Locum doctors are used within the NHS to fill both short- and long-term gaps in staffing. Working in both general practices and hospitals, they undertake the same duties as permanent doctors. But how well are they integrated into the clinical teams where they work, how are they supported in the workplace, and how do they differ from permanent staff in their interactions with patients? Here, Dr Thomas Allen, Dr Jane Ferguson and Professor Kieran Walshe outline the findings of their research into the use of locums in the NHS, and what this means for policymakers.

• Compared with permanent doctors, there were few significant differences in the safety and quality of locum doctors in primary care, though there was variation in some aspects of practice like prescribing and referrals.
• Persistent issues around their access to information systems and the support, guidance and oversight they receive were found to affect locums’ ability to provide optimal care.
• Work is needed to improve awareness of existing national guidance on the use of locums, alongside steps to address NHS reliance on locums.

Locum doctors play a crucial role in the NHS, across both primary and secondary care, by maintaining workforce capacity and flexibility. They are not a homogenous group; some locums may be wholly new to an organisation, while others may be existing staff picking up extra shifts. Regardless, they are vital to the smooth running of health systems, but the temporary nature of their contracts creates challenges around induction and support.

Previous work on the how doctors are regulated highlighted discrepancies between the experiences of permanent doctors and locum doctors. The transient nature of locum work, characterised by frequent changes in employment, poses unique challenges in maintaining consistent revalidation standards. This prompted research into the broader issues surrounding locum doctors, including their prevalence, quality of care, and safety concerns.

Locum utilisation patterns

Our research found that locum use was more prevalent in GP practices with lower Care Quality Commission (CQC) ratings, in rural practices and in single-handed practices. In NHS trusts, locum use was also higher in trusts with lower CQC ratings, as well as in smaller trusts. These finding suggests a complex interplay between organisational performance and reliance on locum staff, though the causality remains unclear.

Quality and safety concerns

Within general practice, quality and safety of care by locums was generally viewed to be the same as that provided by permanent GPs, though there were pockets where it was viewed less favourably. Some practices reported that locums did not perform the full range of duties, although it was also found that practices were largely unfamiliar with national guidance for engaging locums and providing feedback and professional development.

Locum doctors were more likely to prescribe antibiotics and strong opioids compared to their permanent counterparts, though less likely to order tests and make onward referrals. The study found no significant differences in patient outcomes, such as medication errors or hospitalisation rates, between patients seen by locums or permanent doctors.

The elevated prescribing rates among locum doctors could be attributed to several factors. Locums often handle acute cases requiring immediate intervention, which may necessitate antibiotic prescriptions. Additionally, the lack of long-term patient relationships and familiarity with patient histories might influence locum doctors’ prescribing decisions. The lower levels of tests and referrals may be explained by constraints practices place on locums, requiring their decisions to be reviewed or approved by another GP in the practice. The study adjusted for patient sickness levels and other biases, but the observational nature of the research means some factors remain unaccounted for.

Within NHS trusts the picture was similar. Locums were generally viewed as the same or somewhat worse in providing care compared to permanent doctors, particularly in areas like continuity of care and adherence to internal policies. As with general practice, trusts were found to be broadly unfamiliar with national guidance for supporting locums, focusing more on compliance checks and induction rather than feedback and appraisal.

Implications for policy and practice

Ensuring that locums are up to date with current guidelines and receive adequate training is crucial. This could involve regular updates and refresher courses to maintain high standards of care and help locums stay aware of and compliant with practice prescribing guidelines. Currently, there is no regulatory body responsible for locum agencies, or indeed medical staffing agencies more broadly, and responsibility for training locums is split between their employer and the locums themselves. A higher level of governance and regulation is needed, which self-organised locum chambers, supported by the National Association of Sessional GPs, could provide. With locums required to revalidate their GMC registration through annual appraisals, this could provide an opportunity for ensuring they are compliant with current guidelines.

A significant concern identified in the study is the inconsistent induction and integration of locum doctors into healthcare organisations. Locums often lack access to essential systems and resources, hindering their ability to provide optimal care. Implementing standardised induction processes and ensuring locums have the necessary tools and support can enhance their effectiveness and integration into the healthcare team. Guidance in this area already exists, but it is clear from this research that both general practice and NHS Trusts do not have high awareness of it.

Reliance on locum doctors is partly driven by challenges in recruiting and retaining permanent staff, particularly in rural areas. Addressing these underlying issues requires a comprehensive workforce plan that prioritises the recruitment and retention of permanent doctors. This could involve offering incentives, such as protected time for supervision and mentoring to support career advancement; improving working conditions; and providing career development opportunities to make permanent positions more attractive. A targeted strategy to implement these measures should be developed by the Department of Health and Social Care, and delivered through Integrated Care Systems (ICS).

While the primary focus of this work was on England, it also explored regional variations in locum use. Preliminary findings indicate differing patterns across regions, with some areas exhibiting higher locum employment rates. These insights underscore the need for region-specific strategies, developed by ICS, to address locum utilisation effectively.

The utilisation of locum doctors in the NHS presents a complex challenge for healthcare delivery and policy. While locums play a vital role in addressing staffing shortages, their employment raises important questions about care and outcomes for patients, and their integration with the practices and trusts hiring them. By addressing these issues – particularly training, integration, and oversight – through targeted policies and improved practices, the NHS can optimise the use of locum doctors and ensure high standards of care for all patients.

The full research team who carried out the work this article is based on also included Evan Kontopantelis, Darren Ashcroft, Gemma Stringer, and Christos Grigoroglou. This project was funded by the National Institute for Health and Care Research (NIHR) (Health and Social Care Delivery Research programme [project reference number: NIHR128349]). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.