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
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The majority of us working in an acute medical speciality will have
read Chris Isles' article with a wry smile. Absences from on call rotas
will always occur due to unavoidable sickness or personal reasons.
Obtaining competent locums in these situations, often with only a day's
notice, is typically an impossible task for two reasons.
Firstly, there appears to be an assumption on behalf of human
resources that a locum will seamlessly slip into the absentee's shoes
without requiring formal induction. Even the best doctors struggle
initially with unfamiliar computer and telephone systems, radiology
requests and antibiotic policies. From personal experience, expecting
locum doctors to "pick it up" for the short time period they work in the
trust, borrowing passwords and identification badges to survive through a
single night or day on call is unrealistic and clearly does not work.
Secondly, as Chris Isles points out, the ability of locums is
variable with a minority proving incompetent. We have both worked with
locums who have not known the correct dose for basic medications like
paracetamol, let alone proved able to run a medical or surgical take.
So what can be done? On discussing this we happened upon an
intriguing solution. What human resources have failed to recognise is
that they have an army of locums readily available, familiar with the
hospital's systems and paid by trusts to be on call, often sleeping
through the night. They are called consultants.
Perhaps it is only a matter of time before this underused resource
will be summoned from home to plug gaps in the on call rota arising at
short notice. Controversial though this is, would it not be preferable to
the current system?
Competing interests:
David King has previously worked as a locum through a locum agency.
Competing interests: No competing interests
Dr. Isles's frustrating hunt for adequately qualified locum medical
staff is alarming, and one must agree with his contention that the locum
agencies require regulation because they are apt to offer poorly trained
doctors for inappropriate locum positions.
Many locums - probably a majority - are competent, well trained, and
perform well and to the benefit of patients. But there is no doubt that
incompetent, poorly trained locums exist, and their poor performance
places patients at grave risk. There are many instances of locum positions
being occupied - sometimes repeatedly - by individuals who have no valid
medical qualifications.
Locum agencies should be regulated and inspected, and should be
closed down if they do not meet standards to be set by the General Medical
Council. It should be the responsibility of these agencies to ascertain
that the qualifications of the locums they supply are genuine, that the
locum's experience is properly documented, and is appropriate for the
position to which they are being recruited. Thus patients will be
protected.
Competing interests:
None declared
Competing interests: No competing interests
No ma'am, I am a well-trained and very experienced professional
capable of working in several different areas of medical practice. After
my full-time GP post nearly killed me I decided to seek safer work---safer
as it relates to my health. I locum as a career choice and have gained a
lot from it. Likewise patients and colleagues, nearly all of whom ask me
to stay on for good or at least come back soon.
High-profile abuse of locums serves none of us well.
If a trust has difficulty attracting doctors to its substantive posts
then it is unlikely to attract a regular supply of good locums.
Regulating locum agencies will not deal with the shortage of good
locums and Chris Isles article unfortunately distracts attention from the
question of why on earth this civilised nation cannot organise medical
manpower well enough to provide the necessary cover.
As for agencies getting more information on prospective locums, I
have been meaning to sign up with a well-known UK agency for some time but
the paperwork puts me off! Looks like about a day's work to fill up all
the forms and provide all the necessary certificates! If that is not
enough paperwork to allow the agency to place locums in the right posts
then I give up.
Did the EWTD really screw things up so badly? There was plenty of
locum work available back in the 80s and 90s, long before EWTD came in.
EWTD may possibly have been an over-reaction to the horrendous 72 and 96
hour on-call sessions but I'm not sure if it is possible to over-react to
those on-calls. Didn't do my health any good and I nearly resigned umpteen
times back then.
Yours etc
Declan Fox
Competing interests:
None declared
Competing interests: No competing interests
The fact that I do not appear on the specialist register of the GMC
does not mean I have not received specialist training or that I do not
have the experience and qualifications to carry out my role very
competently or successfully. I achieved my qualifications overseas and
spent much of my early career there and have successfully demonstrated my
abilities in the roles I have filled to date in the UK. It is not a legal
requirement for a doctor to be on the GMCs specialist register in order to
practice within a speciality - the only requirement is that the doctor
hold full registration with the GMC, and can demonstrate skill and
experience commensurate to the position - which I certainly do. "Lisa
Smith" needs to acquaint herself with the regulations in this regard.
This needs to be distinguished from the appointment of a substantive
consultant post within the NHS, for which the specialist register is
required. My access to the specialist register, via Article 14 of the
PMETB and its successor, is an extremely expensive tick-box exercise which
would in my circumstances, serve no useful purpose whatsoever currently,
although I have not entirely discounted its use for the future.
"Lisa Smith" also needs to take care before jumping to erroneous
conclusions about the specialist register and the ability for some senior
clinicians to practice as such without being on it. And just to correct her further error - I indeed spent some four
years in Worcestershire, as a LOCUM Consultant, not a substantive position.
It is also clear that she is attempting to deflect interest away from the main
issue here, and that is the BMJ's branding of Locum Doctors as "MISFITS",
in the medical world and in society as a whole - that is deplorable,
untruthful and sensationalist gutter-type journalism at its worst.
Competing interests:
I am employed as a Locum consultant
Competing interests: No competing interests
Dear Editor,
I am very concerned about who is treating us patients.
Thanks to guidance from my GP and GMC web page I can check qualifications
of each registered doctor in UK.
From what I read there Dr Chris Isles is on a specialist register however
Dr Laurianne Eugena Durand is not on a specialist register.
In her letter of 08 July to BMJ she presents herself as a Locum Consultant
Forensic Psychiatrist and Acting Head of Psychiatry in Rowan House
Hospital managed by Care Principles in Norfolk.
Does Locum Forensic Psychiatrist in Care Principles practise without
specialist training?
This is very confusing for the public. Patients and their families have a right to be informed about the specialist qualifications of their consultants.
In another place on the net (worcestershirehealth.nhs.uk) I could read
that Dr Laurie Durand was employed by NHS Worcestershire Mental Health
Partnership as a "Consultant Psychiatrist", no word locum used.
I hope NHS, GMC and Care Principles Ltd help us public to understand who
is treating us.
Sincerely,
Lisa Smith
retired HR advisor
Competing interests:
None declared
Competing interests: No competing interests
The subtext of this debate is about the difference between a 'good
doctor' and a 'not such a good doctor'.
One becomes a good doctor by 'hands on' practice with continuing
involvement in the care of the patient and thus gaining an insight into
the process of disease and recovery.
The non-engaging, shift based and target chasing training is only
going to produce doctors focused on delivering forms and documents that
will satisfy the demands of the GMC.
The present day NHS clinicians have already been maimed enough so as
not to raise concerns where they matter.
Most clinicians now switch off as they sign off and that is what a
locum does, and so are we all !
Competing interests:
None declared
Competing interests: No competing interests
Junior doctors in the NHS are trained in either in the UK, the
European Economic Area (EEA) or other overseas countries.
UK doctors undergo competitive entry into medical schools and receive
a high standard of medical training that will cater the needs of NHS
working. The other 2 group of doctors can have variable entry routes and
standards of training in medical schools. Many medical schools in Asia
(& perhaps others too) that are not state- funded do not have
competitive entry criteria & students can enrol based on eligibility
to pay huge sums of fees.
There is variation in training & exit exams in different
countries. However, there are appropriately dealt with by ensuring
rigorous standards of English (IELTS) & appropriate clinical knowledge
by PLAB exams.
The GMC website states that: “If you are from outside the European
Economic Area (EEA), you need satisfactory scores in the International
English Language Testing System (IELTS) test. These are the minimum scores
you must achieve: Overall 7, Speaking 7, Listening 6, Academic reading 6,
Academic writing 6. The general modules are not acceptable.”
Many suitable qualified & skilled doctors from overseas countries
find the IELTS as a road block before the PLAB exam. Many doctors have to
undertake the English test a few times before achieving the desired
scores.
There is no concession based on experience, research or other
academic achievements. However, many Universities in UK require an overall
IELTS score of 6.0 or 6.5 for post-graduate courses like an MSc in
Clinical Research or a Masters in Public Health.
If these UK universities consider a lower IELTS score to be adequate
for graduates, should there be a more rigrous screening for overseas
doctors?
Should all locum doctors be tested for their English proficiency-
this can be debated. However, lowering the competence required in English
language slightly can enable more doctors to prove their clinical
competency.
Lowering the IELTS score may enable more doctors to sit for the
standardized PLAB clinical exam. This is needed in the current crisis of
shortage of doctors & will ensure uniform standards in NHS.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
I am shocked and dismayed by the BMJ’s choice of headline for the
recent issue, BMJ Vol 341 No 7762
“Misfits: The Trouble with Locums”
There is a longstanding and unspoken discrimination of Locums within
the medical establishment with an assumption that those who work as locums
lack clinical integrity, commitment or skills to hold a permanent
position.
Although I am sure that there are doctors who fall in to the above
categories who locum (just as there are in established training, staff
grade, consultant or in GP principle or salaried positions) there are also
doctors who locum who maintain high levels of clinical standards, CDP and
professional integrity who may be locuming for many reasons.
I feel that it is irresponsible of the BMJ - the journal of an
organization who is the “voice of all doctors in the NHS” giving
“essential support” and “safeguarding futures” (i) to use such negative
language with regard to locums which further fuels this discriminative
practice.
The headline, a poor choice of words, was not even representative of the
article, which called for the regulation of locum agencies, and
highlighted the difficulty in matching overseas experience to UK hospital
positions, rather than making judgment on a current work situation as did
the headline.
The trouble with this type of headline-grabbing journalism is that
such discrimination and negative perceptions of locuming may lead to the
alienation of competent locums, or dissuade other doctors from practicing
as locums.
The NHS has an ongoing demand and need for experienced, professional and
competent locums. In General Practice 25% of GP’s work as locums, seeing
36million patients a year.(ii)
Locums must be respected and supported.
I challenge the BMJ to publish an apology and reflection on the
damage of such reporting, which is surely a sign of deeper and ongoing
discriminative and old-fashioned judgments within the profession.
i)
http://www.bma.org.uk/_top/join_bma/jointhebmaintroduction.jsp?page=1
ii) Locum GP’s: The Skills we need and how to achieve them NASGP
Competing interests:
Self employed GP Locum with previous experience of A&E and Surgical SHO Locum posts
Competing interests: No competing interests
The Editor
BMJ
I am appalled and astonished at being labelled a “MISFIT” as per the
BMJ’s front cover, 3 July 2010. The unbalanced and vitriolic diatribes
launched at all Locum Doctors in general in the main article, and your own
editorial, is disturbing and presents a wholly inaccurate portrayal of the
standard of locum doctors in general.
It is unfortunate that there are inadequate and under-performing
doctors out there – I have certainly had the misfortune of encountering a
number of sub-standard GPs and hospital doctors during the course of my
professional and personal contact with the medical profession over the
course of my professional career: this does NOT mean that all doctors are!
I am a senior clinician, I have an excellent reputation amongst peers
and patients and was recognised some years ago as the Recruitment and
Employment Confederation’s “Locum of the Year” at a ceremony in London. I
have worked tirelessly to open new services and restore the function of
ailing services, both in the private and the NHS sector, and am recognised
as one of the best trouble shooters in my field. But the BMA, to whom I
have faithfully paid membership fees year after year, sees fit to brand me
as a “MISFIT”. This is offensive and defamatory to the thousands of
locum doctors, who like myself, provide superb services, often under poor
conditions unlikely to attract substantive applicants.
Perhaps Chris Isles should seek to find the root cause of his
hospital’s lack of middle grade staff – poor working conditions and
equally unrewarding pay are unlikely to attract the best applicants, if
any at all, for the multiple posts he cites as being vacant. And what on
earth is wrong with a locum doctor wanting to know how many on-calls he or
she would be given by a prospective employer? It’s just plain business,
really, unpalatable though it may be to him – locums do not have paid
holiday leave, sick leave, pension perks or any of the other perks of
substantive employment within the NHS, and it is perfectly normal for a
locum or indeed their representing agency, to try to get the best possible
deal for their doctors.
The locum agencies were all but destroyed in a concerted effort by
the NHS a few years ago to totally destroy the locum market. Agencies
which continue to operate do so under strict rules, and NHS trusts can
hand-select their preferred agency providers, ensuring that their selected
agencies provide ALL the documentation and checks required of a locum in
order to employ them safely. There are Regulations in this respect, in any
event. My agency, which has represented me for approximately 10 years,
does absolutely that. Chris Isles’s frustrations would be better directed
at selecting appropriate agencies after his root analysis of why doctors
apparently have no desire to work in his hospital.
It is perfectly disgusting that the BMA should be branding and
demonising an entire cohort of doctors, most of whom perform a valuable
service in the provision of health services across the UK, as “MISFITS”
and underperforming, useless, money-grubbing individuals. I challenge
you to prove your damaging rhetoric – until this is done, you owe the
locum doctors in the UK an unreserved apology!!! I have noted over the
years, your very negative and dismissive attitude to locums, although our
BMA subscriptions are cheerfully snatched up by the BMA. Locums are also
barely considered in the Revalidation proposals and the BMA has no
apparent interest in locums either, as shown by the BMJ's pervasively
negative attitude and unbalanced, inaccurate and sensationalist reporting;
something I would have expected from the gutter press, not the BMJ!!
In the same way that General Practitioners are not all Shipmans-in-
disguise, Locum doctors are certainly not Ubanis-in-disguise either. Poor
practice exists in all areas of medical practice and continuing efforts to
eradicate it must continue, but to demonise locums and brand us on your
front cover as “MISFITS” is completely out of order and an absolute
disgrace to decent journalism. If I was aware of any regulatory body to
whom I could complain about your misleading coverage and demonising of
locums, I would do so.
I reject the branding as a MISFIT or any of the other negativity
suggesting that I as a locum am in any way less capable or performing at a
lesser level than any colleagues, with the contempt it deserves and wonder
whether you will have the morals or the even-mindedness to print any of
the responses you receive about your demonisation of locum doctors. As one
of the countrys’ leading locum doctors, I would welcome a balanced
interview / debate about the subject giving a better perspective on the
subject than your clearly wholly one-sided, negative view.
Dr Laurie Durand
Locum Consultant Forensic Psychiatrist and Acting Head of Psychiatry
Competing interests:
I am currently employed as a professional locum doctor
Competing interests: No competing interests
What's the trouble with locums?
We were sorry to hear of Professor Chris Isles’ frustrating
experiences when seeking to hire a locum doctor (BMJ 2010; 340c:1412).
Whilst we can’t speak for all locum agencies, we entirely reject Professor
Isles’ description of locum agencies as “cattle markets” and the
implication that doctors who choose to work as locums are by definition
incompetent.
All practising doctors have a GMC licence - the ultimate proof of a
doctor’s fitness to practice. It is inaccurate to imply that doctors who
choose to work as locums are somehow different or inferior to those with
permanent positions – especially since many doctors undertake locum work
outside the hours required by their permanent NHS posts. It is similarly
inaccurate to imply that doctors who did not train outside the UK are not
as good as those who did; over a third of doctors on the GMC register
undertook their primary medical qualification outside the UK.
HCL plc employs the highest standard of vetting and credentialing
procedure on all locum doctors who apply to register with us. As an OCG
(formerly PASA) approved agency on the NHS National Framework for locum
supply, we are bound to employ more checks than even the NHS itself and
are frequently audited by OCG.
With a 5.2% vacancy rate for hospital doctors in England and Wales,
the strictures of the Working Time Directive, and a workforce that is
increasingly female and more and more inclined to flexible working, locum
cover is a vital part of the NHS infrastructure. Using locums enables
medical staffing officers to flex their workforce up and down to meet
fluctuating demand. Since doctors employed via agencies do not incur the
extra costs of pension provision, annual leave study entitlement and sick
leave, they are economically viable as the public sector is pruned back.
Recruitment consultants, while highly specialised in their field, are
not clinicians. This is why, when they receive a request for a locum, they
try to field several candidates, with as much information as possible, to
allow the medical director or other clinician to make the final decision
based on all of the evidence supplied. It is also the role of the MD to
ensure that locum doctors receive a proper induction on day one so that
they are confident and secure in their practice.
We all have a shared responsibility in ensuring that locum doctors
serve patients well. The doctors themselves must be honest with agencies
about their experience and ability and agencies have a professional
responsibility to communicate this effectively to their clients. Medical
directors should ensure that a formalised system is in place for the
proper induction of locum doctors, and if there is any dissatisfaction or
cause for concern, hospitals must cooperate fully with agencies in order
to get to the bottom of the matter and take appropriate action. HCL
supplies an assessment form for the hospital to complete and return on the
completion of every locum assignment. The current return rate is
approximately 1%. Of the small number of complaints we have received about
our locum doctors, 40% were not followed up by the client hospital when we
asked them for further information in order to resolve their concerns.
Trusts and Medical Directors must accept that they have a responsibility
to feed back to us, as agencies can only work with the information
provided.
It is time that locum doctors were properly recognised and valued for
the vital contribution they make to the day to day operation of the NHS.
We are calling for more communication between NHS Trusts and agencies to
give locum doctors confidence and security in practice.
Competing interests:
Executive Director of HCL plc, a leading healthcare staffing company.
Competing interests: No competing interests