The challenge of locum working arrangements in New South Wales public hospitals

The use of locum medical officers to fill resident and registrar shifts in the New South Wales public hospital system has increased markedly in recent years.1 Doctors providing locum services to hospitals include recent medical graduates, specialist trainees, and experienced clinicians who have worked previously in the hospital system as career medical officers. A proportion of doctors undertake locum shifts in addition to full-time hospital positions. Locum medical officers can be used to temporarily replace permanent staff on leave, but are increasingly used to manage chronic vacancies, with appointments ranging from days to years. Hospitals in other Australian states, New Zealand and the United Kingdom are also increasingly dependent on casual medical labour.1

Changes in the nature of medical work and the medical workforce have created a doctor shortage in Australia.2 The shortfall is most keenly felt in certain specialties (emergency medicine, psychiatry) and parts of the health system (public metropolitan, regional and rural hospitals). In February 2004, there were an estimated 906 vacancies for trainees and non-specialist doctors in NSW hospitals, 348 of which were in emergency medicine (unpublished preliminary results of the NSW Health Medical Officers Workforce Data Collection 2004 medical survey, January 2005).

Public hospitals in NSW have traditionally relied heavily on recent medical graduates and specialist trainees to perform day-to-day clinical work. The junior medical workforce has changed significantly in the past two decades. The introduction of graduate medical programs across Australia in the mid 1990s means that medical graduates are now older, are more likely to have partners and dependants when they begin their medical career, have higher levels of debt than previous generations, and have experience of other workplaces.3 Career decisions are greatly influenced by personal, family and financial needs, with graduates more attracted to procedural specialties with high private income expectations than to generalist, hospital-based disciplines.4 Female medical graduates now outnumber males, but doctors of both sexes are increasingly electing to work fewer hours, reflecting broader community preferences for balancing work and private life.5

Patterns of medical work have also changed. Regulation of working hours and introduction of safe-staffing formulae have increased the number of doctors necessary to provide adequate medical care. More high-intensity work is occurring after hours. Many specialties have exchanged call-back arrangements for formal 24-hour rotating rosters, with an expectation that junior doctors will undertake regular after-hours shifts.

Concurrently, regulation of vocational training schemes has increased, with restriction of provider numbers by the federal government in 1996, introduction of the national general practitioner training quota, development of registrar training networks and introduction of capped training times by many specialty colleges.

As larger numbers of practitioners are opting to work fewer hours, demand for public hospital services is increasing.6 NSW emergency departments reported that presentations increased by over 10% in 2005 compared with 2004 (unpublished data, Clinical Services Redesign Program, NSW Health, November 2005). The Australian population is ageing, increasing the burden of chronic disease. Lack of timely access to GPs and community services drives additional patients into the acute hospital system. The public and the media expect 24-hour, immediate, high-level care.

As the demand for clinical services has outstripped medical workforce supply, work intensity has increased. Tension between service and training demands on interns, residents and registrars may affect their ability to develop key cognitive and procedural skills. Morale in the public hospital system is low, with clinicians feeling they lack control over “system issues” such as waiting lists, access block and staff shortages. Often, budget concerns and patient flow improvements are perceived by clinicians as having higher priority than maintaining a high standard of patient care. In many settings, infrastructure, technical and clerical support is inadequate to meet increased patient turnover. Under these conditions, many positive aspects of hospital work are seriously compromised, and locum work, which offers good rates of pay and flexible hours, becomes an attractive alternative.

Use of doctors without vocational training as a temporary hospital workforce poses significant challenges to the NSW hospital system (Box 1). Locum medical officers are not employed pursuant to the Public Hospital (Medical Officers) Award, and can earn up to three times the relevant award rate, with locum agencies charging 10%–15% commission per shift. Skills and experience of locum doctors are variable, and locums are not subject to usual junior medical officer credentialling, training and performance review systems. Locums often lack familiarity with the workplace, local process and protocols, and with other clinical team members. Working hours of locums are not monitored for safety purposes, and the use of locums may affect continuity of care in some inpatient settings.

Employment arrangements for locum medical officers are often ambiguous, and legal relationships between hospitals, locum agencies and individual doctors may be unclear. Responsibility for indemnity, occupational health and safety, supervision and professional development is rarely explicit when a locum doctor is employed.

Perhaps the greatest challenge posed to the hospital system by locum arrangements is the potential impact that diversion of medical graduates into the locum market will have on long-term medical workforce sustainability. While there is a role for locums to fill ad-hoc, short-term vacancies in the hospital system, chronic vacancies in some specialties enable primary locum employment to be an alternative to an accredited training position, potentially reducing the number of specialists available to the public hospital system in the future.

The medical workforce is highly mobile. It is clear that in times of medical workforce shortage, no solution to the problems posed by locum employment will emerge unless broader issues concerning the training structures and working conditions of all junior and middle-level hospital doctors are addressed.

The Greater Metropolitan Clinical Taskforce (GMCT) was asked to examine locum employment arrangements on behalf of the NSW Minister for Health in September 2004. The working group comprised 52 junior and senior clinicians, health administrators, academic advisors, and representatives from key organisations, including the Australian Medical Association, the Postgraduate Medical Council of NSW, the Medical Training and Education Council, the NSW Resident Medical Officers Association and NSW Health. Local and international literature was reviewed. Locum arrangements were further explored through semi-structured interviews with administrators, senior and junior medical officers, nursing staff and recent graduates working as locums (see Box 2). Problems and solutions were workshopped at a weekend meeting. Hospital clinicians and administrators were invited to comment on proposed reforms through a series of open hospital forums. Recommendations developed during this process are shown in Box 3.

NSW Health has given in-principle support to the recommendations of the locum project, and is currently working towards implementing them in association with clinicians, administrators, industrial advisors and medical educators.

A key development is the formation of the NSW Institute of Medical Education and Training, which will provide continuity across prevocational and vocational training, with development of a hospital skills program, aimed at both locum and non-locum doctors, a priority.

Any attempt to regulate the locum medical market must be undertaken with caution. The NSW public hospital system relies heavily on locum medical staff, and overly strict regulation may increase pressure on an already stretched workforce. The challenge is to find an appropriate balance between casual and permanent employment, encourage professional development of all doctors, and support hospitals facing chronic vacancies by applying flexible industrial arrangements and non-financial incentives.