Intended for healthcare professionals


Why bother with a substantive post if you can locum?

BMJ 2015; 351 doi: (Published 16 September 2015) Cite this as: BMJ 2015;351:h4353
  1. Marika Davies, freelance journalist, London
  1. daviesburdett{at}


Applying for a substantive post after many years of training is the natural career path for most doctors, but to some the flexibility of locum posts is more attractive. Marika Davies reports

Locum doctors are an invaluable resource for the NHS, filling gaps in rotas at short notice and covering planned absences such as maternity or study leave. Many doctors work as locums after completing their training while they wait for the right substantive post to come up.

For most, this is a temporary measure, providing income and short term flexibility as well as the added benefit of extra experience before they take up a permanent post. But some doctors find that having autonomy over where and when they work as a locum is a more attractive option than committing to a substantive post. A recent survey by the BMA found that the majority (72%) of locum general practitioners choose their job for its flexibility and work-life balance.1

Since completing his specialty training in 2014, Oliver Sykes, an anaesthetist in London, has worked as a locum consultant. He plans to do this as a long term career option; the main reason for his choice is the flexibility it gives him. “Primarily I do this because my wife is training in obstetrics and gynaecology, with inflexible long days, nights and weekends, and we have two small children to organise,” he says.

There are disadvantages to working as a locum, Sykes says, such as the safety implications of constantly working in new environments. Being able to cope with the uncertainty and risks of constantly moving hospital is part of the life of a locum, and sometimes he will not know where he will be working until the day before. “My skill is being able to turn up somewhere new and get the job done safely and competently,” he says.

Although all locum doctors should be provided with an induction which is appropriate to the post and the length of the appointment, in reality this may not happen or it may be variable in its quality.2 Sykes says that he has a strict process for ensuring that his practice is safe. “I think [locuming] can actually make you a very good doctor, with the emphasis on maintaining standards, checking and back up plans,” he says.

A lack of respect from colleagues is another disadvantage, but Sykes considers this to be a small price to pay in return for the flexibility the role allows him. Sykes points out that locum doctors are an “unknown quantity,” as the rest of the team does not know how experienced the locum is or how they will respond in an emergency. He says, “Making sure that you get on with the other staff is so important, this is a safety aspect in its own right.”

Sykes acknowledges the lack of job security that could concern many doctors considering life as a locum. He is also aware that the NHS will want to reduce locum costs in the future but is confident that there will always be a need for competent locums. “It may well get more competitive in time and I need to stay current and capable,” he says.


Locum doctors may be employed directly by a trust or practice, employed through an agency, or work through their own limited company. GPs may also join locum chambers, which are small, independent groups of local GPs who work together under a shared management structure.

The salary for a locum consultant employed by a trust is dependent on years of seniority as a consultant: a locum who has never held a substantive consultant post is usually paid at the first point on the national salary scale. Once they have completed 12 months of service, either continuously or cumulatively, locums may receive pay progression in the same way as substantive consultants.3

Locum consultants on fixed term contracts are entitled to receive no less favourable treatment than the holder of a “permanent” consultant post. They should have access to the same resources, such as administrative support and continuing professional development, as other consultants.

A trust that employs a locum consultant must consider the doctor’s position with regard to annual or study leave and access to training. A locum in post for six months will be entitled to a job plan with objectives, which should be reviewed three months into the post.4 Sykes says that, when doing ad hoc agency locum work, benefits such as annual, study, and sick leave are non-existent, but the rates of pay help even this out.

Most GP locums will arrange their locum appointments and negotiate their rates of pay directly with practices. The BMA professional fees committee has produced a “locum calculator” document, which helps GPs to calculate their own locum rates for each job.5 There is an additional administrative burden for self employed GPs, who must organise their own accounts and pay tax and national insurance contributions on their income.

Agency pay is not pensionable under the NHS pension scheme as the agency is the employer. However, locum consultants directly employed by an NHS trust can join the NHS pension scheme, and self employed or freelance locum GPs may also pension NHS earnings received directly from a practice.6


Revalidation requirements represent a particular challenge for doctors who choose a career as a locum, as they develop fewer collegial relationships and are given less access to governance activities.7 Locum doctors revalidate in the same way as other doctors on the medical register, so they must have a formal link to a designated body to provide them with annual appraisal.

A trust that employs a locum consultant will be that doctor’s designated body. Some locum agencies are identified as designated bodies under the responsible officer regulations, and they will appoint a senior doctor as a responsible officer to make recommendations to the General Medical Council about the locum doctor’s fitness to practise. For locum GPs not attached to an agency, the designated body will be the NHS England local area team that covers their GMC registered address.

Collecting the supporting information necessary for appraisal and revalidation can be difficult for locum doctors. Richard Fieldhouse, a locum GP and chairman of the National Association of Sessional General Practitioners (NASGP), says that this is particularly the case for locums who work in isolation and are not part of a team. “You can’t do multisource feedback or significant event analysis by yourself,” he says.

Locums, and any agency they have been supplied through, must be given feedback on their performance after every assignment.8 Although not all trusts or practices give this feedback, it is an essential part of the evidence a locum doctor needs to collect in order to revalidate and it should be requested. NASGP recently launched an online appraisal aid package, which contains guidance, locum specific templates, and practical methods to help locum GPs perform appraisal activities and gather supportive evidence.9

Length of post

Department of Health guidance says that the appointment of a locum consultant should be a temporary measure of limited duration: appointments should be limited to a maximum period of one year and should be for an initial period not exceeding six months, it says. This can be extended for a maximum period of a further six months subject to a satisfactory review by the trust and consultation with the relevant college.

The length of GP locum appointments is negotiable between the GP and the practice. The BMA recommends that there should be a written agreement between the locum GP and the contracting practice setting out the terms of the engagement. This should be negotiated before the locum starts work and should include details of fees, responsibilities, and arrangements for terminating the contract.

How to make it work

  • Wear a name badge, use a door name plate, and introduce yourself to colleagues and patients.

  • Make sure that you have your own password for computer systems so your entries will be identified.

  • Be aware that potentially you will be thrown in the deep end and always be sure to work within the limits of your competence.

  • Consider how you want your career to develop and what you want to gain from your locum positions so you can plan accordingly.

  • As far as possible, be familiar with policies and procedures in the trust or practice in which you are working.

  • Collect information for appraisal relating to the types of role you undertake, rather than information from every place of work.10

  • Get on with your chosen agency, as jobs can go quickly and a good relationship with the agency will help in making sure you are put forward for work.

  • Be organised and ensure you have all the paperwork that an agency or practice will need to see, ready to be sent as soon as you are notified of a post.

  • Consider taking out an income protection policy, in case there are times when you are unable to work.

  • Ensure you have adequate indemnity, and keep your defence organisation informed of any changes to the work you are doing.

  • Consider joining a locum peer support group or self directed learning group.


  • Competing interests: I have read and understood BMJ’s policy on declaration of interests and declare the following interests: I am employed as a medicolegal adviser by the Medical Protection Society.


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