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How I tried to hire a locum

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1412 (Published 29 June 2010) Cite this as: BMJ 2010;340:c1412

This article has a correction. Please see:

  1. Chris Isles, professor
  1. 1Medical Unit, Dumfries and Galloway Royal Infirmary, Dumfries DG1 2AP
  1. chris.isles{at}nhs.net

    Chris Isles’ frustrating hunt to fill his medical staff rota using locums led him to some critical conclusions about the poorly regulated locum sector in the UK

    The medical unit in my district hospital has around 150 beds. There is funding for 21 middle grade and specialty doctor posts, although at the time of writing only two thirds have been filled. Monthly adverts for locum training posts in the medical press got responses from several apparently suitable doctors working overseas, but it would be at least three months before their paperwork would be complete to allow them to come to the UK and they were therefore of no use for our current crisis.

    There was a European doctor with no previous NHS experience who had been working on a cruise ship for the past year; a gastroenterologist whose curriculum vitae (CV) stated that his knowledge of psychosomatics allowed him to treat disorders such as globus hystericus but gave no clear idea that he would know what to do if confronted by a patient with life threatening haematemesis. There were many other CVs like these. Human resources tried their hardest to procure suitable locums from staffing agencies, but with no success. It was at this point that I decided to become involved in the procurement process. All the case histories that follow relate to a three month period and are true.

    Case histories

    Dr A—Around Christmas 2009 an agency emailed offering “a fantastic doctor with very good UK experience. He is very flexible and can work days and nights.” I booked him immediately. Four days later came another email from the agency: “He is not wanting to work in Scotland (too cold!!)—only wants to work in or around London.” You win some, and you lose some.

    Dr B—The email from the agency read: “I have a very good general medicine SHO [senior house officer], who is available. If he is of interest, snap him up as he won’t be around for long as his CV looks brilliant.” Buried within the CV was a reference from a UK consultant which stated that this doctor’s basic skills were equivalent to a foundation year 1 or foundation year 2 doctor. “Due to only a short period of attachment on my ward I am unable to comment about his competence in great detail but I think he should be suitable for a locum SHO post under close supervision.” We decided not to proceed.

    Dr C—This doctor’s UK experience amounted to two months as a locum senior house officer for which no references were provided. Undeterred, the agency were determined to make the most of their investment by writing: “I can confirm that this doctor is still available as of this point, but things change really quickly with SHOs as they seem to be in short supply! For example, I had an SHO in medicine available at 1430 and by 1450 he was gone!” I felt this level of enthusiasm was likely to have been misplaced, but sure enough the doctor had been snapped up in the time it took me to say “book him.”

    Dr D—This European doctor was working in the UK and had reasonably good references. I decided to go ahead and wrote a nice welcoming email. The agency assured me that the booking had been accepted and that all the paperwork was in order. Two days later I received an email from Dr D that read “Sorry. I received your message but I do not understand about which company you are talking. I do not know anything about your hospital (that should I can go). If you can tell me more details or it is a mistake?” I phoned the agency to ask for an explanation but no one was able to provide me with one. We never heard from the locum again.

    Dr E—This doctor was offered to us as a SHO locum. We booked the doctor but our human resources department subsequently discovered that the locum had only a student visa. A student visa means that a doctor can work only at foundation year 1 level and for 20 hours a week. We did not take the doctor. The agency wrote to us later to say that because the doctor had not acted professionally with their staff and not provided them with information requested they would be taking that person off their books. Because agencies do not share information about doctors who behave unprofessionally with other agencies, this doctor will presumably have no difficulty signing up somewhere else.

    Dr F—This doctor had trained for many years overseas and now wanted to move to the UK. The agency offered the doctor to us as an SHO, and the CV said that the doctor had worked at this grade in another UK hospital. The reference stated that the doctor showed very good reliability, timekeeping, clinical and communication skills, and good relationships with patients and colleagues. But the doctor looked terrified on arrival—so much so that we felt we had to employ another SHO to cover during the acute medical take. Fortunately, one of our SHOs had a week off and was prepared to do this. It soon became apparent that Dr F’s comfort zone was somewhere between that of a final year medical student and a foundation year 1 doctor. I urged the doctor and the agency to reconsider their strategy and suggested that it would be better to start off life in the NHS with a clinical attachment and then apply for a foundation year 1 post before considering a more demanding role. We ended the contract. The agency had already offered the doctor another SHO locum.

    Dr G—One of our core medical trainees had decided to relinquish her post for personal reasons and did so just as she was due to start a three week receiving block. We advertised for a locum to cover her first weekend but no one materialised. Then unexpectedly, with three or four days to go, we received word that a doctor working as a consultant overseas would be prepared to cover the three 12 hour shifts provided we paid over the odds. We held our noses and duly did so. There were no complaints during the first two nights on call, but during the third night the doctor was discovered asleep on a chair in the doctors’ mess. The doctor with whom the locum was on call asked for help with a difficult patient during the night but was told that the locum was “too tired” to assist. One of the staff nurses filed a critical incident report over the locum’s handling of another case, which she thought was not up to standard. I forwarded both complaints to the locum agency, which in turn forwarded them to the locum for comment, though we have heard nothing since.

    Dr H—The agency said this doctor was looking for a full time medicine post. The doctor’s referee stated: “I have found Dr H as an honest dedicated and conscientious doctor who is keen to provide excellent care in all settings. [Dr H] has good communication skills and provided administrative support on an NHS ward setting in the last six months. [Dr H] is happy to work within general medicine, ENT [ear, nose, and throat], and general surgery.” When we asked the agency for more details we were told that Dr H had spent the last six months working as a ward clerk.

    Dr I—We were offered this specialty registrar (SpR) in medicine at the eye wateringly high rate of £70 a hour plus value added tax. The general manager sanctioned this because we were so short of staff. The doctor’s only UK experience has been as “locum SpR” for six weeks in another district general hospital. I spoke to one of the consultants at this hospital, who said the locum was functioning somewhere between foundation year 1 and 2, and had spent an hour seeing one patient at a clinic. He said that he never asked the doctor to do any medical receiving on the grounds that he felt this would be “asking for trouble.”

    Dr J—I received an email from an agency offering, “a VERY good SHO in general medicine.” I phoned the agency to ask if this doctor was capable of undertaking medical clinics and receiving acute cases, to which the agency’s team leader for junior doctors replied, “I can ask.” If the agency did not know then should they be advertising him? The structured reference looked satisfactory so I emailed back to the effect that we should book him. An hour later I received an email “Just spoke to the doctor, other agencies looking to book him out as well at a different trust. But Dr J would like to work at your trust. He wants to know what shifts he will be working and how many hours. He would like as many on-calls as possible.” For locum agency read “cattle market,” with locums going to the highest bidder.

    Frustration

    I have spent the best part of three months trying to fill our middle grade rota without success. A huge amount of time has been wasted attempting to book doctors with little experience of working in the UK, whose competencies I have been unable to assess, who did not always have the right paperwork, and who could break an agreement at will and without repercussion.

    I believe the responsibility for this must lie with the European Working Time Directive and Modernising Medical Careers, which have created a health service in which we are forced to rely so heavily on locums. But most of all I rage at the locum agencies whose abject failure to regulate themselves should surely have led to intervention by the GMC by now. We pay lip service to patient safety by allowing this scandalous state of affairs to continue.

    Locums: the state we are in

    Demand for agency locum doctors has increased in recent years, but the ability of agencies to meet requests has fallen. This is the finding of a recent report on locum doctors by the public sector watchdog Audit Scotland, Using Locum Doctors in Hospitals. It found the NHS in Scotland spent £47m (€57m; $70m) on locum doctors in 2008-9, 43% of overall medical staffing expenditure. About £27m of the spend was on agency locums.

    Demand has been fuelled by the full implementation of the European Working Time Directive for doctors, as well as increasingly hard to fill vacancies. Agencies’ ability to meet demand for locum doctors fell from 83% of all requests filled in 2006-7 to 71% in 2008-9.

    With such a high demand for suitable agency staff, hourly rates are high. Audit Scotland found pay rates ranged from £34 to £87 an hour, excluding VAT. National procurement arrangements that required trusts to hire locums only from agencies on an approved list lapsed in 2009. Since then hourly rates have risen, according to Audit Scotland.

    Employment agencies are supposed to vet locum staff, but NHS Boards are also responsible for making sure that pre-employment checks are carried out when appointing agency locum doctors. Because these arrangements are not always formalised, there is a risk that checks sometimes may not be completed.

    Feedback on performance is often verbal, rather than written. This means poor performance isn’t always fed back to the agencies. Even when it is reported to agencies, the NHS does not always receive feedback on any action taken. Audit Scotland also found that procedures for induction and supervision of locum staff were vague and therefore more likely to be overlooked.

    With so many weak links in the chain, it is unsurprising that hospitals are often sent locum doctors who are inappropriate in terms of experience, qualifications, immigration status, and fatigue.

    Chris Isles’ account illustrates some urgent employment issues that are relevant elsewhere in the NHS as well as in Scotland. In England, the Department of Health does not centrally collect figures to show how much NHS trusts spend on locum doctors.

    Notes

    Cite this as: BMJ 2010;340:c1412

    Footnotes

    • doi:10.1136/bmj.c3385
    • Competing interests: The author has completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from him) and declares (1) no financial support for the submitted work from anyone other than his employer; (2) no financial relationships with commercial entities that might have an interest in the submitted work; (3) no spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; and (4) no non-financial interests that may be relevant to the submitted work.

    • Provenance and peer review: Not commissioned; not externally peer reviewed.

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