Table 4.

Perspectives on locum doctors and locum agencies

Theme	Illustrative quotes
Workforce capacity and flexibility	“Helps us fill our gaps by accessing doctors that we do not have access to, particularly at short notice.” [Trust 19] “Locums provide cover to support the permanent workforce when gaps arise, which could otherwise compromise patient care and safety.” [Trust 19] “Advantage is a flexible workforce has helped us over the last 2-years to overcome the difficulties in staffing levels and activity.” [Trust 83] “Locum doctors work is flexible, it gives the doctor the chance to see many aspects of medicine without the requirement of a long term commitment, however the organisation employing the doctor in the future will need to support the doctor’s requirements and take on RO responsibilities, revalidation and appraisal etc.” [Trust 6]
Compliance	“Assurance that they have already had all appropriate background checks and connection through a single RO makes communication easier.” [Trust 46] “Full compliance not always complete at the time of putting the medic forward creating delays from CV approval.” [Trust 10]
Lack of alternative options	“No option in the current climate” [Trust 21] “Used as a last resort” [Trust 36] “exhausted all other options” [Trust 49] “Needs must! Not enough doctors so no choice” [Trust 39] “a necessary evil” [Trust 14] “I would like to see this become an exception to support short and immediate staffing issues and not become a reliance to solving NHS recruitment gaps” [Trust 46] “We would like to reduce our reliance on locums, but this is a hard slog in terms of agreeing new establishments and recruiting permanent staff” [Trust 7] “I would like to see all locum doctors working via a national NHS locum bank with fixed rates so there is no bargaining for increases in rates and playing Trusts off against each other” [Trust 42]
Cost and control	“They will just keep getting more expensive.” [Trust 40] “Becoming more expensive, working relationships worsen.” [Trust43] “I would like to see a shift in culture of being realistic regarding rates of pay. This can almost feel that the NHS is being held to ransom to deliver patient care and maintain patient safety. I understand this is the case regarding supply and demand due to the pandemic.” [Trust 31] “You need to have eyes in the back of your head and micro manage the appointment otherwise you will be overcharged on pay and commission rate. They will also cut corners on due diligence and checks.” [Trust 42] “Agencies drive up rates and use the top of the above capped rate as the new baseline, i.e. no one will work within the capped rates.” [Trust 54] “[Locum agencies] play the market and prices are always high and negotiations are time consuming and energy sapping” [Trust 55] “Expensive and operate a monopoly over cost as they control the flow of doctors and compete with each other for placing a doctor, offering higher rates to entice new business.” [Trust 83] “Agencies sometimes manipulate messages and information for their own gain, making things frustrating when we're working with tight timescales (e.g. keeping us chasing about a specific locum who will never actually start, in order for them to not lose the booking).” [Trust 44]
Familiarity and continuity of care	“Lack of familiarity and engagement with the department and organisation.” [Trust 16] “They fill the staffing gap but we would really prefer our own internal locums rather than external locums for continuity and org knowledge.” [Trust 35] “There is a huge difference between using an unknown doctor from an agency and using one of our own current or former doctors via our Medical Bank. We always prefer to use Bank for that reason. Bank is usually (but not always) cheaper.” [Trust 48] “Better to have a long term locum rather than occasional shifts as this allows for understanding the policies of the organisation, team work and continuity of care.” [Trust 33] “Would be nice to see further development of passport between Trusts, so that info can be handed over, particularly across the ICS. Would also be good to provide a shadowing / placement process for locums new to the NHS—we have concerns about taking on a locum for their first ever shift in the NHS.” [Trust 19]
Organisational development	“Disadvantages: when the primary driver is financial as is invariably the case, their assumptions and reason for being there is framed in their minds in that way. It does not support a developmental approach either personally or with the team. If we were to be more hospitable and offer the 'NHS' privileges of training and time for study etc. and all the other trust support for being a substantive member of staff, then what is the point of being within the NHS? We will have permanent staff and that is not conducive to building a stable workforce which is the requisite for workforce development, flexibility in services and the meeting of the transformation agenda. Additionally, locums are seldom interested in service improvement, do audits of any worth or take part in quality improvement. Being financially driven these are not seen as important enough. Finally, self-development is not seen as a priority which comes through reflection and a deep understanding of their practice and if not in the same place for long enough to develop good relationships that they trust to give them difficult information, this is very limited” [Trust 55] “The bottom line is that it inhibits the development of teams, reduces continuity of care, probably doesn't work for the locum in terms of career development, makes organisational development more difficult and is way more expensive.” [Trust 27]
Reliability	“Service instability due to locum doctor leaving with short notice.” [Trust 24] “Short term cancellations resulting in staffing gaps which could lead to patient safety risks.” [Trust 45] “Quality not always reliable, service provision is not always as good as that we would usually get from a substantive doctor especially at higher grades.” [Trust 62]