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According to Scottish government figures annual expenditure on locum doctors in the Scottish NHS has almost doubled over the past four years to more than £36 million. This figure would not be quite so alarming if the entire sum went to the doctors for their extra hours of work, but based on standard locum agency commission rates of 25% this equates to commission of more than £9 million. And what critical service or care-enhancing product has that £9 million delivered? With regard to the Scotland statistic such a rapid increase is remarkable, but Scotland is not alone in experiencing soaring locum costs. It is not unusual for figures to be in the millions for NHS trusts and health boards throughout the UK.

Responsive workforce planning

So what has caused an increase in demand? Lack of responsiveness in the strategic planning of doctors’ working arrangements is one factor which can influence the need for locums. Where a junior doctor rota has always had twelve SpRs on it, or a department has always had eight consultants, the assumption is that the number of doctors on the shop floor is a sacred cow. However, this number is often not based on the minimum number of doctors to maintain safe clinical practice, but on residual or historic requirements. By simply redesigning rotas or changing job plans to accommodate changes in doctors numbers, this more effective planning of doctors’ contractual working arrangements can help reduce locum demand.

Effective rostering systems

Even when rotas and job plans have been designed with current clinical needs in mind however, the day-to-day organisation of a department can affect locum need. Annual leave, if mismanaged, can also lead to increased demand. If too many doctors are on annual leave at once the clarion call for locums goes out. In the case of junior doctors many rotas are ‘prospectively covered’ meaning that essentially doctors can be paid more to provide internal cover for one another when leave is taken. If prospective cover is not enforced then the department will suffer the cost of locums in addition to higher pay banding costs. Ensuring there are never too many medics taking leave at one time can be achieved through effective rostering. Likewise, if medics need to take emergency time off then a good rostering system can properly manage swaps of on-call or late duties and minimise the requirement to get a locum in. In a recent study Bedford hospital reduced its locum spend by 44% using an e-rostering system for its junior doctors which increases the visibility of internal doctors who are available to provide cover for absent colleagues.

Engaging with agencies

But not all locum demand can be eliminated. People get sick and emergencies happen. But there do appear to be ways to reduce the cost of sourcing locums to fill this demand. If NHS trusts must engage with locum agencies then they must be organised in their dealings with them. A trust must have a good understanding of the details of a locum transaction – for example, whether it can reclaim VAT or whether an agency should be passing on employers’ NI contributions. Lack of control can easily increase the cost of acquiring external locums.

 

Harnessing the value of internal resources

The best way of minimising the cost of securing (high quality) locums is to utilise the workforce the NHS already has. It has to be possible for the NHS to engage the major proportion of locums that already hold substantive posts within the NHS yet are being hired back to the health service by agencies. This will depend on the NHS being better organised and having better information and technology is the way to make this possible. The current number of locum agencies and their level of activity should have no place in a modern, efficient NHS, and their decline will be one sign that the health service is meeting David Nicholson’s productivity challenge.

 

Published in the Public Service Review