To the Editor: I read with interest the MJA supplement The student and junior doctor in distress — "our duty of care".1 It is encouraging to see the time, effort and research currently being devoted to the health and mental wellbeing of our colleagues.

One aspect of the medical workforce that was not discussed is that of locum doctors, who, in metropolitan and rural New South Wales, are increasingly called upon to staff public hospitals.

Under this system, a doctor registers with a locum agency, hospitals advise the agency (often multiple agencies) of the shifts they need filled, and the agency then sends to all the doctors on their books a list of shifts available. Doctors then choose which shift(s) they would like to work and the agencies supply their names to the hospitals. They are paid by the hospital — the current rate for all doctors, Post Graduate Year (PGY) 1 and upwards, being a minimum of $70–$80 an hour — and the agency receives a 10%–15% commission. In contrast, the base hourly rate for a full-time PGY 1 doctor is $23.11, with a loading of 75% on Sundays and 100% for any hours worked beyond a 10-hour shift.

The only barrier to locum work is that a doctor is unable to have two rates of pay within the one Area Health Service. There is thus a strong incentive for full-time employees to refuse extra overtime work at their own hospital and do locum work at other hospitals. The number of shifts needing to be filled by hospitals increases as Junior Medical Officers choose this option. The current restrictions on access to provider numbers, rather than serving as an incentive to remain in the hospital system, have encouraged many junior doctors to seek locum work.

It is also relevant that, as more graduate students come through the system, more doctors are older and have financial obligations. Many have had good incomes prior to studying medicine and wish to maximise their earnings once they graduate. Wilhelm2 and Mouret3 both observe that financial concerns are a major stressor for Junior Medical Officers.

There are significant disadvantages for the locum doctor (eg, lack of ongoing education from patient follow-up, feedback about mistakes, mentor and peer support; inadequate supervision of "safe working hours") and for the healthcare system (eg, lack of continuity of care; locums' unfamiliarity with the hospital and its procedures; variable skill levels of locums; resentment by regular staff of pay rate discrepancies; cost). While there is no doubt a role for locum doctors within the healthcare system, there is no overall control of the situation.

Locum agencies are businesses that exist to make money for their owners. The hospitals see themselves as paying top dollar for locum doctors and therefore see no obligation to provide training and counselling. The doctors are in the middle.

To protect the doctors and also the hospitals, changes must be considered. Representatives of the NSW Medical Board, Postgraduate Medical Council and Area Health Services need to discuss this issue.