The practices were asked how the care provided by locums compared with that provided by permanent doctors in a number of areas (Table 3). Generally, care provided by locums was viewed as about the same as or worse than care provided by permanent doctors. Practices employing higher numbers of GPs were significantly more likely to report worse adherence to organisational policies and guidelines, continuity of care, and reporting of adverse events or untoward incidents when care was provided by locums rather than permanent doctors. There was a statistically significant difference between clinical and non-clinical responders about how care was perceived when provided by locums rather than permanent doctors in regard to adherence to organisational policies and guidelines (z = 4.56, P<0.001), continuity of care (z = 6.87, P<0.001), avoiding administrative errors (z = 4.38, P<0.001), reporting adverse events (z = 3.12, P<0.05), appropriateness of referrals (z = 2.87, P<0.05), and the functioning of the healthcare team (z = 3.27, P<0.05; Supplementary Information S2).
Perspectives about locum doctors and locum agencies
Practices were asked about the advantages and disadvantages of engaging locum doctors and locum agencies, and how they see locum doctor work changing in the future. Maintaining workforce capacity was one of the main advantages reported by responders. Locums filled gaps in the rota and provided cover for sickness, holidays, and maternity leave, which in turn allowed practices to meet patient demand, maintain appointment levels, and relieve workload challenges:
‘Obvious advantages are to maintain appointment levels and support workload challenges in the event of an absent permanent GP.’
(Practice 20)
This was particularly important for short- term and short notice cover. Some also felt that locums brought a new perspective and fresh ideas to a practice based on their experiences in different settings. However, some practices noted that locums were not always available when required at short notice:
‘Locums can bring their own expertise which can be utilised by the practice as they often have “other roles in the NHS”, e.g. minor ops, MSK [musculoskeletal] conditions.’
(Practice 119)
Responders emphasised the advantages of flexibility in the use of locums:
‘They provide access to large numbers of locums and offer greater flexibility regarding availability and choice of locums.’
(Practice 102)
They can be used when needed and contracts can be ended easily when they are no longer required. Some practices saw it as more cost-effective to have short-term cover without the longer-term financial commitment of permanent staff:
‘Can be cost-effective if you have a robust administrative team to support GP admin work. Lack of financial support for paying sick leave, mat [maternity] leave etc. and the need to bring in a locum doctor to cover their work when off makes locums a more attractive prospect (as in some cases a salaried doctors’ fees may end up costing a practice up to 30% more than the base salary you’d pay a locum).’
(Practice 75)
Some thought locum agencies were efficient in sourcing locums and doing all necessary pre-employment checks and paperwork required.
On the other hand, lack of familiarity with the practice, the area, the patients, and local referral pathways was a disadvantage for practices. It was time consuming for practices to get a new locum set up on all the practice systems. Not knowing the locum resulted in uncertainty about the quality of their work, their efficiency, and whether they would create more workload:
‘You end up with another new locum who doesn’t know the practice or the patients. New locums take time as there is paperwork and IT set-up to do, checking CVs and certificates etc. You don’t know what you’re getting, how quickly they work, whether they’re good or whether they create more work for the GPs to come back to.’
(Practice 171)
GP practices preferred to work with locums that were familiar with the practice and its patients as this meant that the locum was able to get on with the job and also meant the benefit of continuity of care for patients:
‘If you are able to have the same GPs come back to you for the next periods … they become more familiar with surgery policies etc. and are increasingly autonomous in their work.’
(Practice 99)
‘Having regular locums helps with patient services and continuity of care for patients.’
(Practice 218)
However, continuity was likely to be shorter term and episodic. Consequently, locum use was generally considered to have a negative impact on continuity of care and this was particularly problematic for patients with long-term or complex conditions:
‘Can be more difficult when trying to achieve continuity and they often work at a slower pace.’
(Practice 27)
‘Good to see patients for acute on-the- day conditions, not so great for long-term problems and conditions.’
(Practice 138)
Cost was one of the main disadvantages reported about locum agencies. Responders felt that locum agencies control the market and drive up rates:
‘Signing up most regional locums to mainly one agency reduces competition between individual locums and results in high locum rates, and high locum rates in turn affect the affordability of locums and reduce the likelihood of locums ever again joining the workforce as salaried GPs or GP partners.’
(Practice 102)
For some, the use of locum agencies to source a locum was a last resort because of the additional costs. The view that locums are expensive contributed to a negative view of locums and created tensions between locums and permanent staff:
‘Many [locum] GPs are charging astronomical fees which are not appropriate for the work they are doing, yet often surgeries have no choice. I think this can create ill feeling.’
(Practice 104)
High locum pay rates were also considered to be a reason why locums would not join the permanent workforce:
‘I think more and more GPs will turn to locum work rather than regular work as the money is better and the terms of work are better as they can take time off when they want and do the hours they prefer.’
(Practice 2)
‘I hope that locums would be regulated with regard to charges, as demand often means that practices do not have any choice with regard to how much they have to pay locums. Locums can, therefore, earn much more than GP partners or salaried GPs and specify clinic sizes and times worked, which does not encourage them to take permanent posts in practices.’
(Practice 119)
Responders felt that the use of locums would continue to increase because of the higher pay, lower workload, and greater autonomy. To encourage locums to take up permanent posts some responders wanted stricter regulation of locum pay and access to pensions. Another suggestion was the use of a pool of locums employed locally to reduce costs and improve familiarity and continuity of care.
Responders reported that locums generated increased workload for other practice staff, particularly administrative work. The way that locums negotiate terms and conditions was felt to result in them not always performing the full range of duties, for example, not doing administrative work. Other reasons for increased workload included high referral rates, differences in prescribing practices, and locums asking patients to return for another appointment. Sometimes patients would refuse to see a locum or would return to see their regular GP after seeing a locum because they were dissatisfied:
‘Some locums just defer work telling patients to call back another day or prescribe in a way we don’t.’
(Practice 168)
‘Disadvantages: non-clinical workload, issues passed down the line for later and not sorted out, increased clinical and non-clinical burden on permanent team, expense, adherence to protocols, medicines optimisation, referrals, lack of familiarity with local services can increase workload for GPs, limits to workload (e.g. no visits, no duty Dr, no cover, won’t work alone), continuity, permanent Drs “picking up the pieces”.’
(Practice 61)
For some, locums were viewed positively but for others locums were seen as a last resort and did not present a long-term solution to staffing problems:
‘Some locums are very good and work hard.’
(Practice 2)
‘But in most other respects e.g. continuity of care, working within the MDT [multidisciplinary team], being aware of local policies etc., being able to help with admin in the practice, they are not as good.’
(Practice 136)
‘They are a sticking plaster only really.’
(Practice 55)
There was a perception that locums were not invested in the practice or team. Examples of this included not contributing to quality improvements and achieving targets:
‘They have no loyalty to the surgery or patients.’
(Practice 67)
In order for locums to have a better understanding of general practice some wanted locums to have a permanent position either before or during their locum work, and felt that this would provide locums with a community of practice and improve team working and shared workload:
‘I consider different regulation is needed, and doctors who want to do locums should have also a regular job — perhaps one day a week based in one place — to understand better general practice, continuity of care, team work, sharing workload, importance of coding, of electronic health records and problem lists maintenance.’
(Practice 77)
