Locums: A risk to patient safety - or untapped resource?

Are locum doctors an untapped resource or a patient safety risk? As the NHS spends increasing sums on 'freelance' medics, it is becoming increasingly important to look at how they are being used, and where improvements are needed.

Quality of care

Research published this week in the BMJ highlighted the risks of a health service that is overly-reliant on locum cover, as well as the "difficult and lonely" life of a locum.

In NHS Scotland, spending on locums has nearly doubled, from £67.4 million in 2013/14 to £119.6m in the year to March 2023.

In areas such as psychiatry, one in five consultant posts are filled by locums.

Researchers from the universities of Manchester and Birmingham noted that there is "limited good quality empirical" evidence to substantiate the widespread concerns that locum working is worse for quality and safety, so set out to investigate through interviews with locums, patients, and permanently-employed doctors.

While their work was carried out in hospitals and GP surgeries in England, the findings are relevant for the NHS as a whole.

Spring Sale: Get a full year of access to HeraldScotland for just £20 

In interviews, locums described frequently working in unfamiliar environments "sometimes with minimal induction and varying levels of support".

They were "not always able to do their job safely" due to issues such as a lack of access to computer systems, and were "likely to be scapegoated if things went wrong".

Most locums said they faced stigma and "negative attitudes" about their competency.

This was most acute for female or ethnic minority locums.

Such discrimination and exclusion was "detrimental to morale, retention, and patient outcomes", said the researchers.

READ MORE: 

• £1.2m on locum psychiatrists is tip of the iceberg for short-staffed NHS 
• Rural patients at risk from 'dangerous' shortage of doctors
• Medic blames NHS Highland 'dysfunction' for exodus of clinicians 

However, feedback from other healthcare staff highlighted perceptions that some locums "were simply avoiding work and evaded responsibility for patients by pushing work onto others or into the future".

Where complaints did arise, locums had "often moved on".

Summarising their findings, the researchers said there were "some profound and concerning insights for patient safety and quality of care", adding: "The ways in which locums were recruited, inducted, deployed and integrated, and supported by organisations undoubtedly affected quality and safety."

Professor Richard Lilford, director of the National Institute for Health Research - which funded the study - said the evidence points to working arrangements for locum doctors which are "unkind and unfair, and potentially harmful to patient safety”.

His solution? There "seems to be a good case for bearing down on the market and strongly encouraging all posts to be filled with non-locum staff - less money spent on locum doctors with more money for the substantive posts".

That is obviously a long-term objective, however.

In the short-term, many NHS services would collapse without locums to plug rota gaps.

Untapped resource?

A separate analysis suggests that locums are being under-used in general practice.

Polling by the BMA found that locums in England are seeking on average to work 6.34 sessions a week (eight sessions a week is 'full-time') but are securing just 5.24 sessions.

This was "unconscionable" in the midst of a GP workforce crisis where patients were sometimes having to wait weeks for an appointment, said the trade union.

The situation was blamed on a real-terms "erosion" of general practice funding, which has left GP partners with less cash available to recruit extra staff.

Monthly GP consultations in Scotland: physical (in-person) and virtual (Image: PHS)

According to analysis carried out by GP Online, if practices were funded to hire locums to work to their full capacity, general practice in England could gain at least 250,000 GP appointments a week.

In Scotland, the number of locums working in GP practices by 2022/23 - 342 - was the highest in at least a decade.

This has coincided with a steady decline in the number of GP partners, and a growth in part-time working.

Nonetheless, it is reasonable to suppose that locums are also being used less than they might like north of the border as GP practices here have also experienced a similar real-terms erosion in funding.

Sign up for the Inside the NHS newsletter and read our health correspondent every week in your inbox    

So how much difference might an extra 25,000 appointments make here, if the figures were roughly equivalent?

By January this year, a total of 3.1 million GP consultations were being carried out - 2.52m face-to-face plus 592,000 virtual - which compares to 2.9m in January 2018.

An extra 100,000 appointments a month would be an uplift in activity of 3.2%.

Going back to the patient safety issues raised by the BMJ, however, it might make more sense to invest a larger percentage of health spending into general practice in the first place to stem the exodus of GP partners.