The use of locum doctors by Northern Ireland Hospitals
REPORT BY THE COMPTROLLER AND AUDITOR GENERAL1 July 2011
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ReportbytheComptrollerandAuditorGeneralforNorthernIreland
TheuseoflocumdoctorsbyNorthernIrelandHospitals
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TheuseoflocumdoctorsbyNorthernIrelandHospitals
Contents
Page
Executive Summary 1
Part One Introduction and Background 7
LocumdoctorsareusedinNorthernIrelandhospitalstoensure 10 continuityofcareforthepatient
Wehaddifficultyobtainingdetailsofthetotallocumspendacrosstrusts 10
Theuseoflocumsmustbemonitoredcarefullyifthecostandquality 14 ofcareistobemaintained
ThisreportconsiderstheeffectivenessofTrustcontrolsovertheuseof 15 locumdoctorsinhospitals
Part Two Managing the demand for locum cover 17
Workforceplanninginthehealthserviceattemptstobalancethe 18 availabilityofsuitably-qualifiedmedicalstaffagainstpatientneeds
ThelatestReviewofthemedicalWorkforcewaspublishedin2010 18
Changestothehospitalenvironmenthavehadanimpactonthe 18 availabilityofstaff
Managementinformationisinsufficienttoenableeffectivemonitoring 20 andcontroloftheuseoflocums
The2010WorkforcePlanningReviewwascompletedintheabsence 20 ofdetailedinformationonspecialtyplanning
Usinglocumdoctorscancreateconsiderablefinancialrisks 21
TheuseoflocumdoctorsbyNorthernIrelandHospitals
Page
Part Three Safeguarding the quality of care provided to patients 25
TrustsandtheDepartmentmustmanageriskstoprovidesafe,high-quality 26 caretopatients LocumdoctorsprovidedtoTrustsbyexternalagenciesarenotregulated 26 bytheRegulationandQualityImprovementAuthority
TheCodeofPracticeinLocumDoctorAppointmentandEmployment 27 (thecode)wasintroducedinNorthernIrelandin1998andsetsoutkey controlsfortheuseoflocums
TheCodesetsouttherequiredpre-employmentchecksforeachlocum 27 episode
Weidentifiedseveralweaknessesinproceduresforemployinglocums 28 fromexternalagencies
TheCodesetsoutproceduresforassessingthequalityofservicefor 29 eachlocumepisode
Thelimitationsofexistingmanagementinformationcancreatedifficultiesfor 31 TrustsattemptingtoverifycompliancewiththerequirementsoftheEuropean WorkingTimeDirctive(EWTD)
TheConfidenceinCareprogramme,introducingrevalidationofalllicensed 32 doctors,isintendedtoimprovethequalityofpatientcare
WhereTrustsdonotundertaketherequiredpre-employmentchecks, 33 completeappraisalsforeachlocumepisodeorenforcecompliancewith theEWTD,thereisariskthatpatientsafetywillbecompromised
TheuseoflocumdoctorsbyNorthernIrelandHospitals
Contents
Appendices 37
Appendix 1: Structure of Northern Ireland Health and Social Care Trusts 38
Appendix 2: Health and Social Care Hospitals in Northern Ireland 39
Appendix 3: The Cost of Agency and Internal Locums in Northern Ireland 41 2007-08 to 2010-11
Appendix 4: Audit Methodology 43
Appendix 5: Implications of the EU Working TIme Directive 44
Appendix 6: Medical Demand and Supply Problems Identified by the 45 Department – Review of Workforce Planning for the Medical Profession (September 2006)
Appendix 7: Good Practice Examples identified from the NHS Employers 47 publication “Controlling the use of temporary staff through large scall workforce change”
Appendix 8: Regionally Managed Medical Locum Service for Northern Ireland 52
TheuseoflocumdoctorsbyNorthernIrelandHospitals
Abbreviations
A&E AccidentandEmergency
AHP AlliedHealthProfessional
BSO BusinessServicesOrganisation
DHSSPS DepartmentofHealth,SocialServicesandPublicSafety
ENT Ear,NoseandThroat
EWTD EuropeanWorkingTimeDirective
GMC GeneralMedicalCouncil
GP GeneralPractitioner
HR HumanResources
HSC HealthandSocialCare
IT InformationTechnology
LDA LocumDoctors’Association
NIAO NorthernIrelandAuditOffice
NIMDTA NorthernIrelandMedicalandDentalTrainingAgency
NHS NationalHealthService
PASA PurchasingandSupplyAgency
RMMLS RegionallyManagedMedicalLocumService
RQIA RegulationandQualityImprovementAuthority
RST RevalidationSupportTeam
SAI SeriousAdverseIncident
SHO SeniorHouseOfficer
USA UnitedStatesofAmerica
Executive Summary
2TheuseoflocumdoctorsbyNorthernIrelandHospitals
Introduction
1. Properly-manageduseoflocumdoctorsallowsHealthandSocialCare(HSC)Truststorespondflexiblyandefficientlytovaryingactivitylevelsandtocovershort-termabsencesorvacancies.However,inordertosafeguardthequalityofpatientcare,Trustsmustnotonlycontrolcostsbutmusttakestepstoreducetheclinicalrisksassociatedwithlocumdoctorswhomaybeunfamiliarwiththeircolleagues,theirsurroundings,thepatientsundertheircare,orwithlocalproceduresandpractice.
2. ThisreportexaminestheuseoflocumdoctorsinhospitalsacrossNorthernIreland.ItconsiderswhethertheDepartmentofHealth,SocialServicesandPublicSafety(theDepartment)andTrustshavedevelopedaplannedapproachtocontrollingandmanagingthesupplyofanddemandforlocumdoctors.Thereportalsoexploresthesafetyandqualityissuesassociatedwiththeuseoflocumdoctors.
On average, Trusts spend around 8 per cent of total medical staffing expenditure on locum doctors
3. Inthefouryearsto31March2011,Trustsspentover£100millioncoveringdoctorshortagesinhospitals.In2010-11alone,locumcostsamountedto£22.5million,almost8percentofallmedicalstaffingexpenditure.WithintheWesternTrustthepercentagewasmorethandoublethisrate(at17percent).IfitwerepossibleforallTruststomaintain
locumcostswithintheregionalaverage,thismightyieldpotentialsavingsof£5millioneachyear.LocalcircumstancesmaymakethischallengingtoachievebutTrustsshouldbecapableofmakingsavingsbymoreeffectivemanagementofthedemandforlocumsandimprovingpurchasingprocedures.
Better information on the use of locum doctors is needed to identify where efficiency can be improved
4. ThequalityofmanagementinformationusedacrosstheHealthandSocialCaresectorvariesconsiderablyand,asaresult,itcanbedifficulttoobtainanoverallpictureoflocumdoctoractivityandcosts.Costsrelatingtolocumsemployedthroughrecruitmentagenciesareroutinelyidentified.However,informationontheuseandcostofinternallocums(i.e.doctorsemployedwithinTrustsworkinghoursadditionaltothosestatedintheircontract)tocovergapsinrotasisnotcapturedinthesameway.Inordertomanagetheuseoflocumdoctorseffectivelyandmakesavings,Trustsneedaccurateandcomprehensivesummaryinformationonhowmuchisbeingspentonlocums,thegradesandspecialtiesbeingusedandthetypeoflocum–internaloragency.MonitoringexpenditureinthiswaymayhelpTruststotargetareaswheretheycouldbemoreefficientintheiruseoflocumsandtobenchmarklocumuselocallyandagainstotherUnitedKingdomcomparators.
Executive Summary
TheuseoflocumdoctorsbyNorthernIrelandHospitals3
Managing the demand for locum doctors could be improved
5. ConsultantmedicalstaffworkforcecomplementsarefixedbyTrustsincollaborationwiththeHealthandSocialCareBoard.Inrelationtojuniordoctors,theNorthernIrelandMedicalandDentalTrainingAgency(NIMDTA)isresponsiblefortherecruitmentofdoctorsintraining.Trustshavenoauthoritytopermanentlyappointjuniordoctorstofillpostswhichcreategapsinrotas.
6. Demandforlocumdoctorsismainlydrivenbytheneedtoprovideasafeandeffectiveservicewheretherearehard-to-fillvacanciesandwheremedicalstaffarerequiredtocomplywiththe48-hourweekEuropeanWorkingTimeDirective(EWTD).Periodicreviewsofthemedicalworkforce,producedbytheDepartment,provideahighleveloverviewoflikelystaffingneedsbutarenotdesignedtoidentifygapsatmedicalspecialtylevel.WeacknowledgethattheDepartmenthascommencedworkaimedataddressinghowitcanstrengthenplanningandintelligenceatmedicalspecialtylevel.
7. ItisimportantforTruststohavethekeymanagementinformationavailablelocallytoinformdecisions.ThereforeTrustsshoulddevelopstrategiestoimprovetheirunderstandingandmanagementofdemandforlocumdoctors.Trustsshoulduseastandardsystemforrecordingthereasonswhyemployinglocumdoctorswasdeemednecessary;thegradeandspecialtyinvolved;thetypeoflocum(internaloragency);andthetimeand
durationofshift.Trustmanagersshouldthenusethisinformationtoimproveworkforceplanningarrangements.
Improved procurement could lead to more efficient use of locum doctors
8. AccordingtoTrustprocedures,onlywhentheoptionsofcoverbymedicalteamsortheappointmentofinternallocumshavebeenexhaustedwillTrustsgrantapprovaltoapproachexternalrecruitmentagencies.AllTrustshavecontractsinplacewithanumberofagencies,throughtheBusinessServicesOrganisation(BSO),forthesupplyoflocumdoctors.Truststoldusthatwherethecontractedagenciesareunabletoprovidelocums,theywillmoveoutsidethecontract.
9. Inordertofurthergenerateefficiencysavingsandreduceclinicalrisk,weconsiderthatTrustsneedtoexploreandadoptbetterpracticeintheprocurementoflocumhoursbyimprovingcollaborationandpartnershipworking.Towardsthisend,weacknowledgethatTrustsaretakingstepstodeveloparegionally-managedmedicallocumserviceforNorthernIreland.Wheninplace,theregionalserviceshouldenabletheTruststoplanlocumusemoreeffectivelyandtodemonstratethatlocumsarebeingusedappropriately.Inaddition,therisktopatientsafetyoflocumdoctorscouldbereducedifalllocumsavailableundertheservicereceivedappropriateinductionsandhadtheirperformancefullyassessed.
4TheuseoflocumdoctorsbyNorthernIrelandHospitals
Improvements need to be made to assure the quality of locum doctors
10. Controllingthescaleandcostoflocumuseisonlypartofthechallenge.Perhapsmoreimportant,isthedutytoprovidesafe,effectiveandqualitycaretopatients.Trustsmustaddresstheirresponsibilitytoensurethatlocumsarecompetenttoundertakethedutiesrequiredofthem.WhileeachoftheTrustshasproceduresinplaceforprocuringlocumdoctors,InternalAudithasidentifiedseveralinstanceswherecheckstoensurethecompetenceoflocumdoctorshadnotbeenundertakenorwerenotproperlydocumentedandwhereTrusts’arrangementswithagenciessupplyinglocumsexposedthemtorisk.
11. In2006,theDepartmentintroducedInterim Arrangements for the Appraisal of Locum Doctors.Thesearrangementsrequiredthatalllocumepisodesshouldbesubjecttoastandardperformancereviewassessingtheclinicalskillsofthelocum.However,areviewin20081indicatedthat,incertainareas,therewasasignificantshortfallinthenumberofconsultants(andpossiblylocums)appraised;thattherewerenoformalsystemsforthereviewandperformancemanagementofappraisers;andthattherewaslittleevidenceoftheevaluationoftrainingoroftheoutcomesoftheappraisalprocess.Amorerecentseriesofreviewsin20102reportedimprovementoverallbutnotedthatTrustsdonotalwaysreceiveendofplacementreportsfromlocumagenciesorpreviousemployersandthatnotallTrustshavesystems
inplacetoprovideexitreportsforalllocumdoctors.TheneedforTruststomaintainrecordsoftheperformanceofindividuallocumswillbecomeevenmoreimportantastheGeneralMedicalCouncil(GMC)movesforwardwithaprocessofrevalidationwhereadoctor’slicencetopracticewillbereissuedeveryfiveyearssubjecttothesatisfactoryassessmentoftheirfitnesstopractise.TheDepartmenttoldusthatitispreparingforrevalidation.
12. Whilethedetailedaspectsoftheemploymentoflocumdoctorsare,inpractice,delegatedtostaffwithinthespecialtyrequiringcover,eachoftheTrustsoperatesacentralaccountabilitysystemthroughwhichseniordoctors(AssociateMedicalDirector/ClinicalDirectorlevel),areaccountableforthedemandandtheassociatedsafetyandqualityissues.Itisimportantthatcompliancewithsuchproceduresismonitoredandthatactionistakentoimprovecompliancewherenecessary.
13. TherearenosystemsandsafeguardsinplacetoenableaTrusttoroutinelyidentifywhetheralocumdoctorhasexceededthesafelevelofhourssetundertheEuropeanWorkingTimeDirective.Longworkinghourscanplacerisksonthehealthandperformanceofthelocumsandcanaffectthesafetyofpatientsintheircare.WhileGood Medical Practice3requiresindividualdoctorstoberesponsiblefortheirownwork,inourview,intheinterestsofpatientsafety,Trustsneedtoestablishsystemstoenablethemtocontrolandmonitorthetotalnumberofhoursworkedbyeachlocumdoctor.We
Executive Summary
1 TheRegulationandQualityImprovementAuthority(RQIA)ReviewofMedicalConsultantAppraisal,August20082 TheRegulationandQualityImprovementAuthority(RQIA)ReviewofHSCTrustReadinessforMedicalRevalidation,
December20103 GoodMedicalPractice–FrameworkforAssessmentandAppraisal,TheGeneralMedicalCouncil,November2006
TheuseoflocumdoctorsbyNorthernIrelandHospitals5
acknowledgethatthecurrentregionaldiscussionsandscopingexerciseonthepotentialtodeveloparegionallocumservicecitesthisasapotentialbenefit.
14. IntheDepartment’sview,locumdoctorsprovideanentirelysatisfactoryserviceinthevastmajorityofepisodesinwhichtheyareemployed.However,giventheweaknessesweidentifiedinthearrangementsformanagingtheworkoflocums,webelievethattheTrustsandtheDepartmentneedtoroutinelymonitortheperformanceoflocumdoctors.Truststoldusthattheirmanagementinformationsystemshavethecapacitytoprovideinformationonadoctor-specificbasis,althoughsomealterationstothewayinwhichdataisrecordedmayberequiredtospecificallyidentifylocums.
Part One:Introduction and Background
8TheuseoflocumdoctorsbyNorthernIrelandHospitals
1.1 InNorthernIreland,theDepartmentofHealth,SocialServicesandPublicSafety(theDepartment)isresponsibleforimprovingthehealthandsocialwell-beingofthepeopleofNorthernIreland.Partofitsresponsibilitiesinvolveensuringtheprovisionofappropriatehealthandsocialcareservices,bothinclinicalsettings(suchashospitalsandGeneralPractitioners’(GPs’)surgeries)andinthecommunitythroughnursing,socialworkandotherprofessionalservices.
1.2 Inrecentyears,thehealthandsocial
caresectorhasbeensubjecttomajorstructuralreforms4.On1April2007,fiveintegratedHealthandSocialCareTrustsreplaced18ofthe19Trusts(seeAppendix1).TheremainingTrust,theNorthernIrelandAmbulanceServiceHealthandSocialCareTrust,stayedinplace.OtherchangeswithinthesectorhaveincludedthecreationoftheHealthandSocialCareBoard(HSCBoard),fiveLocalCommissioningGroups,theBusinessServicesOrganisation(BSO),thePatientandClientCouncilandthePublicHealthAgency.
1.3 ManagementofhospitalservicesfallstothefiveHealthandSocialCareTrusts.Therearecurrently39hospitalsinNorthernIreland.Ofthese,13provideacutehospitalserviceswhiletheremaining26provideeithercommunity-basedservices5ormentalhealthservices.Thereportingstructuresforhospitalservicessince1April2007aresetoutinFigure1below.
1.4 NorthernIrelandhospitalsprovideawide-rangingprogrammeofcaretopatients.Somehospitalsoperate24hourseachday,365daysayear(acuteandmentalhealthhospitals).Othersprovidecarewithinspecifiedperiods(communityhospitals).Hospitalscanonlymaintaincrucialserviceswheretheyensurethatappropriatenumbersofdoctorsareavailableforeachshift.
1.5 Inrecentyears,anincreasingnumberofdoctorshaveelectedtoworkfewerhours,reflectingbroadercommunitypreferencesforbalancingworkandprivatelife.Inaddition,newimmigrationlawshaveledtoadeclineinthenumberofinternationalmedicalgraduatesandtheEuropeanWorkingTimeDirective(EWTD)hasintroducedrestrictionsonthenumberofhoursdoctorscanwork.Thesechangeshavemadeitdifficultforhospitalstoensurethattheoptimalnumberofdoctorsisavailabletocovershiftsatalltimes.
1.6 Whereahospitalhasinsufficientnumbersofdoctorsavailabletoprovidetherequiredservices,itwilleither:
a. payexistingstaff(internallocums)tocovertheadditionalhours;
b. recruitadditional(temporary)staffwherethepostistolastseveralmonths;or
c. whereneither(a)or(b)isfeasibleorsuccessful,approachanexternalagencytoprovidestaff(agencylocums).
4 ThestructuralreformsprimarilyreflectedchangesrequiredthroughtheReviewofPublicAdministrationandtoaddressthefindingsoftheApplebyReview.
5 AlistofNorthernIrelandhospitalsisincludedatAppendix2.
Part One:Introduction and Background
TheuseoflocumdoctorsbyNorthernIrelandHospitals9
Figure 1: Structure of the Northern Ireland Health and Social Care sector
*LurganandSouthTyroneHospitalsprovideinpatientservicestonon-acutepatients,aswellasofferingdaycareandoutpatientsinarangeofspecialitiesSource: DHSSPS and various other health and social care websites
Hospitals
Acute:Belfast City
Mater Infirmorum
Royal Group of Hospitals
Musgrave Park
Non-acute:Forster Green (Neurology & Elderly)
Shaftesbury Square (Drugs and Alcohol Counselling)
Knockbracken Mental Health Services (Acute Psychiatric)
Muckamore Abbey (Learning Disability)
Hospitals
Acute:Antrim Area
Causeway
Non-acute:Dalriada (Community)
Mid-Ulster (Community)
Moyle (Community)
Robinson (Community)
Whiteabbey (Community)
Holywell Hospital (Mental Health)
Hospitals
Acute:Altnagelvin Area
Erne
Non-acute:Tyrone County (Community)
Gransha (Mental Health)
Tyrone and Fermanagh (Mental Health)
Lakeside (Mental Health)
Hospitals
Acute:Craigavon Area
Daisy Hill
Non-acute:Armagh (Community)
Banbridge (Outpatients/Day cases)
Lurgan*
Mullinure (Geriatric Medicine)
South Tyrone*
Bluestone Unit (Mental Health)
St Luke’s (Mental Health)
Longstone (Learning Disability)
Hospitals
Acute:Downe
Lagan Valley
Ulster
Non-acute:Ards (Community)
Bangor (Community)
Thompson House (Physical & Sensory Disability)
Downshire (Mental Health)
Belfast Health and
Social Care Trust
Northern Health and Social Care
Trust
Western Health and Social Care
Trust
Southern Health and Social Care
Trust
South Eastern Health and Social Care
Trust
Northern Ireland
Ambulance Service
Health & Social Care Trust
Business Services Organisationproviding support to health and social
care bodies
Public Health Agencyresponsible for health improvement and health
protection
Patient and Client Councilrepresenting the interests of, and promoting
the involvement of the public
RQIA(Regulation and Quality Improvement Authority)
non-departmental public body responsible for monitoring and inspecting the availability and
quality of health and social care services
Local Commissioning Groups5 groups overseeing the activities of
individual Trusts
Health and Social Care Boardcommissioning, resource management, performance
management and improvement
DHSSPSresponsible for the provision of health and
social care services in Northern Ireland
10TheuseoflocumdoctorsbyNorthernIrelandHospitals
Locum doctors are used in Northern Ireland hospitals to ensure continuity of care for the patient
1.7 ‘Locum’,fromtheLatinphraselocum tenes,referstoapersonwhotemporarilyfulfilsthedutiesofanother.A‘locum doctor’isaprofessionally-qualified,medicalpractitionertemporarilycoveringforstaffshortagesorunexpectedpeaksinworkload.Locumsassistinhospitalsintwokeyareas.Forinstance,theycanprovideshort-termshiftcoverfordoctorswhoaretemporarilyunavailableforwork,ortheycanbeappointedonalongertermbasistofillvacantpostsorascoverforstaffonextendedabsence,suchasmaternityleave.
1.8 Therewillalwaysbeaneedforlocumstafftocoverperiodsofsickormaternityleave,toovercomeshortagesinthenumberofdoctorsintrainingwithinsomespecialtiesand,increasingly,tocompensateforthedesireofstafftoworkmoreflexiblehours.However,Trustsacknowledgethateffectiveplanningcanhelpcontroltheextenttowhichlocumsarerequired.
1.9 DoctorsprovidinglocumservicesareeitherTrustemployeesworkingoutsidetheirnormalhoursoraresuppliedbyLocumAgencies.
• Internal Locums –Hospitalsusetheirowninternalstaffaslocums.StaffareusedtocoverabsencesandarenormallyremuneratedatnationallyagreedratesasspecifiedinDepartmentalcirculars.The
Departmenthasacknowledged,however,thatsincetheseratesaresubstantiallylowerthantheratesavailabletoAgencylocums,internallocumsoftenrefusetheadditionalhoursunlessanincreasedrateisoffered.ApartfromtheBelfastTrust,theotherfourTruststoldusthatinternallocumsoftenbarterforratesabovethoseapprovedbytheDepartment.
• Agency Locums –TherearecurrentlynineLocumAgenciesinNorthernIrelandwhosupplylocumdoctorstohospitals.TheseAgenciesrecruitdoctorsfromwithintheNorthernIrelandHealthandSocialCaresector,indeedmanyofthestaffsuppliedbytheseAgenciesarealreadyworkingforTrusthospitals.Thepaymentrates,althoughinlinewithagreedcontractrates,tendtobesignificantlyhigherthanthesalariespaidtohospitalstaff.Forexample,ratesforsomeofthelargerAgenciesrangebetween£31to£72perhourcomparedagainstsubstantivepostratesofbetween£26to£31perhour.
We had difficulty obtaining details of the total locum spend across Trusts
1.10 Attheoutsetofouraudit,weaskedeachTrusttoprovidedetailsofthetotalpaymentsmadeinrespectoflocumdoctors.Informationonpaymentstoexternalagencies(foragencylocums),hasbeencollectedbytheDepartment’sWorkforcePlanningUnitsinceOctober2006andwas,therefore,readily
Part One:Introduction and Background
TheuseoflocumdoctorsbyNorthernIrelandHospitals11
available.Informationonthevalueofpaymentstointernallocumsprovedmoredifficulttoobtain.Throughoutouraudit,individualTruststoldusthatitwasnotpossibletoextractthisinformationfromtheirmanagementinformationsystems.
1.11 Sometimelater,duringthelatterstageofthereportingprocess,theDepartmentprovidedtheinformationwehadpreviouslyrequested(seeAppendix36).TheDepartmenttoldusthattheinformationcouldbeextractedfromthemanagementinformationsystemsofTrusts,albeitwithsomeinterrogationofsystems.
1.12 Figure2belowshowslocumdoctorexpenditurewithinNorthernIrelandTrustsovertheperiodfrom1April2007to31March2011.Overall,inthefouryearfrom2007to2011,NorthernIrelandTrustspaid£109milliontocoverstaffshortages.Expenditureonagencylocumsrosesteadilyovertheperiodfromalmost£14millionin2007to£22.5millionin2010-11.Since2007,thecostofagency-suppliedlocumdoctorshasamountedtojustunder£74millionforprovidinglocumdoctorstoTrusts.Overthesameperiod,Trustspaidjustover£35milliontointernalstaffforhoursworkedoverandabovetheircontractedhours.
6 WehavenotundertakenanyvalidationworktoassesstheaccuracyofthecostinformationprovidedtousbytheDepartment.
0
10
20
30
40Total Locum CostsAgency Locums
Directly Employed (Internal) Locums
2010-112009-102008-092007-08
Expe
nditu
re £
mill
ions
Year
Figure 2: Total Locum Expenditure within Northern Ireland hospitals over the period 2007-2011
Source: Department
12TheuseoflocumdoctorsbyNorthernIrelandHospitals
1.13 Figure3shows(inpercentageterms)theleveloflocumexpenditurecomparedtopaymentstopermanentdoctorsforcontractedhours.Themajorityofexpenditure(around92percent)in2010-11relatestopaymentstodoctorsfortheircontractedhourswithintheTrust.
1.14 Onaverage,8percentofoverallspendonemployingdoctorswithinhospitalsrelatestotheuseoflocums-6percentofthisbeingpaidtoexternalagencies.A2010reportbyAuditScotland7identifiedthatlocumexpenditureinScottishNHSBoardsin2008-09accountedfor4.3percentofmedicalstaffingexpenditure.
7 UsingLocumDoctorsinHospital–AuditScotlandJune2010
1.15 IfitwerepossibleforallTruststomaintainlocumcostswithintheregionalaverageof8percent,thismightyieldpotentialsavingsof£5millioneachyear.Theoretically,thiswouldinvolveallTrustsminimisingtheuseoflocumdoctorsbydeployingamoreoptimalnumberandmixofpermanentdoctors.Inpractice,however,werecognisethatforsomeTruststhisisnoteasy.Forexample,theWesternandNorthernTrustshavefaceddifficultiesinrecruitingstaffinsomespecialtiesandgrades.Despitethepressurestouselocumscreatedbysuchastrategicworkforceissue,Trusts,inourview,shouldbecapableofgeneratingsavingsbymoreeffectivemanagement
Part One:Introduction and Background
80
85
90
95
100
Internal Locums Cost Agency Locum Costs Cost of hospital doctors working contracted hours
AverageSouthernWesternSouth EasternNorthern Belfast
Trust
Perc
enta
ge o
f Ove
rall
Doct
or C
ost
Figure 3: Percentage split of total NI hospital doctor costs between contracted hours, Agency locums and internal locums over the period 2007-2011, by Trust
Source: Department
TheuseoflocumdoctorsbyNorthernIrelandHospitals13
ofthedemandforlocumsandimprovingprocurementprocedures,particularlyaroundthepaymentofpremiumratestolocumdoctors.
1.16 FurtheranalysisofthefiguresfromTrustseachyear(Figure4above)shedssomelightonthespecificdifficultiesfacedbyTrusts.LocumexpenditurewithintheBelfastTrusthasremainedfairlyconstantoverthefouryearperiodto31March2011ataround5percentoftheoverallcostofhospitaldoctors.LevelswithintheSouthEasternTrustalsoremainedrelativelyconstantataround5percent,apartfromaslightincreasein2008-09whichsawthelocumlevelrisetojustunder7percent.
0
5
10
15
20
WesternNorthern Southern South Eastern Belfast
2010-112009-102008-092007-08
Perc
enta
ge
Year
Figure 4: Trends in Locum Expenditure over the period 2007-2011
Source: Department
1.17 ThepercentageoflocumexpenditurewithintheSouthernTrusthadbeenhigher,withtheaverageforthefouryearsofaround9percent.However,thishasfalleninthelastthreeyearsandnowstandsatjustunder8percent.
1.18 PercentagelevelsintheNorthernTrustandtheWesternTrusthavebeenthehighestoverthefouryearperiod.WithintheNorthernTrust,thelevelstoodatalmost16percentin2008-09,althoughlevelshavefallenineachofthesubsequentyears.
1.19 WithintheWesternTrust,ontheotherhand,thepercentageoflocumuse
14TheuseoflocumdoctorsbyNorthernIrelandHospitals
hasrisensteadilyoverthefouryearsfromalmost11percentin2007-08tonearly17percentin2010-11astheTrustbecomesmorereliantonlocumstomaintainservices.The2010-11levelwithintheWesternTrust(ofalmost17percent)isthehighestforanyTrustoverthefouryearsexamined.TheWesternTrusthadalwaysplacedrelianceonInternationalMedicalGraduates(IMGs)andtherecentchangestoimmigrationlawshasresultedinthisdisproportionateuseoflocumcover.
The use of locums must be monitored carefully if the cost and quality of care is to be maintained
1.20 LocumdoctorsprovidecoveratalllevelsinmedicalspecialtiesacrossNorthernIreland’shospitals.Althoughmostmedicalandhealthandsocialcarepersonnelagreethattheuseoflocumdoctorswithinhospitalsprovidesflexibility,thepracticealsocreatesspecificchallenges.Forinstance,followingourpreviousreportonacutehospitalservicesin19938,thePublicAccountsCommitteeatWestminster9concludedthat,whiletherewasarecognisedneedforlocumdoctorstobeusedonoccasions:
“.....the Department must monitor carefully the quality of service provided in such situations on a regular basis so as to assure itself that quality of care is not being compromised.”
1.21 Asubsequentreportbyus10in2007highlightedthecircumstancessurroundingtheemploymentofalocumconsultantradiologistwhowaspaid£240,000forworkduringtheperiod2003-04.Apermanentstaffmemberwouldhavecostapproximately£71,000.Whenthepermanentpostwasfinallyadvertised,thelocumdidnotapply.Thereportalsoidentifiedaseriesofweaknesseswhichexistedinthemanagementoflocumdoctors(andagencynursingstaff)suchas:
• inadequateTrustguidanceonagency/locumstaffengagementprocedures;
• failurestouseformalcontracts;
• theappointmentofstafffromnon-contractedagencies;and
• weaknessesinvouchingprocedures.
1.22 Onthebasisofthesefindings,theComptrollerandAuditorGeneralmadeacommitmentinhisreporttoundertakeaseparatereview“.....into the use of locum doctors, with particular focus on the effectiveness of management arrangements in this area.”
1.23 ThecostoftemporarystaffinghasalsobeenthefocusofattentionintheNationalHealthServiceinGreatBritain.InDecember2005,theDepartmentofHealthlisted“managing temporary staffing as a major source of efficiency”11
8 Department of Health and Social Services: The Provision of Acute Hospital Services in Northern Ireland,NIAO,4November1993
9 Department of Finance and Personnel, Memorandum on the 12th and 13th Reports from the Committee of Public Accounts,Session1993-94,Cm2555,London,HMSO
10 Financial Auditing and Reporting: 2003-04 and 2004-05, Combined General Report on the Health Sector by the Comptroller and Auditor General for Northern Ireland, NIAO,NIA66/06-07,6July2007
11 A National Framework to Support Local Workforce Strategy Development,DepartmentofHealth,December2005
Part One:Introduction and Background
TheuseoflocumdoctorsbyNorthernIrelandHospitals15
asoneofitstenhighimpactworkforcechanges.Whilefindingssuchasthesesupportthecaseforadetailedstudyoflocumuseandcosts,therearealsopotentiallymoreimportantissuesconcerningclinicalriskandstandardsofpatientcare.
1.24 Truststakeadvantageoftheflexibilitythatusinglocumdoctorsaffordssothattheycanensurethatservicesaresafelymaintainedandthattheycanaddresstheclinicalrisksoffailingtofillgapsindoctors’rotas.Ifthedoctorsappointedarecompetentinallrespectstodotheworkrequired,theywillprovidethesamequalityofcareasadoctorinapermanentpost.However,thecircumstancesunderwhichlocumdoctorsareappointedandcarryouttheirdutiesmayposecertainrisks.Forexample,wherealocumisbroughtinonashort-termbasis,theirinductionmaybelimited.TheirlackoffamiliaritywiththeTrustworkingenvironmentandotherstaffcancreatearisktopatientsafety.Further,theirlimitedstayonawardraisesconcernsoverthecontinuityofcare.
1.25 Trustshaveacknowledgedthatitwouldbepreferabletohaveamorerobust‘bank’oflocumstaff,whoprogressthroughaformaltrainingupdateprogramme,onanannualbasis.Withthisinmind,Trustsareengagingwitheachotherwithaviewtodevelopingaregionally-managedlocumsystem(seeparagraph2.16).
This report considers the effectiveness of Trust controls over the use of locum doctors in hospitals
1.26 ThisReportconsiderstheeffectivenessofmanagementarrangementsovertheuseoflocumdoctorsbyTrusts;
• Part2examinesthearrangementsinplacetomanagethedemandforlocumdoctors;and
• Part3considersthearrangementsinplaceforsafeguardingthequalityofcareprovidedtopatients.
MoredetailonourmethodologyissetoutatAppendix4.
Part Two:Managing the demand for locum cover
18TheuseoflocumdoctorsbyNorthernIrelandHospitals
Workforce planning in the health service attempts to balance the availability of suitably-qualified medical staff against patient needs
2.1 Workforceplanningprovidesorganisationswithanopportunitytoidentifytrendsandanticipateshortfallsinstaffinglevels.Medicalworkforceplanningisacomplexprocess.InNorthernIreland,theexerciseconsistsofamajorreviewofserviceseverythreeyearsandinvolvesseveralorganisations,notablytheDepartment,theMedicalSchoolatTheQueen’sUniversityofBelfast,theTrustsandtheNorthernIrelandMedicalandDentalTrainingAgency12.Theobjectiveofmedicalworkforceplanningistobalancetheavailabilityofsuitably-qualifiedmedicalstaffagainstpatients’needs.
The latest Review of the Medical Workforce was published in 2010
2.2 InApril2010,theDepartmentpublisheditslatestReviewoftheMedicalWorkforce13.Thepurposeofthereviewwastoprovidecomprehensive,currentinformationonthemedicalprofessionalgroupinNorthernIrelandtobeusedbytheDepartmenttoforward-plantrainingoverafivetotenyearperiod14.
Changes to the hospital environment have had an impact on the availability of staff
2.3 Theenvironmentinwhichhospitalservicesaredeliveredhasgonethroughaperiodofsubstantialchange.Thishasimpactedontheavailabilityofstaffandthereforeontheneedtouselocumsifcrucialservicesaretobedelivered.GiventhecomplicatedinterplaybetweenworkforceplanningattheregionallevelandindividualTrusts’overallmedicalstaffingarrangements,inevitablythesupplyoftraineddoctorswillnotalwaysmatchdemand.Wheredemandforclinicalservicesoutstripsmedicalworkforcesupply,keyservicesmayhavetobewithdrawn.Forinstance,duringSeptember2009,theobstetricsandgynaecologyserviceattheErneHospitalwassuspendedfortwoweeksduetoagapintheserviceprovisioncreatedbyalackofjuniordoctors.In2010,AccidentandEmergencyservicesattheWhiteabbeyandMid-UlsterHospitalswereclosedandtransferredtoAntrimAreaHospitalforanumberofreasons15.Onereasonwasthelossofseniorclinicalstaffattheformertwolocationsandtheimpactthiscouldhaveonthequalityofclinicaloutcomes.
2.4 Primaryresponsibilityforplanningstaffingneedsinrelationtoservicedeliveryrestswiththeemployer–asdoessuccessionplanning.ThisisdoneatTrustlevel,andtheresultsprovidedto
Part Two:Managing the demand for locum cover
12 TheNorthernIrelandMedicalandDentalTrainingAgencyisresponsibleforfunding,managingandsupportingpostgraduatemedicalanddentaleducationwithinNorthernIreland.Itisresponsiblefortheorganisation,developmentandqualityassuranceofPostgraduateMedicalandDentalEducationandforthedeliveryandqualityassuranceofContinuingProfessionalDevelopmentforgeneral,medicalanddentalpractitioners.
13 The2010Reviewrelatedto2008whilethepreviousreview,publishedin2006,relatedto2005.14 The2010WorkforcePlanningReviewrelatedtothetenyearperiodfrom2008.15 OtherreasonsfortheclosureincludedtheabsenceofcriticalcarefacilitiesandapaediatricserviceatWhiteabbey
Hospital,thelackofaccessateitherhospitalstoacutesurgicalinpatientservices,theabsenceofintensivecareunitsatbothsites;andthelimitationsmoderntechnologiesincardiologyhaveplacedoncardiologists’abilitytocovertwositessimultaneouslyout-of-hours.
TheuseoflocumdoctorsbyNorthernIrelandHospitals19
theDepartment,sothatregionalgaps/shortages/trendscanbeidentifiedandremedialactiontaken.Theregionalpositionisanoverallsummarywhichcannotreplacecloseplanninginrelationtoserviceneeds.TheDepartmenttoldusthatworkiscurrentlyunderwaytopromptimprovementsinthisarea.
2.5 Severalfactorshavecontributedtothelimitedavailabilityofsuitablyqualifiedstaffacrossthehealthandsocialcaresectorasfollows:
a. Changes to the immigration rules:InFebruary2008,anewpoints-basedimmigrationsystemwasintroducedsettingouttheconditionsunderwhichoverseasdoctorscouldqualifyforentrytoworkintheUK.ThenewregulationsrestrictthenumbersofoverseasdoctorseligibletoworkintheUK.
b. Introduction of the European Working Time Directive (EWTD):TheEWTDwasintroducedinNorthernIrelandin1998toprotectthehealthandsafetyofworkersbyintroducingminimumrulesforrestperiods,leaveentitlements,lengthofworkingweekandnightwork(additionalinformationontheimplicationsoftheDirectiveissetoutatAppendix5).FromAugust2004,thelegislationlimitedjuniordoctors’workinghoursto58perweek.Thiswasfurtherreducedto56hoursperweekfromAugust2007andto48hoursfromAugust200916.
c. Individual specialty and location preferences of staff: HospitalslocatedoutsideBelfastoftenexperiencedifficultyattractingandretainingstaff.Small,ruralsitescanstruggletoconsistentlyprovideadequatecoverforpatients.Withinthesehospitals,thelossofevenonememberofstaff(throughsickleave,resignationorotherreason)canhaveamajorimpactontheabilityofthesitetomaintainitsservices.Inevitablythisputspressureonremainingconsultantsandstaffandmakestheirpositionslessattractive.
d. Flexibility of working hours and early retirements:Doctorsofbothsexesareincreasinglyelectingtoworkfewerhoursduringtheircareerandtoretireearly.ThisreflectsbroadercommunitypreferencesforbalancingworkandprivatelifebutplacespressureonTrustsasexperiencedstaffareavailableforareducedperiodoftime.
e. Change in the female to male ratio of students:Anincreasingnumberoffemalesarechoosingmedicineasacareer.ThecurrentfemaletomaleratioamongmedicalstudentsatQueen’sUniversity,Belfastisalmost60:4017.Thiswillultimatelyimpactonthecompositionoftheworkforce-overthelasttwoyearsfemalerepresentationhasincreasedby3percentand,infutureyears,thisisexpectedtorise.Theemploymentofadditionalfemalescanplacefurther
16 ResearchundertakenbytheDepartmentin2008identifiedthatdespitethepotentialimpositionofheavypenalties,non-compliancewithEWTDishighacrossthefiveNorthernIrelandHealthandSocialCareTrusts.TheresearchidentifiedthatlevelsofcompliancecouldbesignificantlyimprovedbytheimplementationofinternalmeasuresbyeachoftherespectiveTrusts.
17 QUBMedicalSchoolData–January2009-Femaletomaleratiois57:43
20TheuseoflocumdoctorsbyNorthernIrelandHospitals
pressureonTrustswherecoverisrequiredforperiodsofmaternityleave.
2.6 TheDepartmenttoldusthatithastakenstepstoaddresstheshortageofjuniordoctors.In2005,fundingwasprovidedtoincreasethenumberofmedicalstudents.Theextenttowhichtheseadditionalgraduatesreducetheuseoflocumswilldependontheirchosencareerlocationandtheirchoiceofspecialty.
2.7 Whilelocumappointmentsareintendedtofillgapsresultingfromtheunavailabilityofpermanentdoctors,thereisevidencethatthelocalsupplyoflocumsisalsobecomingaconcern.TheDepartmentrecentlydrewattentiontothehighcostsofbringingindoctorsfromoutsideNorthernIrelandtoprovidecoverinAccidentandEmergencydepartments,commentingthat,insomecases,temporaryreplacementdoctorswerebeingpaidalmostthreetimesmorethanstaffdoctors18.Trustsneedtobeabletodemonstratethatsuchpracticeisanappropriateandcosteffectiveuseofresourcesinthelongerterm.
Management information is insufficient to enable effective monitoring and control of the use of locums
2.8 IndividualTrustscollectinformation,tovaryingdegrees,ontheusageandcostsoflocumdoctorsandreportthistomanagementperiodically.However,theinformationcollectedisnotcomprehensivenorisitbroughttogetherinasystematicmannertoprovidethebasisforanalysing
themostappropriatewaytouselocumsthroughouttheTrusts.Failuretocollateandanalysecomprehensivemanagementinformationmakeseffectivestrategicplanningandcontroloflocumsverydifficult.TheabilityofTruststoplanstrategicallyandworkflexiblybecomesincreasinglyimportant,iftheyaretoaddressmedicalworkforcechanges.
2.9 TheTruststoldusthatitisessentialthatinformationisavailabletoassistinplanninganduseoflocums.TheTrustsseegreatmeritinthedevelopmentofaregionalmanagementinformationsystemwhichwouldbemanagedbyadedicatedresourceandwouldensurethatinformationiscollatedconsistentlyacrosstheregion.Thiswouldalsofacilitateregionalmonitoringofactivityandtrendsandinter-trustcomparisons,providinggreateropportunityformanagingtheuseoflocumsholisticallyacrosstheservice.
The 2010 Workforce Planning Review was completed in the absence of detailed information on speciality training
2.10 Iftheuseoflocumdoctorsistobeeffectivelyplanned,itisessentialtohavegoodqualityinformationonlikelystaffingdifficultieswithinthesector.TheworkforceplanningreviewpublishedinSeptember200619indicatedpotentialstaffingshortfallsinthefollowingspecialties(seeAppendix6forfurtherdetail):
• anaesthetics;
• communitypaediatrics;
18 InformationwasextractedfromanarticlewhichappearedintheIrishNewson2April2010.19 ReviewofWorkforcePlanningfortheMedicalProfession,September2006
Part Two:Managing the demand for locum cover
TheuseoflocumdoctorsbyNorthernIrelandHospitals21
• orthopaedics;
• psychiatry;and
• radiology.
2.11 ThenextWorkforcePlanningReview,publishedin2010,statesthat“...detailed specialty planning will be required to address specialty specific training and recruitment needs”.WhiletheDepartmenttoldusthatplanningforallspecialtieshadbeencompletedbeforeApril2009,theReviewteamwouldnothavehadallofthisinformationatthetimeofitsfieldwork.Inourview,tobemosteffective,itisimportantthatworkforceplanningshouldbebasedonananalysisofthestaffnumbersandgradesthatareneededsothatbothtrainingrequirementsandserviceneedsaremet.ItisonlywhensuchplansareagreedthatTrustswillbeinapositiontoconsiderhowtheirdependenceonlocumsmightbereduced.
2.12 Inordertomaximiseuseoftheworkforceplanningwerecommendthat,forallsubsequentexercises,specialtyplanningiscommissionedandundertakeninsufficienttimetoenabledetailedanalysispriortopublicationoftheten-yearWorkforcePlanningReview.
Using locum doctors can create considerable financial risks
2.13 Therecanbeconsiderablefinancialrisksinappointinglocumdoctors.Trustsarechargedwithensuringthatthey
havesufficientsubstantivepoststomeetforeseenservicedemands,includingplannedabsences.TheDepartmenttoldusthatTrustsmustbalancethisrequirementagainsttheirstatutoryobligationtobreak-eveneachyear.Theuseoflocumsisgenerallyonlypermissibletocovertemporaryabsences(suchasmaternityabsence)fromsubstantiveposts.Locumappointmentsareexpectedtobeprecededbyanassessmentoftherelativecost-effectivenessandviabilityofengagingadditionalpermanentstaffasopposedtoengaginglocumstaff.TheDepartmentassuredusthateachTrustreviewstherelativemeritsofeachcaseandassessescost-effectivenessbeforemakingdecisions.
2.14 WeexaminedInternalAuditreportsontheuseoflocumsproducedsince2005.Thesemadeanumberofcommentsinrelationtopaymentsmadetolocumagencies20:
• itwasoftendifficulttoverifytheratespaidtoexternalagenciesbecausespecificlocumgradeswerenotrecordedonthedocumentation;
• instanceswereidentifiedwhereTrustswereusinglocumsregisteredwithAgencieswhichdonothaveacontractwithTrusts.Inthesecases,Trustswerenegotiatingpaymentratesonanad-hocbasis;
• itwasnotedthatexistingTrustmedicalemployeeswerealsoregisteredwithlocumAgencies(onoccasionmorethanoneagency).Inthesecases,
20 Itisnotpossibletoquantifytheactualextentofnon-complianceidentifiedbyInternalAuditduetothesummarynatureoftheirreports.
22TheuseoflocumdoctorsbyNorthernIrelandHospitals
Trustsarepayinghigherratestotheirownemployeesthroughexternalrecruitmentagencies;and
• instanceswererepeatedlyidentifiedbyInternalAuditwheretheratespaidforlocumworkwereinexcessoftheDepartment’sagreedremunerationrates.Inaddition,otheroccasionswerehighlightedwhereTrusts,needingashiftcoveredatthelastminute,negotiatedpaymentsrateswithlocumsratherthanofferingtheratesstipulatedbytheDepartment(seeCaseExample1).TheDepartmentconfirmedthatinordertofillgapsinrotastomaintainsafeandeffectiveservicesitissometimesnecessarytonegotiatehigherratesthanthoserecommendedinDepartmentalguidance.ThemanagementinformationheldbytheDepartmentandTrustsisnotsufficientlydetailedtoallowidentificationoftheproportionandvalueoflocumpaymentswhichexceedstipulatedrates.
2.15 Giventhecurrentdrivefordeliveringefficiencysavingsacrossthehealthandsocialcaresector,Trustsmusttakeactiontocontrolcostswhenengaginglocumdoctors.DrawingontheexperienceoftheNationalHealthService(NHS)inEngland,wehavesetoutinFigure5,twoexamplesofgoodpracticewhichhavebeendevelopedandimplementedbyparticipatingteams(fulldetailsareprovidedatAppendix7).Eachexamplehasapositiveimpactonproductivity,improvesefficiencyandgeneratescost-savings21.Inparticular,thecollaborationofhospitalsandTrusts,applyingagreedstandardsandrates,hasbeenshowntocontributetomorecost-effectiveuseofmedicallocums.AnumberofTrustsworkingtogetherhavegreaterleveragewithexternalagencies,andeconomiesofscalecandelivermorecompetitiveagencyrates.Additionally,collaborationacrossTrustsenablesthesharingofgoodpracticeandlearning.
21 ThegoodpracticeexampleshavebeentakenfromtheNHSEmployerspublication“Controlling the use of temporary staff through large scale workforce change”.
Case Example 1
Inoneinstance,anInternalLocumConsultanthadbeenpaidaremunerationratearbitrarilydeterminedbytheClinicalDirectorateratherthanthatspecifiedinDepartmentalguidance.TheConsultantwaspaidatotalof£1,500(£500per3-4hoursession).Weestimatethathadadoctorinasubstantivepostundertakenthework,thelikelycostwouldhavebeenaround£100to£125foreach3-4hoursession).ItwasalsonotedthatpaymentforonesessionwasdisallowedbyFinancesinceithadbeenpaidbefore.
Part Two:Managing the demand for locum cover
TheuseoflocumdoctorsbyNorthernIrelandHospitals23
Figure 5: Summary of Good Practice Purchasing Initiatives identified by NHS Employers
Issues similar to those identified in our report were identified in hospitals across UK Trusts as follows:• theuseofagenciesoutsidethoseoutlinedinthenationalframeworkwereregularlybeingused;• individualdepartmentsweredevelopingandusingtheirownsuppliersandproceduresforbookinglocums;• absenceof(orlimited)centralcontroloverexpenditureontemporarystaff;• anabsenceofusefulintelligenceonmedicallocumusageandspend;• insufficientcheckingofinvoicesformedicallocumsepisodes;and• anumberofpositionsreliedonhigh-costmedicallocumstofillvacancies,andthesehadnotbeenreviewed
forsometime.
A range of potential solutions were generated and piloted to address these issues as follows:• useofaconsortiumoftrustswithsharedgoalsandcommitments,todrivedownagencycoststhrough
combinedspendingpower;• developmentofamastervendornetworkallocatingresponsibilityforsupplyingtemporarystafftoasingle
supplier;• introductionofprotocolsandimprovedfinancialcontrolsoverthebookingofmedicallocums;• directphonecallstoagenciesfromwardswerebanned,thephonenumberwasblockedthroughthe
switchboardandout-of-hoursbookingsweredonethroughon-callexecutivedirectors;• useofcentralisedbookingarrangements(forallmedicalstaff)throughonesourcewithinindividualTrusts;• improvedmanagementinformationtoallowmanagerstocontroltheuseoftemporarystaffmoreeffectively;• reviewofrota-planningarrangements;and• postswhichtendedtorelyheavilyonagencylocumswerere-advertised,NHSlocumswerefavouredover
agencylocumsandagencylocumswereencouragedtotransfertoNHScontracts.
Various benefits were secured through these initiatives including:• abilitytosecuremorefavourableratesandbettersharingofgoodpracticethroughcollaborativeworking;• increasedspendingpower,greaterleverageindrivingdowncosts,improvedservicetoTrustsandthe
provisionofimprovedmanagementinformationfromthesupplier;• improvedmonitoringoftheuseoflocums;• releaseofconsiderableclinicalstafftimebyuseofadministrativestafftoarrangelocumbookingsandasingle
supplier;and• improvedstaffmoralebyincreasingfillratesonshifts.
Actual savings were secured as follows:• InoneTrust,theuseofthemastervendorsystemreducedspendonmedicallocums(nursingandmedical)by
justover£2millioneachyear.• InthatTrust,theintroductionofacentralisedbookingsystemreleasedsavingsofaround£0.8million.• WithinanotherTrust,theintroductionofimprovedproceduresreducedtheuseandcostofmedicallocumsby
over£278,000permonth,equatingtoanestimatedannualsavingofover£3.3millionperyear.
24TheuseoflocumdoctorsbyNorthernIrelandHospitals
2.16 GiventhesuccessoftheseexamplesintheNHS,itisencouragingtonotetherecentdecisioninNorthernIrelandtotakestepstointroduceaRegionallyManagedMedicalLocumServiceforNorthernIreland(seeAppendix8).WealsowelcomeassurancesfromtheBusinessServicesOrganisationthatithastakenstepstoimprovecollaborativeworkingandimprovepurchasingarrangements.
2.17 TrustsacrosstheUnitedKingdomexperiencesimilarproblemsmanaginglocumcosts.SuccessfulpilotsinTrustsacrosstheUnitedKingdomgeneratedsubstantialsavingsandthiscouldbereplicatedwithinNorthernIrelandTrusts.WerecommendthatTrustskeepuptodatewithdevelopmentselsewhereintheUnitedKingdomandexplorethesuccessorotherwiseofthevariousinitiativesundertakenasameansofidentifyingimprovedpractices.
Part Two:Managing the demand for locum cover
Part Three:Safeguarding the quality of care provided to patients
26TheuseoflocumdoctorsbyNorthernIrelandHospitals
Trusts and the Department must manage risks to provide safe, high-quality care to patients
3.1 Asdemandforlocumsincreasesandpressureonworkloadgrows,TrustsandtheDepartmentmustensurethat,alongwithcontrollingcosts,doctorsappointedonalocumbasisarecompetenttoundertakethedutiesrequiredofthem.Riskmanagement,therefore,isincreasinglyimportantinensuringthatTrustsprovideasafeandhighqualityservicetopatients.Patientsareentitledtoexpectappropriatestaffinglevelsandprofessionalcompetence.Theuseoflocumdoctorsbothavertsandcontributestotherisk,byenablinghospitalstomaintainappropriatestaffinglevelseventhoughthismightinvolveappointingdoctorswithlessexperienceorskillsthanthosetheyarereplacing.
3.2 Therecanbeotherpotentialrisksforthehealthcaresysteminengaginglocums:lackofcontinuityofcare;orlackoffamiliaritywithahospitalanditsprocedures.Inaddition,therecanbesignificantpotentialdisadvantagesfordoctorswhochoosetoworkonalocumbasis,forexample,thelackofongoingeducationfrompatientfollow-up;andtheabsenceofmentorandpeersupportorinadequatesupervisionofadherencetoconditionsoftheEWTD(seeparagraph2.5b).
3.3 Thepresenceofriskisnotanargumentagainsttheuseoflocums,butthosemakingthedecisionsneedtobeable
toidentify,measureandcontrolthedegreeofriskinvolved.ThecorporategovernancestructureswithinthehealthandsocialcaresectorrequiretheManagementBoardsofindividualTruststoevaluateinternalcontrolsandreporttheresultstotheDepartment.Inrelationtostaffing,theHumanResources(HR)ControlsAssuranceStandard22setsoutkeycriteriaandcontainsguidanceonhowManagementBoardsshouldestablishwhethersystemsaresound.OneofthestatedcriteriaoftheHRStandardistoensurethatallstaffarerecruitedandemployedinaccordancewithrelevantstatutoryemploymentlegislationandanyotherrelevantrequirements.
Locum doctors provided to Trusts by external agencies are not regulated by the Regulation and Quality Improvement Authority
3.4 TheRegulationandQualityImprovementAuthority(RQIA)23isresponsiblefortheregulationofawiderangeofhealthandsocialcareservicesincludingNursingAgencieswhichprovidetemporaryregisterednurses,healthvisitors,andmidwivestothehealthandsocialcaresector.However,itsremitdoesnotextendtoAgenciesprovidinglocumdoctors.
3.5 WeunderstandthatarrangementsinScotlandandWalesalsoexcludetheregulationoflocumagencies.InEngland,unlessthelocumagencyhasadirectroleinmanagingordirectingthecarethenitisexemptfromregulation.
22 HSCControlsAssuranceStandard–HumanResources(latestversionApril2009)23 RQIAistheindependentbodyresponsibleformonitoringandinspectingtheavailabilityandqualityofhealthandsocial
careservicesinNorthernIreland,andencouragingimprovementsinthequalityofthoseservices.
Part Three:Safeguarding the quality of care provided to patients
TheuseoflocumdoctorsbyNorthernIrelandHospitals27
3.6 AlthoughwenotethatthecurrentregulationarrangementsinNorthernIrelandmirrorthoseelsewhereintheUnitedKingdom,inourview,externalagenciessupplyinglocumdoctorsshouldbesubjecttothesameregulationasnursingagencies.WerecommendthattheDepartmentconsidersextendingRQIA’sroletocoverexternalagenciessupplyinglocumdoctorstoTrusts.Formaximumbenefit,theDepartmentshouldconsiderliaisingwiththeotherregionsintheUnitedKingdomwithaviewtodevelopingajoined-upapproachtosuchregulation.
The Code of Practice in Locum Doctor Appointment and Employment was introduced in Northern Ireland in 1998 and sets out key controls for the use of locums
3.7 ItistheclearresponsibilityofTruststoensurethatalldoctorstheyemployarecompetent,appropriatelyqualified,experiencedandcapableofundertakingthedutiesrequiredofthem.ToassistTrusts,inJuly1998,theDepartmentintroducedTheCodeofPracticeinLocumDoctorAppointmentandEmployment.
3.8 TheCodewasdevelopedbytheLocumsWorkingGroupwhichwascommissionedbytheChiefMedicalOfficerinEnglandbecause:
“... the health service, the medical profession and the Health Departments all expressed concerns over the quality of some locum doctors and the apparent ease with which some unsatisfactory
doctors are sometimes able to move between locum posts within the Health Service ...”
The Code sets out the required pre-employment checks for each locum episode
3.9 Theguidanceoutlineskeycheckstobecompletedpriortotheappointmentoflocumdoctorsandrequiredmonitoringandrecordingofthequalityofeachlocumepisode.TheCodeclarifiesthatalllocumappointmentsshouldcomply.ItremindsTruststhat,asemployers,theyhaveultimateresponsibilityforpre-employmentscreening,whetherornotthelocumdoctorhasbeensuppliedbyanagency.Theobjectiveoftheguidanceistosafeguardthequalityofpatientcare.Asanadditionalcontrol,inlinewithDepartmentalguidance,TrustsarerequiredtouseonlylocumssuppliedbycontractedAgencies.
3.10 Followingadecisiontoappointalocumdoctor,eachTrusthasresponsibilityfordeterminingthemostsuitableapplicant.Locumappointmentsshouldbemadewiththesamecareassubstantiveappointments.Priortoofferingtheappointment,Trustsareresponsibleforensuringthatthelocumdoctor:
• hastherequisitequalificationsandexperiencetoundertakethework;
• isnotsubjecttoreservationsaboutthestandardorcompetenceinpreviousemployment;
28TheuseoflocumdoctorsbyNorthernIrelandHospitals
24 Again,itisnotpossibletoquantifytheactualextentofnon-complianceidentifiedbyInternalAuditduetothesummarynatureoftheirreports.
• identifiesandprovidesawrittenreportfromtheirmostrecentlocumemployerand/orrelevantreferences;
• hasbeensubjecttoaformalhealthassessmentandhassignedahealthdeclarationform;and
• disclosesdetailsofanyconvictions–spentorotherwise.
3.11 Inpractice,whereAgencylocumsareused,pre-employmentchecksarecompletedbytheAgency.Internallocums,asTrustemployees,willalreadyhavebeenappointedusingproceduresforsubstantiveposts.
We identified several weaknesses in procedures for employing locums from external agencies
3.12 Aswellasexaminingasampleof30locumappointmentswithintheBelfastTrust,wereviewedpreviousinternalauditreportsontheuseoflocumsproducedsince2005.Wefoundevidenceofproblemswiththewayinwhichchecksonlocumdoctorshavebeenconducted24:
• inoneTrust,Agencieshadnotbeenrequiredtoprovidewrittenconfirmationthatpre-employmentcheckshadbeencompleted;
• inoneTrust,qualificationchecksweremadeonaninformalbasis,increasingtheriskofinappropriateandpossiblyunder-qualifiedstaffbeingused;
• someTrustsusednon-contractedAgenciestoprovidestaff.Thisraisesissuesrelatingtothequalityandsafetyofservicewhereassuranceislimitedthatappropriatevalidationcheckshavebeencompleted.TheDepartmenttoldusthat,wherecontractedagenciesareunabletoprovideappropriatestaff,Trustshavenooptionbuttousenon-contractedAgencies;and
• someTrustshadfailedtocarryoutanyauditoflocumAgenciesforanumberofyears.Undercontractualarrangements,Trustshavetherighttoconductanauditoftheexternalagencyatanytime,toensureitcomplieswithitspre-employmentvettingobligations.SuchauditsshouldincludechecksthatthelocumdoctorregisteredwiththeAgencyhasthenecessaryqualifications/experience/skillsforthepost,hasasatisfactoryhealthassessment,andproperjobreferences.AssuchtheygiveassurancetoTruststhatAgenciesareprovidingproperlyvettedlocums.WeunderstandthatnoauditshavebeenperformedsincetheinceptionofthenewHealthTrustsinApril2007.
3.13 ItisamatterofconcernthatTrustsonsomanyoccasionsdidnotcomplywiththeapprovedproceduresforemployinglocumsfromexternalagencies.Inmanycases,InternalAudit’sconcernsresultedinanassessmentof“partial”or“limited”assurance.
Part Three:Safeguarding the quality of care provided to patients
TheuseoflocumdoctorsbyNorthernIrelandHospitals29
3.14 WerecommendthatallTrustscomplywiththeexistingproceduresforemployinglocumdoctorsfromexternalagencies.Foralllocumappointments,Trustsmustbesatisfiedthatappropriatevettingofapplicantshasbeenundertaken.Intheabsenceofappropriatevetting,Trustsriskcompromisingpatientsafetyandmayfaceseriousfinancialconsequencesifclaimsforclinicalnegligenceweretoresultfromaninappropriateappointment.
3.15 Trustsalsoneedtocarefullyweigh,andfullyaddress,theaddedrisksofusinglocums,especiallywheredoctorsarenewtothehospital,areunfamiliarwithcolleagues,thepatientsundertheircareandlocalproceduresandpractices.WerecommendthatTrustsreviewtheirinductionarrangementsforlocumstafftoprotectpatientsafety.
The Code sets out procedures for assessing the quality of service for each locum episode
3.16 Inadditiontopre-employmentchecks,Trustsneedtohaveproceduresinplacetoensurethatthequalityofserviceisassessedforeachlocumepisode.InOctober2006,theDepartmentintroduced Interim Arrangements for the Appraisal of Locum Doctors in Trusts. Thisenhancesguidancecontainedinthe1998CodeofPractice(paragraph3.7).TherequirementsoftheguidancearesetoutinFigure6.
3.17 InAugust2008,RQIAconductedaReview of Medical Consultant Appraisal.Aspartofthereview,Trustswereaskedtosupplyinformationonthepercentageofconsultantlocumswhohadnotbeenappraisedduringtheperiod1April2006-31March2007.RQIAnotedinthereportthat
Figure 6: Appraisal of Locum Doctors
- wherealocumdoctorisemployedforlessthanoneweekhe/sheshouldbesuppliedwithasuitablereferenceor‘statementofsatisfactoryemployment’
- wherealocumdoctorisemployedforperiodsofmorethanoneweekbutlessthansixmonthsandcannotbeincludedinroutineappraisalprocesses,anend-of-placementreport,whichshowsthattherearenosignificantunresolvedconcernsaboutthedoctor’sfitnesstopractise,shouldbecompleted
- ifthelocumpostisformorethansixmonthsduration,thedoctorshouldbeappraisedaspartoftheroutineappraisalprocess
- wherethelocumdoctorisemployedviaanAgencyandappraisalofdoctorsispartoftheservicesprovidedbythatAgency,theemployershouldensurethatappropriatestandardsandqualityassurancemechanismsareinplacetoensurerobustappraisalmechanismsandpre-employmentchecks.
30TheuseoflocumdoctorsbyNorthernIrelandHospitals
themethodologyledtolimitationsinthequalityofinformationsuppliedbytheTrusts.Thereviewmethodologywasnotconducivetoin-depthanalysisnordiditallowexaminationoftheimplementationofpoliciesandprocedures.Theviewsofappraisersandappraiseeswerenotsought.Therefore,theanalysisoftheeffectivenessoftheconsultantappraisalsystemislimited.ResultsarecontainedatFigure7.
Figure 7 – Percentage of Locum Consultants not Appraised
Trust % locums not appraised
Belfast Informationnotsupplied
Northern 42%
Southern 43%
SouthEastern Informationnotsupplied
Western Informationnotsupplied
Source: RQIA
3.18 OnlytwoTrustssuppliedtherequiredinformation.FortheseTrusts,asignificantpercentageoflocumconsultantshadnotbeenappraised.Reasonsgivenfornon-appraisalincluded:
• changesinmedicalpersonnelasaresultoftherestructuringwithinthehealthsectorhadadverselyaffectedthecompletionofappraisals;
• lossofmomentumasaresultofthedelayinfinalisingarrangementsforrevalidationofhospitaldoctors(seeparagraph3.27below);
• doctorsappraisedbutpaperworknotreturnedtoHumanResources;
• postsnotfilledpermanentlyandhighturnoveroflocumstaff;and
• sickleave.
3.19 Inadditiontotheapparentlowincidenceoflocumappraisal,RQIAidentifiedanumberofotherconcernswiththemedicalappraisalsystem,including:
• therewaslittleevidencesubmittedthatTrustscarryoutanannualauditofmedicalappraisalsystems.Inthemain,Trustsdescribedanaspirationtomeetgoodappraisalcriteria;and
• onlyoneTrust(theSouthernTrust)indicatedithadaprocessinplacetoreviewtheskillsofappraisers.RQIAconcludedfromitsanalysisofinformationfromTrusts,thatthereappearedtobenoformalprocessforreviewandperformancemanagementofappraisers,andlittleevaluationoftheeffectivenessoftheappraisaldiscussion.
3.20 Inamorerecentreviewin201025,RQIAconcludedthattherewasstrongcommitmentinallHealthandsocialcaresectorTrustsinNorthernIrelandtoensuringeffectiveappraisalsystemsareinplaceandthattherehasbeengoodprogresstowardspreparingforrevalidation.However,specificallyinrelationtolocums,thereviewteamobservedthatTrustswerenotalwaysreceivingendofplacementreportsfrom
25 In2010,RQIAworkedwiththeGeneralMedicalCouncil,theNHSRevalidationSupportTeam(RST),QualityImprovementScotlandandtheHealthcareInspectorateWalestopilotaapproachforindependentlyreviewingmedicalrevalidationprocedureswithinTrusts.
Part Three:Safeguarding the quality of care provided to patients
TheuseoflocumdoctorsbyNorthernIrelandHospitals31
locumagenciesorpreviousemployersandthatnotallTrustshadsystemsinplacetoprovideexitreportsforalllocumdoctors.ThereviewteamconsideredthatitwouldbeusefultostandardisearrangementsacrossNorthernIrelandandrecommendedareviewofthesystemsforgatheringandsharinglocumdoctorinformationtoensurethatthesecansupportrevalidation.
3.21 Failuretocarryoutlocumdoctorappraisalsinaconsistentandrigorouswayandtoregularlyauditappraisalproceduresisaseriousbreachofclinicalgovernance.Attheconclusionofeverylocumappointment,inlinewithbestpractice,theTrustspecialtyengagingalocumdoctorshouldprepareabriefstandardisedreturntotheclinicaldirector,providingfeedbackonperformanceandhighlightinganyconcerns.Trustsalsoneedtohaveproceduresinplacetoensurethatappraisers,whoarekeytotheprocess,areselected,trainedandsupportedappropriately.
3.22 Theplannedmovetowardsanewsystemofrevalidationasameansofassessingtheperformanceofstaffprovidinghealthcaretopatientsisapositivestep.WewelcometheassurancethatallHSCTrustsinNorthernIrelandarecommittedtoensuringeffectiveappraisalsystemsareinplaceandhavemadegoodprogresstowardspreparingforrevalidation.However,wenotetherecommendationsofthereviewteamthatworkisrequiredinrelation
totheappraisaloflocumdoctors.WerecommendthattheDepartmentaddressesthereviewteam’sconcernsinrelationtolocumdoctorsasamatterofurgency.
The limitations of existing management information can create difficulties for Trusts attempting to verify compliance with the requirements of the European Working Time Directive (EWTD)
3.23 TheDepartmenttoldusthat,compliancewiththeEWTD(seeparagraph2.5)hascontributedtotheneedtoemploylocums.However,wefoundthatthemanagementinformationsystemsinplacedonotfacilitatemonitoringofthenumberofhoursworkedbyinternallocums.Byimplicationthisthereforeprecludesidentificationofthenumberofhoursresttakenbyinternallocums.AcrucialelementoftheEWTDistheneedfordoctorstotakeaminimumof11hoursrestinany24hourperiod.Whileitisuptoindividualdoctorstobehaveinaprofessionalmanner,itisalsoappropriatetohavesystemsinplacetoensurethatlocumdoctorsdonotworkexcessivehours.AlthoughTrustsmustensurethatthestaffwhomtheyemploydonotbreachthetermsoftheEWTD,whereadoctorchoosestoworkadditionalhoursinanotherTrust,itcanbedifficultforindividualTruststomonitorcontinuedcompliancewiththeDirective.
3.24 AccordingtoresearchundertakenbytheDepartmentin200826,non-compliancewiththeEWTDwashighacrossthefive
26 ResearchwasundertakenbytheDepartment’sImplementationSupportGroupinAugust2008
32TheuseoflocumdoctorsbyNorthernIrelandHospitals
NorthernIrelandHealthandSocialCareTrustsdespitethepotentialimpositionofheavypenalties.TheresearchidentifiedthattheaveragelevelofcompliancewiththeDirectiveacrossTrustswas40percent.
3.25 TheDepartmenttoldusthatamorerecentself-reportingexerciseundertakeninOctober201027indicatedthatthelevelofcompliancewas77.5percent.Theexerciseidentifiedthatnon-complaintpostsweremainlyinspecialtiessuchasMedicine,Surgery,ObstetricsandGynaecology,PsychiatryandPaediatricswheresolutionsremaindifficult.
3.26 WeacknowledgetheimprovementthattheTrustshavemadeintherateofcompliancewiththeEWTD.WealsorecognisethedifficultyfacedbyTrustsanddoctorsincomplyingwiththeDirectivewhileseekingtomeetthedemandsofhospitalservices.However,failuretomeettherequirementsofEWTDcouldresultintheimpositionofsignificantfinancialpenaltiesbytheEuropeanUnion,ormoreseriously,couldcompromisethehealthandsafetyofdoctorsandpatients.Itisimportant,therefore,thatTrustsworkcloselytogetherandwiththeDepartmenttoagreewhatneedstobedonetosupportcompliance.
The Confidence in Care programme, introducing revalidation of all licensed doctors, is intended to improve the quality of patient care
3.27 The2007WhitePaperTrust Assurance and Safetyhaspositionedappraisalasthecornerstoneofaprogrammeofrevalidation.Whentheprogrammeisfullyimplemented,everydoctorwhowishestopractise(eitherasasubstantivestaffmemberorasalocum)willberequiredtoholdalicenseandwillberequiredtoparticipateinrevalidation.Revalidationistheprocessbywhichdoctorswilldemonstratethattheirknowledgeisuptodateandthattheyarefittopractise.
3.28 Undertheprocess,eachdoctorwillmaintainafive-yearportfolioforreviewagainststandards(setbytheGeneralMedicalCouncil)atanannualappraisal.Thisapproachaimstoensuremoreconsistentclinicalgovernanceandthefairerassessmentofdoctors’medicalpracticeagainststandards.ItisimportanttonotethattheLocumDoctors’Association28hasexpressedconcernovertheabilityoflocumdoctorstocollateenoughevidenceofpracticetowarrantrevalidation.
3.29 Wewelcometheplanstomovetowardsanewsystemofrevalidationasameansofassessingtheperformanceofstaffprovidinghealthcaretopatients.
27 TheBoardLiaisonGroup(BLG)withintheHealthandSocialCareBoardactsinanadvisorycapacitytoTrusts,theHSCBoardandtheDepartmenttohelpdevelopEWTDnon-compliancesolutions.TheBLGestimatedtheOctober2010levelofcompliancewiththeEWTDonthebasisoftheresultsofaself-reportingexerciseacrosstheTrusts.
28 TheLDAisatradeunionwhichwasfoundedinJune1997andrepresentshospitallocumdoctors.
Part Three:Safeguarding the quality of care provided to patients
TheuseoflocumdoctorsbyNorthernIrelandHospitals33
3.30 Whenrevalidationisfullyoperational,itssuccesswilldependtoalargeextentontherobustnessofTrustarrangementsandthequalityofchallengeexercisedbyTrustswherethereisanyevidenceoflackofcompliance.Intheperiodpriortotheintroductionofrevalidation,werecommendthatTrustsintroduceinterimarrangementstoassesstheperformanceofhospitallocums.
Where Trusts do not undertake the required pre-employment checks, complete appraisals for each locum episode or enforce compliance with the EWTD, there is a risk that patient safety will be compromised
3.31 Duringourauditwefoundevidencethatpre-employmentchecksandappraisalsarenotcompletedforalllocumepisodes.WealsonotedfromresearchundertakenbytheDepartmentthatTrustswerenotcomplyingwiththerequirementsoftheEWTD.Theseareimportantcontrolsdesignedtoprovideassurancethatpatientsreceivequalitycare.WhileweacknowledgethattheDepartmenthasintroducedclinicalandsocialcaregovernanceandriskmanagementprocessesacrossthehealthandsocialcaresector,inourviewthefailuretocomplywithkeycontrolsincreasestheriskthatcareisnotofsufficientquality.
3.32 Inanattempttoestablishwhetherlocumdoctorsposeagreaterclinicalriskthantheircounterpartsinsubstantiveposts,weexaminedtherecordsheldbytheDepartment29forevidenceastowhether
theincidenceofseriousadverseincidentsinvolvinglocumdoctorswashigherthanthoseinvolvingonlypermanentstaff.Wefoundhowever,thattheDepartment’srecordsdidnotconsistentlyrecordwhetherthedoctorinvolvedwasemployedpermanentlyorwasalocum.
3.33 TheDepartmenttoldusthatsuchareviewofseriousadverseincidentswouldnotproduceanobjectiveassessmentoflocumperformance.WhiletheDepartmentacceptsthat,asaresultoftreatment,somepatientsmaysuffersomeformofharm,maycomplainormayseekcompensation,ittoldusthatevenwhereitisclearthatanadverseeventhasoccurred,itisnotalwaysanindicationofthepoorperformanceofstaff.Rather,adverseeventscanariseasaresultofsystemsorproceduralfailuresaswellasbecauseofhumanerror.
3.34 TheDepartmentadvisedusthattheSupportingSaferServicesReport30isdesignedtosharethelearningfromtheSeriousAdverseIncidentReportingSystem.The2007Report,forexample,detailstheissues,identifiedbyHSCorganisationsforlearning,intheareasofrecruitmentandtraining.Thisincludedguidanceoninductionforallnewlyappointedstaff(whethersubstantiveorlocum)andarrangementstoensurelocumsarefamiliarwithTrustprotocolsandprocedures.
3.35 Whilethelackofdetailedinformationontheextenttowhichlocumswereinvolvedinreportedseriousadverseincidentspreventedcomprehensiveanalysis,we
29 SeriousAdverseIncidentReportingArrangementstransferredfromtheDepartmenttotheHSCBoard(workinginclosepartnershipwiththePublicHealthAuthorityandRQIA)witheffectfrom1May2010.
30 DHSSPS(2006and2007)SupportingSaferServices:AnalysisofSeriousAdverseIncidents
34TheuseoflocumdoctorsbyNorthernIrelandHospitals
wereabletoidentifysomecaseswherelocumsprovidedunsatisfactorycaretopatients.Inourview,theseillustratethepotentiallyveryseriousconsequencesoffailingtooperatepre-employment,appraisalandEWTDcontrolseffectively.Failingsreportedinthesecasesinvolved
unprofessionalbehaviour,breachesofdepartmentalmedicalpoliciesandpracticeandaninabilitytoperformthework.CaseExamples2-4belowprovidesomeindicationoftheimpactofpoorlocumperformanceonpatientcareandsafety.
Case Example 2
Followingconcerns,areviewofexaminationsperformedbyalocumconsultantradiologistwasundertaken.Thereviewidentified“seriousfailureinstandardsinbreastscreeningassessment”.Intotal,44casesrequiredurgentre-assessment.Ofthese,eightwomenwerediagnosedwithbreastcancer.Thelocumradiologistwassuspendedfromclinicalpracticependingdisciplinaryprocedures.AsaresultofthesefindingstheHealthMinistercommissionedanindependentgovernanceinvestigationbyRQIA.InMarch2006,RQIAconcludedthat:• chronicshortagesofradiologistscontributedtothecircumstanceswhichledtothelocumworkingin
adegreeofisolation,withoutpeersupport;
• concernsovertheclinicalcompetenceofthelocumradiologistwerenotraisedordiscussedwiththeindividual;and
• management’sdecisiontocontinueprovidingbreastscreeningservicesdespiteconcernsoverthecompetenceoftheconsultantradiologistwasflawed.
Case Example 3
ConcernswereraisedaboutthequalityofMRIscansundertakenbyalocumradiologistduringtheperiodApril2007toOctober2007.Thelocumhadbeenemployedforfouryears,untilJune2007.
Theaccuracyof620scansundertakenbythelocumradiologistwasindependentlyassessedbyanaccreditedmedicalcompany.Halfoftheindependentassessmentsdifferedsubstantiallyfromthelocum’sresults.Ineachofthesecases,patientrecordswerereviewedtoensurethevalidityofdiagnosisand,wherenecessary,patientswererecalled.
Part Three:Safeguarding the quality of care provided to patients
TheuseoflocumdoctorsbyNorthernIrelandHospitals35
3.36 TheneedforTruststouselocumdoctorstomaintaincrucialservicesinNorthernIrelandhospitalsisnotdisputed.Weacceptthataverylargenumberoflocumsprovidequalitycover.However,theweaknessesinproceduresidentifiedacrossTrustsinrelationtopre-employmentchecks,appraisalprocessesandregulationoflocumsandtheconsequentincreaseinriskexposuremeansthatitisallthemoreimportantthattheDepartmentshouldroutinelymonitortheperformanceoflocumdoctors.
Case Example 4
InJune2008alocumconsultantobtainedapost.Afterafewmonthshiscolleaguesexpressedconcernaboutsomeaspectsofhisgynaecologicalpractice.AfterdiscussionswiththeMedicalDirectorandHumanResources,hewassuspendedfromgynaecologicalworkbutcontinuedinobstetricpracticeatthehospital.Subsequently,furtherissueswereraisedand,followingdiscussion,hiscontractwasterminated.
AnexercisebytheChiefExecutiveoftheTrustidentified25patientswhowerehavingtreatmentwhichmaynothavebeenofasufficientstandard.Thesepatientswereofferedarevisedtreatmentplan.Thedoctorinquestionwasinhisfirstyearofconsultantpractice.TheTrusthasdecidedtodevelopaninductionprogrammefornewconsultants.
Appendices
38TheuseoflocumdoctorsbyNorthernIrelandHospitals
Appendix 1: Structure of Northern Ireland Health and Social Care Trusts
Current Trust Trusts prior to 1 April 2007
BelfastTrust BelfastCityHospitalTrust
GreenparkTrust
MaterHospitalTrust
NorthandWestBelfastTrust
RoyalGroupofHospitalsTrust
SouthandEastBelfastTrust
NorthernTrust CausewayTrust
HomefirstCommunityTrust
UnitedHospitalsTrust
SouthEasternTrust DownLisburnTrust
UlsterCommunityandHospitalsTrust
SouthernTrust ArmaghandDungannonTrust
CraigavonAreaHospital
CraigavonandBanbridgeCommunityTrust
NewryandMourneTrust
WesternTrust AltnagelvinTrust
FoyleTrust
SperrinLakelandTrust
TheuseoflocumdoctorsbyNorthernIrelandHospitals39
Appendix 2: Health and Social Care Hospitals in Northern Ireland
ACUTE:
1. AltnagelvinAreaHospital
2. AntrimAreaHospital
3. BelfastCityHospital
4. CausewayHospital
5. CraigavonAreaHospital
6. DaisyHillHospital
7. DowneHospital
8. ErneHospital
9 LaganValleyHospital
10. MaterInfirmorumHospital
11. MusgraveParkHospital
12. TheRoyalGroupofHospitals:
–RoyalJubileeMaternityService;
–RoyalDentalHospital;
–RoyalBelfastHospitalforSickChildren;
–RoyalVictoriaHospital.
13. UlsterHospital
Non Acute:
14. ArdsCommunityHospital
15. ArmaghCommunityHospital
16. Banbridge–(OutpatientsandDaycases)
17. BangorCommunityHospital
18. BluestoneUnit(MentalHealth)
19. DalriadaHospital(Community)
20. DownshireHospital(MentalHealth)
21. ForsterGreenHospital(NonAcute–Neurology&Elderly)
40TheuseoflocumdoctorsbyNorthernIrelandHospitals
Appendix 2: Health and Social Care Hospitals in Northern Ireland
Non Acute (Continued):
22. GranshaHospital(MentalHealth)
23. HolywellHospital(MentalHealth)
24. KnockbrackenMentalHealthServices(AcutePsychiatric)
25. LakeviewHospital(MentalHealth)
26. Longstone(LearningDisability)
27. Lurgan-Non-AcuteInpatients,DayCareandOutpatients
28. MidUlsterHospital
29. MoyleHospital(Community)
30. MuckamoreAbbey(LearningDisability)
31. Mullinure(GeriatricMedicine)
32. RobinsonHospital(Community)
33. ShaftesburySquareHospital(Drugs&Alcohol,Counseling)
34. StLuke’sHospital(MentalHealth)
35. SouthTyrone-Non-AcuteInpatients,DayCases,DayCareandOutpatients
36. ThompsonHouse(Physical&SensoryDisability)
37. TyroneCountyHospital(Community)
38. Tyrone&FermanaghHospital(MentalHealth)
39. WhiteabbeyHospital
TheuseoflocumdoctorsbyNorthernIrelandHospitals41
Appendix 3: The Cost of Agency and Internal Locums in Northern Ireland 2007-08 to 2010-11
2010/11
HSC Trust Agency Locum
£ million
Internal Locum£ million
Total Locum Costs
£ million
Cost of permanent doctors working contracted hours
£ million
Total Doctor Costs
£ million
Agency Locum costs as % of Total Medical
costs£ million
Total Locum costs as % of Total Doctor
costs£ million
Belfast 5.6 1.8 7.4 145.3 152.7 3.67% 4.85%
Northern 4.0 2.0 6.0 46.9 52.9 7.56% 11.34%
SouthEastern
1.8 0.5 2.3 47.1 49.4 3.64% 4.66%
Western 7.9 1.1 9.0 45.0 54.0 14.63% 16.67%
Southern 3.2 1.2 4.4 51.8 56.2 5.69% 7.83%
Total 22.5 6.6 29.1 336.1 365.2 6.16% 7.97%
2009/10
HSC Trust Agency Locum
£ million
Internal Locum£ million
Total Locum Costs
£ million
Cost of permanent doctors working contracted hours
£ million
Total Doctor Costs
£ million
Agency Locum costs as % of Total Medical
costs£ million
Total Locum costs as % of Total Doctor
costs£ million
Belfast 5.5 2.6 8.1 148.0 156.1 3.5% 5.19%
Northern 5.4 2.7 8.1 44.7 52.8 10.23% 15.34%
SouthEastern
2.2 0.5 2.7 47.4 50.1 4.39% 5.39%
Western 5.1 1.9 7.0 44.6 51.6 9.88% 13.57%
Southern 2.4 2.5 4.9 43.5 48.4 4.96% 10.12%
Total 20.6 10.2 30.8 328.2 359.0 5.74% 8.58%
42TheuseoflocumdoctorsbyNorthernIrelandHospitals
Appendix 3: The Cost of Agency and Internal Locums in Northern Ireland 2007-08 to 2010-11
2008/09
HSC Trust Agency Locum
£ million
Internal Locum£ million
Total Locum Costs
£ million
Cost of permanent doctors working contracted hours
£ million
Total Doctor Costs
£ million
Agency Locum costs as % of Total Medical
costs£ million
Total Locum costs as % of Total Doctor
costs£ million
Belfast 4.5 2.9 7.4 137.0 144.4 3.1% 5.12%
Northern 4.9 2.7 7.6 41.4 49.0 10.00% 15.51%
SouthEastern
2.4 0.7 3.1 43.0 46.1 5.21% 6.72%
Western 3.3 1.9 5.2 43.0 48.2 6.85% 10.79%
Southern 1.9 2.8 4.7 41.6 46.3 4.10% 10.15%
Total 17.0 11.0 28.0 306.0 334.0 5.09% 8.38%
2007/08
HSC Trust Agency Locum
£ million
Internal Locum£ million
Total Locum Costs
£ million
Cost of permanent doctors working contracted hours
£ million
Total Doctor Costs
£ million
Agency Locum costs as % of Total Medical
costs£ million
Total Locum costs as % of Total Doctor
costs£ million
Belfast 3.6 2.9 6.5 126.0 132.5 2.7% 4.91%
Northern 4.7 37.1 41.8 11.24% 11.24%
SouthEastern
1.4 0.8 2.2 40.0 42.2 3.32% 5.21%
Western 2.4 2.3 4.7 39.6 44.3 5.42% 10.61%
Southern 1.5 1.4 2.9 37.0 39.9 3.76% 7.27%
Total 13.6 7.4 21.0 279.7 300.7 4.52% 6.98%
TheuseoflocumdoctorsbyNorthernIrelandHospitals43
Appendix 4: Audit Methodology
ThisreportconsidersthearrangementsinplaceacrossTruststomanagethedemandforlocumdoctorsandthoseforsafeguardingpatientsafety.
OurreportfocusesontheuseoflocumdoctorsbyacuteandcommunityhospitalsbutdoesnotextendtotheuseofGPlocumsintheprimarycaresector.
AttheoutsetoftheauditwewrotetotheDepartmentoutliningourinterestinthefollowingareas:
• theexpenditureincurredineachoftheacuteandcommunityhospitalsinNorthernIreland;
• theusageoflocumdoctorswithinTrusthospitals;
• theworkforceplanningmethodologiesoperatedbyTrusthospitals;
• theextentofTrustcompliancewithlocumpre-employmentprocedures;and
• thequalityofappraisalproceduresinplacetoassesstheperformanceoflocumdoctors.
WeundertookarangeofinterviewswithkeypersonnelwithineachTrust.
InformationprovidedtousbyindividualTrustsinrelationtothecostofinternallocumswaslimited.TheinformationwassubsequentlyrequestedfromTrustsbytheDepartment.FollowingtherequestfromtheDepartment,Trustscarriedoutsomeinterrogationoftheirmanagementinformationsystemsandprovidedtheinformationrequired.GiventhetimetakenfortheDepartmenttoproducethecostinformation,itwasnotpossible
forustoundertakeanyvalidationworktoassesstheaccuracyoftheinformationcontainedintheTrustspreadsheets.
WeexaminedvariousDepartmentalpoliciesrelatingtotheemployment,monitoringandappraisaloflocumdoctorsinhospitalsandwereviewedrelevantInternalAuditworkacrosstheTrusts.
WealsoreviewedthedetailofthoseSeriousAdverseIncidentswhichinvolvedlocumdoctors.
44TheuseoflocumdoctorsbyNorthernIrelandHospitals
Appendix 5: Implications of the EU Working Time Directive
TheEuropeanCommissionintroducedtheWorkingTimeDirectivetoNorthernIrelandin1998toworkalongsidememberstatesemploymentlaws.Itisprimarilydesignedtosafeguardworkersrightsbyputtingalimitonthenumberofhoursthatshouldbeworkedeachweek.Somegroupsofworkerswereinitiallyexcludedfromtheseregulations,howeverfromAugust2004theprovisionsoftheDirectivehavebeguntobeappliedtodoctorsintrainingintheUK.Legislationlimitedjuniordoctorsworkinghourstoa58hourweek,withstrictarrangementsforrestrequirements.FromAugust2007theworkingweekwasfurtherlimitedto56hoursofworkperweekuntilthefullimplementationofthedirectiveinAugust2009,limitingtheworkingweekto48hours.
Inthepast,hospitalsusedjuniordoctorsextensivelyformedicalcoverduringunsocialhours.TheconsensusofallNorthernIreland’sTrustswasthattheprogressiveimplementationoftheWorkingTimeDirectivehashad,andwillcontinuetohave,profoundeffectsonthedeliveryandcontinuityofmedicalcare,andondoctorsintraining.Thereisalargedegreeofpressurenowtoprovideextracover(includingusinglocums)toensurejuniordoctorworkinghoursandrotapatternsarecompliantwiththeDirective.Consultantsreportedthattheyhavehadtoprovidemoreservicecoverduringunsocialhours,thusreducingavailabilityduringthedayandinturnrequiringfurtherexpansionofconsultantnumbers.
TheuseoflocumdoctorsbyNorthernIrelandHospitals45
Appendix 6: Medical Demand and Supply Problems Identified by the Department
Review of Workforce Planning for the Medical Profession (September 2006)
Speciality Demand and Supply Problems
Anaesthetics TherearealargenumberofunfilledpostsinNorthernIrelandandthereisaneedforincreasedconsultantnumbers.
Ear,NoseandThroat(ENT)
ConcernwasexpressedattheunevengeographicdistributionofENTconsultantsrelativetothepopulationserved.Earlierretirementsarepredictedforthefutureandthereareincreasesinlevelsofmaternityleave,familyleaveandrequestsforpart-timeworking,attributedtoahighratiooffemalesinthisarea.IncreaseddemandforENTserviceswasresultingfromGPsnotbeingadequatelytrainedinENT.Itwasestimatedthatatleast30%ofoutpatientsdonotneedtobeseen,resultinginalargenumberofunnecessaryreferralscloggingout-patientlists.
MedicalPaediatrics
ThereisahighfemaletomaleratiowithinPaediatricsanditislikelythattherewillbeanincreaseddemandforflexibleworkingpatterns.Duetothehighlevelofon-callrequirement,itispredictedthatmanyconsultantswillnotworkmuchpasttheageof55.Peripheralhospitalsarefacingdifficultiesinfillingposts.Forexample,theErnehospitalhashadtorecruitincreasingnumbersofnonNorthernIrelandtraineddoctorswhoonlyintendtoremaininpostforashortperiodoftime.
CommunityPaediatrics
Significantdepletionoftheworkforceispredictedgiventheageprofileofthecurrentworkforceandexpectedretirementswithinthenext10years.ThemajorityofTrustshavehaddifficultyrecruitingstaffoverrecentyears.Aneedwasidentifiedtoincreasetrainingatbothundergraduateandpostgraduatelevel.
Neurology FindingsfromtheAssociationofBritishNeurologistshashighlightedshortagesofneurologistsinNorthernIreland:- intheUSAthereisoneconsultantper20,000ofpopulation- inNorthernIrelandthereisoneconsultantper100,000ofpopulation- therearefewerconsultantneurologistsperheadofpopulationinNorthernIreland
thaninmanyotherpartsoftheUnitedKingdom.
Oncology ThedemographictrendswithinNorthernIrelandmeanthattherewillbeagreaternumberofpeopleaged70yearsplusandthereforeahigherfrequencyofcancerincidents.Therewillbegreaterdemandforoncologyconsultantsinthefuture.TheWorkforcePlanidentifiedhaematologyasunder-resourced.TheDepartmentisworkingtotheRoyalCollegeofPhysiciansrecommendationofoneconsultantper250patients.TheUSAratioisoneconsultantper100patients.
46TheuseoflocumdoctorsbyNorthernIrelandHospitals
Appendix 6: Medical Demand and Supply Problems Identified by the Department
Speciality Demand and Supply Problems
Ophthalmology AgeingpopulationisasignificantfactorforOphthalmology.TheRoyalCollegeofOphthalmologistshaverecommendedoneconsultantper50,000to70,000ofpopulation.NorthernIrelandcurrentlysitsatoneconsultantper100,000ofpopulationandwouldneedtoincreasefrom23.5to30tomeetthisratio.TheretirementageofconsultantOphthalmologistshasdecreasedby2-3yearsoverrecentyears.Inadditionthereisahighnumberoffemaleswithinthespeciality,withanincreaseddesiretoworkpart-time,therebycreatingdemandsforextrastaff.
Orthopaedics AnageingpopulationonceagaincreatesgreaterdemandforOrthopaedicservices.NorthernIrelandsitsasaregionwithintheUKwiththelowestConsultantorthopaedicnumbersperheadofpopulation.TheWorkforcePlanidentifiedashortageof40%fromthetargetnumberofconsultants.
Pathology Pathologyisperceivedasalessattractivespecialitythanotherswithnotenoughtraineescomingthroughthesystem.
CommunityCare
ThePlanidentifiedsupplyissuesatTrustlevelandcontinuingrecruitmentdifficultieswerereportedinthewestofNorthernIreland.
Psychiatry ThePlanestimatedthatapproximately120consultantswillberequiredoverthenextfewyears.Thereisahigherproportionoffemalestaffwhichimpactsonworkforcelevelswithhigherlevelsofbreaksofemploymentduetocaringresponsibilities.TheEuropeanWorkingTimeDirectiveishavinganimpactontheabilityoftheprofessiontoprovidenightcoverduetotherelativelysmallsizeoftheworkforce.
Radiology Thereisagreaterdemandforradiologyservicesandthereisasignificantworkforcedeficit.Itisestimatedthattherewillbe80consultantvacanciesoverthenext10years.
TheuseoflocumdoctorsbyNorthernIrelandHospitals47
Appendix 7: Good Practice Examples identified from the NHS Employer’s publication “Controlling the use of temporary staff through large scale workforce change”
Example 1: Kingston Hospitals NHS Trust
KingstonHospitalisanacutegeneralhospitalservingapopulationofaround320,000insouth-westLondon.Itfacessimilarpressurestomanycitycentrehospitalsinhighdemand(ithasoneofthehighestlevelsofdaysurgeryinthecountry)andatransientworkforce.
Issues identified• ahighexpenditureonmedicallocumsacrossthetrust,notablyseniorhouseofficers(SHOs)inthe
AccidentandEmergency(A&E)department• agenciesoutsidethoseoutlinedintheNHSPurchasingandSupplyAgency(PASA)national
frameworkwereregularlybeingused• excessivedelaysintherunningofCriminalRecordsBureaucheckswerecausingpotentialrecruits
tobelosttootheremployers• lackofappropriateauthoritylevelsinthebookingofmedicallocums-bookingswerenot
challengedorvetted• lackofcentralcontrolinbookingmedicallocumsandcontrollingexpenditure-eachdepartment
wasusingitsownsuppliersandproceduresforbooking• lackofusefulintelligenceonmedicallocumusageandspend.
Aims• todevelopamastervendorsystemincollaborationwithothertrusts• toreducespendonmedicalandAlliedHealthProfessional(AHP)agencystaff.
Implementation• establishedaconsortiumwithothertrustswithsharedgoalsandcommitments,todrivedown
agencycoststhroughcombinedspendingpower• pilotedtheuseofapreferredagency(mastervendor)inA&Etoassesstheimpactonexpenditure
andfurtherdeveloptheconcepttorolloutacrossthetrust• establishedprotocolsforbookinglocumsandmeasuringcomplianceagainstexpenditure/use.• establishedfinancialcontrolsforbookingofmedicallocums(forexample,higherlineofauthority
for‘requesting’signatureandfor‘authorisingpayment’signature)• centralisedbookingarrangementsthroughonesourcewithinthetrust-andcombinedthiswiththe
operationforbookingnursebankstaff• developedtheHarlequinITsystem(alreadyusedforthenursebank)andintroduceditfor
managingmedicallocumandAHPbookings• improvedmanagementinformationonmedicallocumusetoallowmanagerstoauditandquery
useofmedicallocumsmoreeffectively
48TheuseoflocumdoctorsbyNorthernIrelandHospitals
Appendix 7: Good Practice Examples identified from the NHS Employer’s publication “Controlling the use of temporary staff through large scale workforce change”
• recruitedstaffbookedthroughtheagencyontothetrustbank• educatedthecoordinatorsofrotasandrotaplanning.
Improvements delivered:
Collaborative workingThetrustnegotiatedwithexternalagenciesincollaborationwiththreeothertrusts.Aswellassecuringmorefavourablerates,trustssharedgoodpracticewitheachotherandenhancedtheirprojectwork.
Developing a master vendorIncollaboration,thetrustdevelopedamastervendornetworkacrossthestrategichealthauthoritytoprovideapreferredsupplierfornursingagencies(andlaterforotherstaffgroups).Theincreasedspendingpoweroffourtrustsprovidedgreaterleverageindrivingdowncosts,improvingtheservicetothetrustand,inaddition,thesupplierwasabletoprovidevaluablemanagementinformationonuse.Themastervendorguaranteestofillvacanciesrequested(againstanagreedfillrate)andwillcontactsecondaryagenciesifunabletofilltheshiftthemselves.Inaddition,becausetheycanrelyonaguaranteedincomefromthetrust,thesupplierisabletojustifyprovidingdedicatedstaffsupportfordealingwiththetrustsneeds.Asaresultofthesechangesthespendingonagencynurseswasreducedfromapproximately£2.8mtoaround£1.0mperannum-asavingof£1.8mforthetrustacrosstheyear.
FromJanuary2006thefirst‘true’mastervendoragreementstarted,withasinglesupplierfornursing,medicalandAHPs.Thisgaveafurtherreductionof26percent,whichequatesto£260,000perannumacrossthetrust.
Management control for medical locums and AHPsThetrustintroducedtightercontrolsontheauthorisationforbookingtemporarystaffandchangedthecultureofacceptancefortheneedforabooking.BookingsarenowcentralisedthroughasinglefunctionandthetrusthasdevelopeditsHarlequinITsystemtomanagemedicallocumandAHPbookings.Agencyspendonthesestaffgroupsreducedfrom£1.8mperannumtolessthan£1.0m.
Clinical and administrative staffByhavingasinglepointofcontactandasingleexternalsupplier(ratherthanmorethan20agencies),clinicalstaffsavedconsiderabletimeonbookingshifts.Clinicaltimepreviouslyspentcontactingfiveorsixagenciestosecureabookingisnowsavedbycontactingthemastervendoronly.Sincethemastervendorpayssecondaryagenciesandtheninvoicesthetrustforallcosts,thissavesadministrativetimeinprocessingmultipleinvoices.Inaddition,themanagementinformationthatthemastervendorwasabletoprovidesavedonadministrativetimeforthetrust.
TheuseoflocumdoctorsbyNorthernIrelandHospitals49
Improving working livesItisanidentifiedfactorthatshiftfillrateshaveamarkedeffectonstaffmorale.Whenstaffareexpectedtodeliverservicesinashiftwithareducednumberofstaffonduty,moraleoftenfallsasaresult.Themastervendorschemesetupguaranteesa90percentfillrateforthetrustandthisratehasinfactbeenbetteredsincetheschemewasintroduced.Thisledtoincreasedstaffmorale.
Kingston Hospital. Annual spend on medical locums and Allied Health Professionals 2005-06
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
After master vendor agreement implemented (Jan 06)
After controls in placePrior to project
mill
ion
Example 2: East Kent Hospitals NHS Trust
EastKentHospitalsNHSTrustisoneofthelargesthospitaltrustsinEngland,withfivehospitalsandseveraloutpatientfacilities.Thetrusthasundergoneamajorservicereconfigurationprogrammeinvolvingextensivebuildsatthreeofitssites.
Issues identified
• thetrusthadarisingspendonmedicallocumusage• somelocumsweresuppliedthroughhigh-costagenciesandoutsideofthePASAframework• therewasalackofcontrolinsomedirectorateswithconsultantsbookingtheirownmedicallocums
withoutauthorisation• therewaslittleornocheckingofinvoicesformedicallocumsoncesubmittedforpayment• anumberofpositionsreliedonhigh-costmedicallocumstofillvacancies,andthesehadnotbeen
reviewedforsometime.
50TheuseoflocumdoctorsbyNorthernIrelandHospitals
Appendix 7: Good Practice Examples identified from the NHS Employer’s publication “Controlling the use of temporary staff through large scale workforce change”
Aims• tocentraliselocumbookingarrangementsindirectorates,withtheexceptionofA&E,anaesthetics
andradiology,witheffectfrom1September2005• torevieweachhigh-costagencylocumwithaviewtoidentifyingthebestwaytoreducecostsby
oneoracombinationofactions
Implementation
Locum bookingArevisedpolicyforemploymentoflocummedicalstaffwasapprovedbytheclinicalmanagementboardandwasimplementedon1September2005.Bookingswerecentralisedthroughareportingmechanismtoasinglepointofcontact.Bookingsarenowmadeforclinicalcareonlyandmustbecapableofclinicaljustification.
Directphonecallstoagenciesfromwardswerebanned,thephonenumberwasblockedthroughtheswitchboardandout-of-hoursbookingsweredonethroughon-callexecutivedirectors.Theseon-calldirectorsadheredtoastrictprotocolinlinewithanewbookingpolicyagreedatboardlevel.Administrativeguidancenoteswereissuedtoallstaffforimplementingthenewpolicyanduniquereferencenumberswereissuedtoeachauthorisedbooking-onlyinvoicesbearingthisnumberwerepassedforpayment.
Thejobplansofsubstantivedoctorswereanalysedandlocumswerenotauthorisedwherethetrust’sowndoctorswereduty-boundtoprovidecover.
Thecoreprojectteamreviewed,studiedandactedonissuesraisedonafortnightlybasistotheendoftheproject.Thiswasespeciallyimportantintheearlyphases.
Individual high-cost agency locumsEachhigh-costlocumplacementwasreviewedandastrategytoreducecostwasadopted.Poststhathadreliedonagencylocumsforseveralmonthswerere-advertisedandNHSlocumsfavouredoveragencylocums.AgencylocumswereencouragedtotransfertoNHScontracts.NHSProfessionalswassoughtasacheaperalternativeifthetrustwasunabletomakesubstantiveappointments.
Annualandstudyleaveperiodswereimposedforlocumswhereprospectivecoverarrangementsapplied.Invoiceswerecarefullyscrutinisedtoensurehoursworkedandclaimedwereconsistentwiththeoriginalhoursbookedwiththeagency,andcostswerecappedtotheratesagreedundertheagencyframeworkagreement.
Dataonlocumusagewascollectedandanalysedandafortnightlyreviewcarriedout.Directorateswithhighusageweretargetedforinterventionandactionplanswitheachdirectoratewereagreed.
TheuseoflocumdoctorsbyNorthernIrelandHospitals51
Improvements delivered• decreaseinbothuseandoverallspendonmedicallocumssinceSeptember2005,whenchanges
werefirstimplemented.Previousyear’saveragemonthlycostswere£548,400(September2004toAugust2005)
• thetargettoreduceexpenditureto£490,000permonthwasbettered.Spendreducedtounder£270,000permonth(September2005toMay2006)-asavingofover£278,000permonth
• ifthissavingweresustainedacrosstheyear,itwouldequatetoanannualsavingofover£3.3millionfortheyear(seegraph)
• thetrustidentifiedseasonalfluctuationsandcannowplantocoveranyknownandpredictabledemand(suchasmedicalexaminations).
East Kent Hospitals NHS Trust: monthly spend on medical locums 2005/06
£70
£120
£170
£220
£270
£320
£370
£420
£470
£520
£570
£620
£670
£720
£770
Target Mothly average Sept 2005to May 2006
Monthly averageSept 2004 to Aug 2005
Monthly agencyspend Sept 2005to May 2006
Monthly agency spend Sept 2004to Aug 2005
AugJulJunMayAprMarFebJanDecNovOctSept
Spen
ding
(£00
0s)
52TheuseoflocumdoctorsbyNorthernIrelandHospitals
Appendix 8: Regionally Managed Medical Locum Service for Northern Ireland
TheRegionallyManagedMedicalLocumService(RMMLS)representsacollectiveeffortbyTrustswithinHSCNItomoreeffectivelymanageexpenditureassociatedwiththeuseoflocumdoctorsinNorthernIreland.
IndividuallyHSCTrustshavebeentakingforwardinitiativestoseektomoreeffectivelymanagetheuseandexpenditureassociatedwithlocumdoctors.ThisprojectpresentsanopportunitytopoolthecollectiveinputsofTrustsandtheBSOtodeveloparegionallyco-ordinatedandmanagedapproachtolocumcoverwithinthecontextofsharedservices.
DiscussionshavetakenplaceacrosstheHSConhowtoregionallytackletheincreasingspendonLocums.TheoutcomeoftheseconversationswastheformationofaHumanResourceledRegionalMedicalLocumGroupcomprisingrepresentativesfromeachTrust(usuallythemedicalHRorrelevantrecruitmentstaff)totakethisforward.
TheRegionalMedicalLocumGrouphasproducedaplantoaddresstheescalatingagencyLocumspendwhichreflectstheneedforacoordinatedregionalapproachtothemanagementoflocumdoctors.Intheshorttermtheimmediateactionistheestablishmentofaregionaldatabasetorecordthedetailsoflocumdoctors,pre-employmentchecks,shiftsworked,anyidentifiedperformanceissuesetc.
Inthemediumtermopportunitiesexistthroughthisprojecttoutilisetheregionaldatabaseasatooltosupportthemanagementoflocumsonaregionalbasisi.e.thesourcingandplacingoflocumdoctorsviaasharedservice.
Inthelongertermthisprojectalsoprovidesavehicletosupporttheprocessesassociatedwith
themanagementofrevalidationofmedicallocumsandthedischargingoftheResponsibleOfficerfunctionforlocumdoctorswhoarenotemployedonafull-timebasisbyaTrusti.e.careerlocums.Thepurposeofrevalidation,whenitisintroduced(currentprojectionsaremid-2012),willbetoassurepatientsandthepublic,employersandotherhealthcareprofessionalsthatlicenseddoctorsareuptodateandarepractisingtothestandardsdefinedby Good Medical Practice31.
Thedevelopmentoftheresponsibleofficerrole(whichwasimplementedinNIinOctober2010)ispartofwiderangingregulatoryreformsetoutintheWhitePaperTrust, Assurance and Safety32.InNorthernIreland,thesereformsarebeingtakenforwardthroughtheDHSSPSConfidence in Care programme.
ThetermsofreferencefortheRegionallyManagedMedicalLocumService(RMMLS)havebeeninformedbytheMedicalLocumRegionalWorkingGroupandreflectthestreamingandpriorityofactivitiestobeundertaken.Thetermsofreferenceundereachoftheprojectworkstreamsaresetoutbelow.
Workstream 1 – Development of the Regional Locum Registration Process and Database (Timescale-Short Term)
• Definethestrategy,scopeandoperationalrequirements/arrangementsofthecentralmedicallocumregistrationprocessanddatabase.
• Developthegovernance,accountabilityandadministrationarrangementsforsame.
31 GoodMedicalPractice–FrameworkforAssessmentandAppraisal,TheGeneralMedicalCouncil,November200632 Trust,AssuranceandSafety:TheRegulationofHealthProfessionalsinthe21stCentury:TSO,February2007
TheuseoflocumdoctorsbyNorthernIrelandHospitals53
• Securefundingfordevelopmentofthecentraldatabase.
• AgreethehostingorganisationandtheoperationalframeworkfortheRegionalLocumRegistrationprocessandDatabase
• Designthespecificationintermsofcontent,operationalrequirementsandcapabilitiesoftheregistrationsystemanddatabase,togetherwiththepracticalaccessarrangementsinaccordancewithdataprotectionrequirements.
• Commissiontheconstructionofthesystem.
• Producetheoperationalregistrationprocessanddatabasewithaccompanyingmechanismsforfeedbackandreviewtocontinuallyensureserviceimprovement.
• PlanimplementationarrangementsensuringthatbothlocumsjoiningtheschemeandtheTrustsusingtheschemeareclearonoperationalarrangements,haveaccesstoinformationonoperationalarrangements,haveaccesstooperationalinstructionsanda‘helpdesk’facility(likelytobeoneforeachTrustinitially).
• CommencethephasedregistrationofLocums.
• ‘Golive’withtheregionallocumdatabase.
Workstream 2 – Shared Service Model for Employment and Management of Locums and service provision to the HSC stakeholders (Timescale-Medium Term)
• DeveloptheoperationalmodeltosupportthemanagementoflocumsundertheumbrellaofBSO,SharedServicesensuringthat
thereisclarityregardingtheemploymentarrangementsofmedicallocumsincludingallrelatedissues(suchassafeguardingchecks,paymentetc)andhowTrustswillaccess,useandpayforthisservice.
• Developthegovernance,accountability,andperformancemanagementarrangementsfortheproposedsharedservicesmodelforthemanagementoflocums
• Developandseekapprovalforthebusinesscasefortheprovisionofsharedservicesforlocumdoctors
• Implementthemodelforsharedservicesforlocumdoctors
Workstream 3 – Development of Regional Contract for the Provision of Locum Services from Agencies (Timescale-Medium Term)
• TheBSOwillworkwithTrustcolleaguesinthegrouptowardsthedevelopmentofasingleregionalcontractwithAgenciesthroughwhichagencylocumservicescanbesecured(shouldtherequiredlocumcovernotbeavailableviatheSharedServiceforlocums).Thiswillinvolvethedevelopmentofadraftcontractandtheassociatedcontentofsame.
Workstream 4 – Revalidation/RO Support for Locums (Timescale-Medium/Long Term)
• InconjunctionwiththeDHSSPSConfidence in Care ProgrammedevelopandimplementthearrangementstosupportthedischargeofResponsibleOfficerfunctionsforthoselocumdoctorsnotemployedbyaTrust
54TheuseoflocumdoctorsbyNorthernIrelandHospitals
• InconjunctionwiththeDHSSPSConfidence in Care Programmedevelopandimplementthearrangementstosupportrevalidation(includingappraisal)forthoselocumdoctorsnotemployedbyaTrust
Appendix 8: Regionally Managed Medical Locum Service for Northern Ireland
TheuseoflocumdoctorsbyNorthernIrelandHospitals55
Title Date Published
2010
CampsieOfficeAccommodationandSynergye-BusinessIncubator(SeBI) 24March2010
OrganisedCrime:developmentssincetheNorthernIrelandAffairs 1April2010CommitteeReport2006
MemorandumtotheCommitteeofPublicAccountsfromtheComptrollerand 1April2010AuditorGeneralforNorthernIreland:Combatingorganisedcrime
Improvingpublicsectorefficiency-Goodpracticechecklistforpublicbodies 19May2010
TheManagementofSubstitutionCoverforTeachers:Follow-upReport 26May2010
MeasuringthePerformanceofNIWater 16June2010
Schools’ViewsoftheirEducationandLibraryBoard2009 28June2010
GeneralReportontheHealthandSocialCareSectorbytheComptroller 30June2010andAuditorGeneralforNorthernIreland–2009
FinancialAuditingandReporting-ReporttotheNorthernIrelandAssemblyby 7July2010theComptrollerandAuditorGeneral2009
SchoolDesignandDelivery 25August2010
ReportontheQualityofSchoolDesignforNIAuditOffice 6September2010
ReviewoftheHealthandSafetyExecutiveforNorthernIreland 8September2010
CreatingEffectivePartnershipsbetweenGovernmentandtheVoluntaryand 15September2010CommunitySector
CORE:Acasestudyinthemanagementandcontrolofalocaleconomic 27October2010developmentinitiative
ArrangementsforEnsuringtheQualityofCareinHomesforOlderPeople 8December2010
ExaminationofProcurementBreachesinNorthernIrelandWater 14December2010
GeneralReportbytheComptrollerandAuditorGeneralforNorthern 22December2010Ireland-2010
NIAO Reports 2010-2011
56TheuseoflocumdoctorsbyNorthernIrelandHospitals
Title Date Published
2011
CompensationRecoveryUnit–MaximisingtheRecoveryofSocial 26January2011SecurityBenefitsandHealthServiceCostsfromCompensators
NationalFraudInitiative2008-09 16February2011
UptakeofBenefitsbyPensioners 23February2011
SafeguardingNorthernIreland’sListedBuildings 2March2011
ReducingWaterPollutionfromAgriculturalSources: 9March2011TheFarmNutrientManagementScheme
PromotingGoodNutritionthroughHealthySchoolMeals 16March2011
ContinuousimprovementarrangementsintheNorthernIrelandPolicingBoard 25May2011
Goodpracticeinriskmanagement 8June2011
UseofExternalConsultantsbyNorthernIrelandDepartments:Follow-upReport 15June2011
ManagingCriminalLegalAid 29June2011
NIAO Reports 2010-2011
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