The use of locum doctors in the NHS – results of a national survey of NHS Trusts in England

Doctors working in temporary roles, often known as locums, may do so because they have greater control over the amount and type of work that they do [1‐3]. Locums give organisations greater workforce flexibility and organisations that use locums can maintain workforce capacity to provide patient services. However, there are concerns that locums are an expensive resource and can have a negative impact on workload for permanent staff, patient safety and team function [4‐6]. A recent survey of locums found they face barriers including lack of familiarity with work settings, instability and being treated differently to permanent staff [3]. A review of the literature suggests that the way locums doctors are engaged and used by organisations may result in some risks to patient safety [4]. A national survey of responsible officers found that there were limitations in the appraisal and revalidation processes for doctors working as locums and that locums had higher rates of deferral of revalidation compared to other doctors [7]. Furthermore, a recent qualitative study found that perceptions of locum doctors as inferior to permanently employed doctors in terms of quality, competency, and safety can result in marginalisation, stigmatisation and limited opportunities for training and development [8].

A number of reports show that in recent years the number of doctors choosing to work as locums is increasing [9, 10]. The use of locums has been linked with staff shortages, doctors leaving the profession early [11, 12] and increased sickness, workload and burnout as a result of the COVID-19 pandemic [13]. In the past it was reported that NHS Acute Trusts in England were spending significantly more on locum agency fees than on recruiting doctors to permanent positions [14]. There has been pressure on the NHS to reduce the spend on locum agencies but this is challenging given huge demands on NHS services [15]. NHS staff banks are managed by trusts and consist of a pool of healthcare professionals, including doctors, who make themselves available for shifts at Trust hospitals. A target was set to all Trusts in England to reduce agency costs by 17% for 2018/2019, this encouraged a ‘bank first’ approach to recruiting temporary staff, making the use of agencies a last resort [16]. However, the cost of agency staff has remained constant and the cost of bank staff has increased between 2017 and 2020 with a spend of over £6 billion on agency and NHS bank staff in England in 2019–20 [17].

There is some data on locum usage in NHS trusts collected by NHS Improvement [18] but this does not include why locums are needed, how their work is organised and how locum doctors are supported by NHS Trusts. The NHS England and NHS Employers guidance highlights ways to support locum doctors in providing safe provision of healthcare [19] but we do not have any information about how this guidance is used by Trusts.

The aim of this study was to seek information about locum work in NHS Trusts in order to better understand why and where locum doctors were needed; how locum doctors were engaged, supported, perceived and managed; and any changes being made in the way locums are used.

We found that the use of locums was an integral part of Trust working. Trusts need locums for all different lengths of engagement and very few Trusts make no use of locums. The use of locums is driven by workforce issues like recruitment, staff sickness and planned workforce gaps. It is important to note that locums come from the finite pool of doctors, and while flexibility is increased for organisations and doctors, the use of locums does not do much to alleviate doctor shortages at a national level. Trusts face challenges with recruitment of doctors, which is reflected in recruitment and retention challenges nationally [29], this results in Trusts often needing locums long-term and having to source locums mainly from agencies at high cost. We found, as others have, that there was poor awareness, ambiguity and confusion about the national guidance for locums from NHS England and who was responsible for following it [7]. Trusts focused on processes such as verifying documentation and completing induction but less was done with regard to feedback and appraisal. This is corroborated by findings from a recent survey of agency locums which recommended that organisations provide greater support for locums to obtain evidence for appraisal and revalidation [3].

Overall, care provided by locums was viewed as about the same or somewhat worse as care provided by permanent doctors, particularly in areas like adherence to organisational policies and guidelines, continuity of care and avoiding administrative errors. One reason for this could be that mistakes are more likely to be made in environments that are unfamiliar [3]. It is concerning that the majority of Trusts in our study reported using locums between one and three months and sometimes without adequate induction and support. Appropriate supervision might prevent locums getting into difficulties; however, there is little in the NHS guidance about the provision of a named supervisor or mentor for locum doctors, despite evidence to suggest locums are at greater risk of isolation and of being complained about [30] Causes of administration errors in hospitals such as inadequate communication, and local working conditions may impact more on locums who are unfamiliar with organisational systems [31]. Locum doctors may also be more likely to make mistakes if permanent staff are unable to support them due to the increased supervisory demands that may be required when locums are unfamiliar with the organisation [6] or because of negative perceptions or discrimination [3]. Yet if a serious incident occurred, not all Trusts would inform the locum agency, RO, GMC, or indeed the locum, limiting the opportunity for shared learning when things go wrong.

While some Trusts felt that continuity of care was worse when care was provided by a locum, it should be recognised that continuity of hospital care requires more than personal continuity at the patient interface. There is a collective organisational responsibility for continuity of care, and team structures and organisational systems should be considered when evaluating continuity of care [32].

In their written responses Trusts felt that lack of familiarity and high cost was a disadvantage but these were not rated as important when recruiting, suggesting Trusts are unable to prioritise familiarity and cost because of high demand to fill gaps. Respondents felt that locum agencies match their needs and provide accurate information about locums, however there were low opinions of locum agencies in relation to cost. Trusts would like to reduce the reliance on locum agencies and make greater use of internal locum banks in order to reduce costs and increase familiarity with the organisation; guidance on establishing and using banks has been produced by the NHS Workforce Alliance and should be accessed by Trusts [33, 34]. The problem of locum cost was linked to challenges in motivating permanent staff, and protecting their contractual advantages. Offering locums NHS ‘privileges’ afforded to permanent staff was perceived to be in direct conflict with building a stable workforce. This may result in the limitation of support opportunities for locums. Research has found that locums were perceived as money oriented, were treated differently than permanent staff and were often excluded from additional support processes [8].

Some respondents expressed concern that short term placement of locums did not allow for building relationships and knowledge of the systems that contributes to self and organisational development. Other research has found that permanent staff in A&E would expect temporary staff to have less vested interest in a department, particularly if they know they are not going to return [6]. Targets have already been set for Trusts to reduce their use of agency locums and increase the use of internal locum banks [18]. This allows for more regular and familiar locums which increases trust and allows for greater investment in temporary staff in the short and long term.

The results from this survey highlight the precarity of locum work. Locum contracts can be ended early following even low-level concerns and locums may have less access to communities of practice within Trusts for providing appropriate governance, leadership and support, meaning remedying performance problems may be more difficult. Similarly, Amery and Griffin (2020) found that short training rotas limited the ability of medical trainees to engage in communities of practice in order to engage in activities and form mutual relationships [35]. This may in part explain why locums are more likely to have formal complaints about them to the professional regulator than permanent doctors [9].

This is the largest survey of the use of locum doctors in the NHS. The survey had good regional coverage, although we cannot distinguish between rural or urban locations, and was completed by different types of Trust and different staff types. The response rate was relatively high for an online survey, and responding organisations appeared to be largely similar to non-respondents in various respects, however it is possible that non-respondents may differ systematically in some way. However, in securing this response rate we were unable to collect data on differences between locums who worked for different lengths of time. Locums are a heterogeneous group and locums who were employed in an organisation for short periods were likely to be different to long-term locums. In order to keep the survey to a reasonable length, we chose to ask questions about all locums rather than repeat questions for short, medium and long-term locums.

The extent to which the views and perceptions collected in the survey are useful depends partly on the representativeness of the respondents (see above) and on how insightful their perspectives are. Medical Directors and leads in medical staffing would be expected to have a good overview of locum work and systems for managing locum engagement, however we cannot be certain if all respondents, in particularly those in other roles, would have enough experience and knowledge to answer all questions accurately or how susceptible respondents were to response biases such as social desirability and acquiescent responding. In addition, each response represents the views of just one person in the organisation and may differ from those of others in the same organisation.

Locum doctors are an important resource for NHS Trusts enabling them to maintain workforce capacity and provide patient services. However, there are also a number of potential issues relating to the ways that locum work is organised, the way locums are supported, and the quality of care provided by locums. In light of our findings, action that could be taken by trusts to improve quality and safety includes making more use of known and familiar doctors to minimise the use of short term placements, which is likely to be where problems arise. Internal staff banks and longer locum engagements may mitigate some problems associated with short-term placements and reduce overreliance on costly locum agencies. Where possible and appropriate, trusts should involve locums in training and development, support appraisal and revalidation, and include locums in clinical teams. Treating locums like permanent members of staff is likely to empower and enable doctors to work more effectively in the organisation. This means allowing time for familiarisation, providing proper induction, arranging access to systems, policies and procedures, and preparing for the challenges of working in unfamiliar organisations. Organisations should be aware that unfamiliar locums often cannot fulfil the whole scope of practice of a permanent member of staff, and that this can increase the workload for permanent staff, which needs to be recognised and planned for. Trusts should familiarise themselves with and follow the NHS England guidance on using locums – and pay particular attention to providing support that goes beyond the essentials of checking locum doctors’ registration, qualifications and other details. For example, trusts should provide feedback to both the locum doctor and the locum agency about locum placements, especially if there are concerns. And lastly, to facilitate learning and improve safety, it should be unacceptable for an NHS trust to terminate a locum placement because of concerns but not act on those concerns. When they are concerns, the process should be documented and the NHS trust and RO should be involved to deal with the concerns as they would for a permanent member of staff.