This article appears as part of the Inside the NHS newsletter.
The cost of agency doctors hit the headlines last week after it emerged that NHS Western Isles spent almost £1.2 million in a single year on two locum psychiatrists.
The details emerged as a result of an employment tribunal, but it hints at a wider – and growing – issue.
The case
The problems began for NHS Western Isles when one of its two permanent consultant psychiatrists retired in 2018. Thereafter, the post was advertised eight times with no applicants. The vacancy was filled instead by a locum.
In September 2020, Denitza Mihaylova was appointed as the islands' second consultant psychiatrist – filling the Lewis-based position on a permanent basis. She and her locum colleague provided 24/7 psychiatric cover, including an on-call rota, regular visits to Uist, Harris and Barra, and home visits to patients in crisis across the region.
In September 2021, Dr Mihaylova was diagnosed with myelopathy – a spinal condition that causes back and neck pain. A second locum was hired to cover while she was off sick.
By March 2022, she was beginning a phased return but an occupational health specialist had advised her against doing overnight on-call.
In March 2023 (by which point she was again on sick leave with no certainty that she could ever return to work full-time), the health board terminated her employment.
Dr Mihaylova sued for unfair dismissal but lost her case because the tribunal judge accepted that the health board has "budgetary responsibilities".
Arguably, the only real saving has been Dr Mihaylova's consultant salary. The health board spent £1,073,308 on two locum psychiatrists in 2022/23 (including the one covering for Dr Mihaylova) and is projected to spend £1,179,076 on two locum psychiatrists in 2023/24, the year since her dismissal. This includes the doctors' salaries as well as the hefty fees paid to medical agencies.
Read more:
- Inside the NHS | Is there any point in giving patients ‘rights’ that the NHS cannot enforce?
- 'Dangerous' psychiatry shortages as quarter of consultant posts in Scotland vacant
- 'Still a lot of fear': Top doctor blames NHS Highland 'dysfunction' for doctor exodus
The context
Across NHS Scotland, spending on medical and dental agency staff has increased 77%, from £67.4 million in 2013/14 to £119.6m in the year to March 2023.
Psychiatry accounts for a significant percentage: 20% of consultant psychiatrist posts are filled by locums.
The true scale of the shortfall is not always clear, however. Official statistics do not count posts as "vacant" if a locum is in place. Previous research by BMA Scotland, in 2022, found that – when they were – the consultant vacancy rate doubled from 6.2% to 14.3%.
Freedom of information data passed to The Herald by mental health campaigner Peter Todd also shows that NHS spending on all locum psychiatrists (not only consultant-level) has gone up by 29% from just under £21m in 2019/20 to more than £27m in 2023/24.
The true cost will be higher, however, as several health boards only provided data for the first nine or 10 months of last year.
The solution?
Over-reliance on locums is an expensive problem for the NHS, but the implications go beyond money.
It can mean a lack of continuity of care for patients, which is associated with poorer outcomes. Temporary medics are also less likely to be invested in improving local services, and – unlike permanent consultants – cannot provide training to junior doctors.
Locums will always be needed to cover sick leave, but the best fix is retention and that is mostly down to the workplace culture.
It could mean more flexibility around job plans to persuade senior clinicians to stay on instead of retiring early.
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All too often, however, issues such as bullying or victimisation of whistleblowers have led to experienced doctors quitting one after the other from the same department or hospital, leading to services which are disproportionately dependent on locums.
The Herald's recent Health Summit also heard suggestions for a "weighting" model that could offer doctors substantially higher salaries if they relocated to areas such as the Highlands and islands where shortages are most acute.
There are no easy answers but the current situation is not a financially sustainable one.
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