts are generally manageable and provide useful clinical breadth. Regular weekly locum work during ST1 or ST2 is considered high-risk for training progress by most experienced supervisors.
🚨 Patient Safety & The GMC — Do Not Underestimate This
Fatigue affects decision-making. A tired doctor makes more errors. This is not an abstract risk — it is a documented patient safety issue. If you are moonlighting and find yourself making clinical errors, struggling to concentrate, or feeling overwhelmed in consultations, stop the extra work immediately and speak to your ES.
The GMC takes a serious view of avoidable patient harm arising from fatigue and overwork. A GMC investigation — even one that is ultimately resolved — can last years and is a far greater financial and personal catastrophe than any moonlighting income could offset. Think it through before you start, and keep reviewing it honestly once you have.
- "If you feel too tired to think clearly — do not work that shift."
- "If you notice yourself making errors — stop and review things immediately."
- Talk to a trainer or a colleague you respect. Find a way to balance financial need with safe working — you do not have to solve this alone.
🌱 Practical Tip — Start With Low-Risk Roles
If you are considering moonlighting for the first time, start with the lowest-risk options and build from there. This protects your training, your patients, and your sanity.
- Medical teaching or lecturing
- Exam marking or item writing
- Non-clinical writing or editorial work
- Medical education administration
- Occasional shifts in a familiar specialty at your previous hospital
- Urgent treatment centres or ED shifts — high cognitive load
- Unfamiliar clinical environments or specialties
- Roles requiring independent decision-making above your current competency
- Any role where the indemnity situation is unclear before you start
🔥 AKT High-Yield Tips — Moonlighting in the Exam
Moonlighting doesn't often appear as a direct clinical topic in the AKT, but it does appear in disguise — as a regulatory knowledge question or as a professional / ethical scenario. These are highly learnable marks if you know the pattern.
Key Legal Facts — The Table to Memorise
| Topic | High-Yield Fact | Why It Matters in the Exam |
|---|---|---|
| Performers List | You cannot work as an independent GP unless registered on the NHS Performers List | ST1/ST2/ST3 trainees are not on the Performers List as independent practitioners — this is a hard legal bar |
| ST1 / ST2 / ST3 | Cannot do independent GP locum work — regardless of clinical ability or supervision arrangements | Questions often try to make supervision sound like a valid workaround — it isn't |
| Form R declaration | All additional work requiring a medical licence must be declared on Form R (Part B, Whole Scope of Practice) — including bank shifts at your own Trust | Non-declaration is a fitness-to-practise issue. AKT trap: "bank shifts within your Trust don't need declaring" — wrong |
| NHS-first obligation | Under the 2016 contract, trainees must offer availability to NHS Staff Bank first before taking private or agency locum work | Distractor: can proceed directly to private/agency work — wrong; NHS Staff Bank offer must be made and documented first |
| Sickness / study leave | Additional work is absolutely prohibited during certified sickness absence or study leave | Working whilst off sick = fraudulent = GMC fitness-to-practise referral |
| Unsatisfactory ARCP | Trainees in extended/remedial training after unsatisfactory ARCP must not undertake additional work | Continuing locum work after ARCP Outcome 3+ has led to formal fitness-to-practise concerns and CCT delay |
| NHS Indemnity (CNSGP) | Covers NHS contracted work only. Does not cover private work, event medicine, aesthetics, or occupational health | Distractor: "NHS indemnity will cover it" — wrong if work is outside NHS contract |
| Working Time Regulations | Maximum average 48 hrs/week over 26 weeks (56 hrs with opt-out). Applies across all employers combined | Questions may give total hours that seem fine per-employer but breach WTR in aggregate |
| Visa (IMGs) | HCW visa holders limited to 20 hrs/week supplementary employment; bank shifts at sponsoring Trust do not count toward this limit | IMG-specific scenario: extra shifts may breach visa even if training rules met; >20 hrs/week = immigration offence |
| 2-year competency rule | Hospital locum shifts must be in roles held within the previous 2 years — feeling competent is not sufficient | COPMeD standard. Distractor: "if the trainee feels capable" — wrong; 2-year record is the standard |
Three-Question Quick Decision Aid
- 1"Does my ES know and formally approve?" → If no: do not proceed.
- 2"Is this role within my 2-year competency record?" → If no: do not proceed.
- 3"Will this take my combined average above 48 hrs/week, or breach rest requirements?" → If yes: do not proceed (unless a valid opt-out is in place and the 56-hour ceiling is maintained).
Typical MCQ Pattern — Spot This Instantly
"An ST2 GP registrar asks about working as a GP locum at a local surgery on weekends to earn extra income. What is the MOST appropriate advice?"
✅ Correct Answer
- They cannot work as an independent GP — they are not on the NHS Performers List
- Legal restriction applies regardless of other arrangements
❌ Trap Answers — Do Not Choose These
- "As long as indemnity is arranged" — wrong: indemnity doesn't override the Performers List requirement
- "If supervised by another GP" — wrong: supervision is not a substitute for being on the Performers List
- "If the TPD agrees" — wrong: TPD agreement is necessary but not sufficient for GP locum work
⚠️ The Examiner's Logic Here
The AKT tests whether you know that some restrictions are legal and absolute — not matters of discretion or local agreement. The Performers List requirement is not a guideline or a preference. It is a statutory requirement under NHS (Performers Lists) Regulations 2013. No amount of supervision, indemnity, or agreement overrides it.
Moonlighting in the SCA — Hidden Domains
Moonlighting doesn't appear directly in SCA consultations, but the consequences of overwork do — examiners test whether you can recognise and respond to them:
- Fatigue and patient safety: A scenario where a colleague or patient describes a doctor who "seems exhausted." The expected response includes recognition of fatigue as a patient safety risk and knowledge of safe working limits.
- Professional boundaries / dual roles: A trainee or colleague working privately while also seeing NHS patients — potential conflict of interest, boundaries, and signposting.
- Fitness to work / burnout: Recognition that chronic overwork leads to errors, and that the appropriate response is to stop, reflect, and seek support — not push through.
Common Pitfalls — What Catches Trainees Out
Every item on this list represents a mistake that has been made before — some of them more than once, some by the same person. You are not obliged to repeat any of them.
- Assuming training indemnity covers extra shifts. It doesn't. This is the most commonly misunderstood point. Always verify separately.
- Assuming NHS indemnity covers event or sports medicine. A specific trap: doing the doctor role for a local sports team or community event and assuming CNSGP covers it. It does not — this is outside NHS contracted work entirely. You need personal MDO cover for any such role.
- Not disclosing to the TPD. Some trainees tell their GP trainer but forget the TPD. Both must be informed.
- Not checking combined hours against the 48-hour rule. Trainees add extra shifts without calculating total weekly hours across both roles.
- Trying to GP locum during training. This is simply not possible and carries serious professional and indemnity risks.
- Starting a pattern of regular shifts that gradually increases. One occasional shift becomes every other weekend. Before you know it, you're working unsustainable hours.
- LTFT trainees taking regular extra work. Most deaneries prohibit this. Don't assume your deanery is the exception without checking.
- Letting the ePortfolio slip. If moonlighting is affecting ePortfolio completion, it becomes an ARCP risk — which is a much bigger problem than a few extra shifts are worth.
- Not getting agreement in writing. A verbal chat is not the same as documented agreement. Email your ES and TPD to confirm.
- IMGs: extra shifts outside visa conditions. Skilled Worker visa holders may have restrictions on additional paid employment. A visa breach is a separate and serious legal matter — check your visa conditions before any extra work, not after.
🎓 What Trainees Wish They Knew
Recurring insights from trainees who've been through it
- "Nobody told me that my bulk MDO cover through the scheme doesn't cover locum shifts. I found out the hard way."
- "I genuinely didn't know I couldn't GP locum as a trainee. I thought being a doctor was enough."
- "I was overworking and it was showing in my consultations. My trainer noticed before I did."
- "The money isn't worth failing an ARCP. I wish I'd done the maths earlier."
- "Event medicine and sports team work seem harmless — but they're uninsured unless you sort it yourself."
💡 Trainee Wisdom — The Conversation to Have First
Before arranging any moonlighting work, have a direct conversation with your ES: "I'm considering picking up occasional extra shifts — I want to be transparent with you and make sure we both think this is manageable given where I am in training. What would make you concerned?" That conversation will tell you everything you need to know.
For Trainers & TPDs — Teaching Pearls
- Most trainees are unaware that their bulk HEE/NHSE MDO cover does not extend to moonlighting shifts. Actively address this in induction conversations.
- Many trainees assume "the practice" is their employer and direct disclosures there — but most are employed by the Trust. Clarify the employment arrangement early.
- Trainees often underestimate the cumulative fatigue of even occasional extra shifts on top of a full training workload.
- The GP locum restriction is not widely understood — many trainees genuinely don't realise they cannot locum in a GP practice until they are on the Performers List post-CCT.
🗣️ Discussion Prompts for ES Meetings and Tutorials
- "How is your workload feeling at the moment — are you managing to keep up with the ePortfolio comfortably?"
- "Are you doing any additional clinical work outside your training post? Tell me about that."
- "What's drawing you toward extra shifts — financial pressure, keeping skills up, or something else? Let's think about that together."
- "Do you know what indemnity cover is in place for any extra work you're doing?"
- "If you're finding things tight financially, are there any other avenues we should explore together?" (e.g. BMA financial support, deanery hardship funds)
🚨 When Moonlighting Becomes a Concern for ARCP
Moonlighting crosses from background concern to ARCP concern when:
- ePortfolio is significantly below expectation without clear alternative explanation
- Clinical performance shows a pattern of fatigue, distraction, or reduced engagement
- Attendance at HDR/teaching is poor
- The trainee has not disclosed additional work and this comes to light via a third party
- WTR limits appear to have been breached based on the trainee's disclosed rota
Address concerns promptly and supportively — the goal is to understand what's driving the extra work (often financial) and to find a sustainable path forward. Punitive responses without exploring the underlying need are rarely helpful.
💡 Useful Frameworks for Supporting Trainees Who Want to Moonlight
- The "green light" conversation: Establish explicit conditions upfront for what would lead you to withdraw agreement (e.g. if ePortfolio falls significantly behind, or clinical concerns arise).
- Regular review: Check in at each supervision meeting with a brief "how's the extra work going — any impact on training?" This normalises the topic and catches problems early.
- Focus on the trainee's motivation: Financial pressure is real, especially for trainees from overseas or those with caring responsibilities. Signpost to BMA support services, deanery hardship funds, and financial advice resources if appropriate.
- Form R reminder: Actively ask "is all your additional work declared on Form R?" at review meetings. Discovering undeclared work at ARCP creates much bigger problems than addressing it proactively.
- COPMeD authority: When a trainee pushes back on rules, the COPMeD framework is the formal national standard — not a local preference. This is useful to cite when having difficult conversations.
🗣️ Trainers & TPDs — Some Things to Ask and Consider...
🔍 Opening and context-setting
- "It sounds like you're in a really difficult position — you want to do the right thing, but financially you feel you have no choice. That must be exhausting in itself."
- "Working those kinds of hours would push anyone to their limits — it's not a failing on your part."
🔍 Exploring impact at home and at work
- "How is taking on this extra work affecting your life outside of work — your sleep, your relationships, your sense of yourself?"
- "I want to make sure we think about this safely — have there been any moments at work recently where you felt your tiredness might have affected how you were looking after a patient?"
📋 Sharing relevant information (non-lecturing)
- "There are working time rules in place specifically to protect doctors in training from this situation — you're entitled to a maximum average of 48 hours a week, and there are people whose job it is to make sure that's being respected."
- "If this has been going on for a while, your Guardian of Safe Working is exactly who you'd go to — they're independent of your employer and their job is to act on your behalf."
🔗 Signposting support
- "Have you heard of NHS Practitioner Health? It's a free, confidential service set up specifically for NHS staff in situations exactly like yours." (www.practitionerhealth.nhs.uk)
- "The BMA also has a 24-hour counselling and support line — 0330 123 1245 — it's completely confidential, including from your employer."
🛡️ Safety-netting
- "If anything changes — especially if you're worried you might have made a mistake at work because of how tired you are — please come back straight away. Occupational Health and your GP can both support you."
- "If you find yourself driving to work after a night shift and feel unsafe — please don't. It's not worth the risk and there are options we can explore."
FAQs — Straight Answers to Common Questions
❓ Q: Do I need permission from my GP Trainer to do extra hospital shifts?
❓ Q: My combined hours are under 48/week — am I definitely fine?
❓ Q: My previous hospital has asked me to cover a shift because they're short-staffed — do I have to?
❓ Q: I'm an IMG on a trainee visa — can I moonlight?
This depends on your visa conditions as well as the training rules — they are separate legal frameworks with separate consequences.
If you hold a Health and Care Worker (HCW) Visa (formerly Tier 2), the following rules apply:
- You may undertake supplementary employment of up to 20 hours per week without updating your visa
- The work must be in an eligible occupation code — medicine qualifies
- You must remain employed in your sponsored training post — locum work cannot substitute for training
- Bank shifts at your sponsoring NHS Trust do not count toward the 20-hour limit — only external supplementary employment counts
- Working more than 20 hours/week in non-sponsored supplementary employment without a visa update is a visa compliance breach and potential immigration offence
The RCGP has highlighted that IMGs who complete 3-year GP training but require 5 years of NHS employment for Indefinite Leave to Remain face particular financial pressure to moonlight — making it even more important to know and stay within the 20-hour limit.
If you are uncertain about your specific visa conditions, check with UKVI or an immigration adviser before accepting any additional work.
❓ Q: Do I need to declare moonlighting on Form R?
Yes — all additional work requiring a medical licence must be declared on Form R, Part B (Whole Scope of Practice section). This includes bank shifts at your own Trust, event medicine, private work, and voluntary clinical work. There is no minimum threshold below which declaration is not required. Failure to declare is a fitness-to-practise issue. See the Form R section of this page for full detail.
❓ Q: What is the Guardian of Safe Working and when do I contact them?
The Guardian of Safe Working is an independent role established under the 2016 Junior Doctors' Terms and Conditions. Their job is to act on your behalf — they are not a management figure. Contact them if:
- Your combined working hours (training + moonlighting) are consistently exceeding WTR limits
- Your moonlighting is creating rest break violations that you have been unable to resolve with your employer
- You feel under pressure to work unsafe hours and no other route has worked
You can also use the exception reporting mechanism under the 2016 contract to formally log rest break violations — this creates a medico-legal record that protects you.
❓ Q: Does ePortfolio work from moonlighting shifts count toward my training?
❓ Q: What if my GP trainer says no to moonlighting — can I appeal?
❓ Q: I'm in financial difficulty — is there any support available beyond moonlighting?
❓ Q: Can I do non-clinical moonlighting (e.g. medical writing, teaching)?
Final Take-Home Points
Before starting any moonlighting work, run through SNAP CIF. If any answer is "no" or "I'm not sure" — stop and resolve it first.
"If it's not safe, not legal, or not covered — don't do it."
A comprehensive pre-shift checklist. Every letter must be green before you start. Nine checks — considerably fewer than most NHS referral forms, and considerably more important.
| Letter | What to Check |
|---|---|
| B | Bank first — offer your availability to NHS Staff Bank before private/agency work (2016 contract obligation) |
| E | ES approval — written agreement from your Educational Supervisor (and TPD). Verbal is not enough. |
| S | Sickness / study leave? — If yes on either: do not proceed. Absolute bar. |
| T | Trained for it — is this a role you have held in the last 2 years? (COPMeD 2-year competency rule) |
| L | Log it on Form R — declare all additional work in Part B, Whole Scope of Practice section. Even single bank shifts. |
| I | Indemnity sorted — block scheme does not cover locum work. Arrange separate MDO cover before the shift, not after. |
| G | GP setting? — If it's a GP practice: hard no. GP trainees cannot locum in any GP practice setting. |
| H | Hours check — will combined hours stay within EWTD limits? (48 hrs/wk average; 56 max with valid opt-out) |
| T | Training on track — no unsatisfactory ARCP? Not on extended programme? If either applies: do not proceed. |
- 1Moonlighting is possible for full-time trainees — but only with explicit written agreement from your TPD, ES, and GP Trainer, and only when all COPMeD conditions are met.
- 2Your training indemnity does not cover moonlighting shifts. Arrange separate MDO cover before any extra clinical work — never after.
- 3Working Time Regulations: 48-hour average across all jobs over 26 weeks. With a valid opt-out: 56 hours maximum. Rest requirements apply regardless of opt-out.
- 4All additional work must be declared on Form R (Part B). This includes bank shifts at your own Trust. Non-declaration is a fitness-to-practise issue.
- 5Under the 2016 contract: offer to NHS Staff Bank first before private or agency work. Document the offer.
- 6You cannot GP locum as a trainee — including at your own training practice. Hospital-grade shifts in roles held within the last 2 years are the appropriate avenue.
- 7Absolute bars: sickness absence, study leave, unsatisfactory ARCP outcome. No exceptions. Breaching these carries GMC and training consequences.
- 8LTFT trainees face additional restrictions — most GP Schools prohibit regular extra employment, especially where LTFT was granted for health reasons.
- 9IMGs on HCW visas: 20 hours/week maximum supplementary employment. Bank shifts at your sponsoring Trust do not count toward this limit. Exceeding it is an immigration offence.
- 10If the ePortfolio is sliding, you're arriving exhausted, or errors are happening — stop the extra work immediately and speak to your ES. The GMC does not overlook fatigue-related patient harm.
💬 Final Word
Extra work during training is a real and understandable choice for many trainees. The NHS system that depends on you tomorrow needs you to complete your training well today. Moonlighting with honesty, good indemnity, and genuine self-awareness about its impact on your development? That's fine. Moonlighting quietly, without cover, while your ePortfolio falls to pieces? That's a problem. The difference is entirely in your hands.