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The trouble with locums
Abstract
It’s not all about the money
The role of locums—and temporary clinical staff more generally—is in the spotlight. On one side, the release last month of Keith Pearson’s report on medical revalidation pinpoints weaknesses in the oversight of, and support for, doctors working in short term locum positions,1 findings acknowledged by the General Medical Council.2 On the other side, the regular quarterly statements from NHS Improvement on the financial performance of NHS trusts now contain updates on progress in reducing NHS spending on agency staff.3 As at least some of the recent increase in the use of temporary staff has been driven by persistent staff shortages, questions are now also being asked about the quality of NHS workforce planning that has allowed such drastic shortfalls in the workforce to arise in the first place.
There are two related concerns about the use, or overuse, of temporary staff in the health service. The first is the effect that such staff may have on the quality of care. Staff moving rapidly between …
... This was attributed to, for example, inadequate pre-employment checks and induction, unclear line management structures, poor supervision and lack of reporting of performance. 2,7,11,13,15,[30][31][32][33][34][35][36][37][38][39][40][41][42][43] Locums were described as professionally isolated 41 and less likely to be aware of the local context necessary for delivering safe and efficient care. 7,11,32,35,44 This was regarded as not only detrimental to patient safety, but this lack of preparation for practice may also be potentially detrimental to locum wellbeing and the wider healthcare team who might have to work beyond their scope of practice to compensate for the locums' lack of knowledge. ...
... 7,11,32,35,44 This was regarded as not only detrimental to patient safety, but this lack of preparation for practice may also be potentially detrimental to locum wellbeing and the wider healthcare team who might have to work beyond their scope of practice to compensate for the locums' lack of knowledge. 39 Other inefficiencies related to locum working included increased workload for the healthcare team if patients returned to their usual doctor after initially seeing a locum, resulting in duplication and waste of resources. 45 The quality and quantity of information exchange about locum working was described as absent or poor. ...
Locum doctors are often perceived to present greater risks of causing harm to patients than permanent doctors. After eligibility and quality assessment, eight empirical and 34 non-empirical papers were included in a narrative synthesis to establish what was known about the quality and safety of locum medical practice. Empirical literature was limited and weak methodologically. Locums enabled healthcare organisations to maintain appropriate staffing levels and allowed staffing flexibility, but they also gave rise to concerns about continuity of care, patient safety, team function and cost. There was some evidence to suggest that the way locum doctors are recruited, employed and used by organisations, may result in a higher risk of harm to patients. A better understanding of the quality and safety of locum working is needed to improve the use of locum doctors and the quality and safety of patient care that they provide.
... This has led to more gaps within rotas, leading to increased spending on locum doctors and greater strain on departments and on other junior doctors. 1 Data released from the foundation programme have demonstrated significantly fewer foundation year 2 doctors entering either core or specialist training: in 2011 71.3% entered further training compared to 37.7% in 2018. 2 Within our department (general and vascular surgery) we experienced significant rota gaps during this period, which put strain on the remaining workforce, led to increased expenditure on locums and potentially put patient safety at risk. ...
Introduction:
Staff shortages and rising locum costs prompted Barking, Havering and Redbridge University Hospitals NHS Trust to design an innovative training pathway for doctors in surgery. The 'Academy of Surgery' is a 2-year structured educational programme with rotations through surgical and emergency care specialties and includes a funded MSc.
Methods:
We recruited 27 doctors over a 2-year period. The first cohort started in October 2018, the second in October 2019. These doctors are heavily supervised in a 2-year programme that aims to prepare them for higher specialty training. They undergo regular assessment and annual review of competencies and progression. They receive regular formal classroom teaching and there are regular sessions to discuss welfare.
Results:
Surgical rotas are now fully staffed and not reliant on locum doctors. This has led to significant cost savings. Locum spending in 2017 was £3,856,000 vs £1,284,000 in 2020 - a net saving of £1,187,000 over 2 years.
Conclusion:
This innovative training programme has contributed to full staffing of a number of surgical rotas within our Trust and delivered a large financial saving for the NHS. We hope to expand this work into neighbouring trusts.
Objectives
A systematic review was undertaken to understand the nature of the relationship between the UK National Health Service (NHS) labour force and satisfaction, retention and wages.
Design
Narrative systematic review.
Data sources
The literature was searched using seven databases in January 2020: MEDLINE (1996–present), the Cumulative Index to Nursing and Allied Health Literature (CINAHL via EBSCO) (1984–present), Embase (1996–present), PsycINFO (1987–present), ProQuest (1996–present), Scopus (all years) and Cochrane library (all years). We used medical subject headings and key words relating to ‘retention’, ‘satisfaction’ and ‘wages’.
Eligibility criteria for selecting studies
Primary research studies or reviews that focused on the following relationships within the NHS workforce: wages and job satisfaction, job satisfaction and retention or wages and retention.
Data extraction and synthesis
Two independent reviewers screened all titles, abstracts and full texts, with arbitration by a third reviewer.
Results
27 803 articles were identified and after removing duplicates (n=17 156), articles were removed at the title (n=10 421), abstract (n=150) and full-text (n=45) stages. A total of 31 full-text articles were included. They identified three broad themes, low job satisfaction impacting negatively on job retention, poor pay impacting negatively on staff satisfaction and the limitations of increasing pay as a means of improving staff retention. Several factors affected these relationships, including the environment, discrimination, flexibility, autonomy, training and staffing levels.
Conclusions
This review highlighted how multiple factors influence NHS labour force retention. Pay was found to influence satisfaction, which in turn affected retention. An increase in wages alone is unlikely to be sufficient to ameliorate the concerns of NHS workers. More research is needed to identify the role of autonomy on retention. A system leadership approach underpinned by data is required to implement bespoke job satisfaction improvement strategies to improve retention and achieve the goals of the NHS Long Term Plan.
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