Locum doctors putting patients 'at risk'

THE heavy reliance on locum doctors by NHS hospitals in the UK is putting the safety of patients at risk, a senior Scottish physician has warned.

• Picture: PA

Many wards rely on locums - temporary workers often trained overseas and supplied by agencies - to cover gaps in their rotas caused by staff shortages, sickness and other absences.

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But Professor Chris Isles, based at Dumfries and Galloway Royal Infirmary, has expressed concern about the quality of staff being sent to hospitals and the misleading information supplied about their experience, a problem he believes is occurring across the UK.

In an article in the British Medical Journal today, Prof Isles recounts his frustrating hunt to fill his medical staff rota using locums who were trained overseas and referred by agencies.

He was dismayed to be offered locum doctors who were inappropriate due to a lack of experience or qualifications or who were suffering fatigue.

His comments come after the British Medical Association warned on Monday about inadequate checks being made on foreign doctors' language and clinical skills when they come to work in the UK.

There has been an increase in demand for agency locum doctors following the implementation of the European Working Time Directive, which limited junior doctors' hours to 48 a week.

In one case highlighted by Prof Isles, the hospital was offered a general medicine SHO (senior house officer). The agency said: "If he is of interest, snap him up as he won't be around for long as his CV looks brilliant."

But buried in the CV, Prof Isles said, was a reference from a UK consultant who said his skills were only equivalent to a doctor in their first or second year out of medical school. The consultant said he would be suitable for a post under close supervision, so the hospital decided not to continue.

The hospital was offered a European doctor and Prof Isles sent an email welcoming him. The agency said the booking had been accepted and paperwork completed.

But two days later Prof Isles received an email from the doctor, in poor English, stating: "Sorry. I received your message but I do not understand about which company you are talking. I do not know anything about your hospital (that should I can go).

"If you can tell me more details or it is a mistake?"

In another case a doctor who had worked overseas was offered as a SHO with good clinical and communication skills. But Prof Isles said on arrival, the doctor looked "terrified" and another medic had to be brought in.

The hospital was forced to pay over the odds for a doctor working as a consultant overseas. During his third night shift, the doctor fell asleep in a chair.

CASES OF LOCUM DOCTORS HIGHLIGHTED BY CHRIS ISLES (from ten used in BMJ)

Dr B: The email from the agency read: "I have a very good general medicine SHO (senior house officer], who is available. If he is of interest, snap him up as he won't be around for long as his CV looks brilliant." Buried within the CV was a reference from a UK consultant which stated that this doctor's basic skills were equivalent to a foundation year 1 or foundation year 2 doctor (first or second year out of medical school). "Due to only a short period of attachment on my ward I am unable to comment about his competence in great detail but I think he should be suitable for a locum SHO post under close supervision." We decided not to proceed.

Dr D: This European doctor was working in the UK and had reasonably good references. I decided to go ahead and wrote a nice welcoming email. The agency assured me that the booking had been accepted and that all the paperwork was in order. Two days later I received an email from Dr D that read "Sorry. I received your message but I do not understand about which company you are talking. I do not know anything about your hospital (that should I can go). If you can tell me more details or it is a mistake?" I phoned the agency to ask for an explanation but no one was able to provide me with one. We never heard from the locum again.

Dr F: This doctor had trained for many years overseas and now wanted to move to the UK. The agency offered the doctor to us as an SHO, and the CV said that the doctor had worked at this grade in another UK hospital. The reference stated that the doctor showed very good reliability, timekeeping, clinical and communication skills, and good relationships with patients and colleagues. But the doctor looked terrified on arrival—so much so that we felt we had to employ another SHO to cover during the acute medical take. Fortunately, one of our SHOs had a week off and was prepared to do this. It soon became apparent that Dr F's comfort zone was somewhere between that of a final year medical student and a foundation year 1 doctor. When another doctor asked for help with a difficult patient, the locum was "too tired" to assist.

Prof Isles wrote in the BMJ: "A huge amount of time has been wasted attempting to book doctors with little experience of working in the UK, whose competencies I have been unable to assess, who did not always have the right paperwork, and who could break an agreement at will and without repercussion."

A recent report by Audit Scotland found that the NHS in Scotland spent 47 million on locum doctors in 2008-9 - 43 per cent of overall medical staffing expenditure. About 27m of this was on agency locums.

Audit Scotland also found that procedures for induction and supervision of locum staff were vague and therefore more likely to be overlooked.

Prof Isles stated: "Most of all I rage at the locum agencies whose abject failure to regulate themselves should surely have led to intervention by the GMC by now. We pay lip service to patient safety by allowing this scandalous state of affairs to continue." Speaking to The Scotsman yesterday, Prof Isles said he was concerned by the unregulated nature of the locum agencies.

"They are not giving us the assurances we need that the doctors they are offering to us, at hugely exorbitant rates, are competent to do the job.

"I have a concern for the doctors themselves because they are coming from Eastern Europe, they are coming from Africa, and they are led to believe because they have been trained in these countries they can cope with the NHS. Their training leaves them woefully ill-prepared for that. I actually feel very sorry for them as they live nomadic existences, moving from one hospital to another."

Prof Isles said the CVs they received about the doctors did not give a proper assessment of what they were able to do.

"When you start probing a little more deeply, you find, actually, [they say] I have not done any procedures, and I'm not very good at clinics. All the fluffy stuff is good - he has good communication skills - but can he actually diagnose a heart attack and treat it appropriately? Those are big issues."

Prof Isles said they had 16 locums from overseas referred in a row, ten of which are detailed in the BMJ. The bulk of them were not accepted, and the ones who did start work were dismissed when they were found not to be up to the job.

Prof Isles added: "I think nowadays there will be doctors who can't cope, but all of us are sufficiently anxious about overseas doctors that we would be keeping a very close eye on them.

"It is a risk and it is only by extreme vigilance in a hospital setting and by weeding these guys out, by not employing them or sending them packing, that we are avoiding the near misses and other calamities that do occur in hospitals."

In an accompanying commentary in the BMJ, Niall Dickson, chief executive at the General Medical Council, said Prof Isles' article was "disturbing" and highlighted the "continuing shortage of doctors in some parts of the country and the apparent failure of some agencies and doctors to provide reliable information about their skills and competence".

But he said the onus was on employers to make checks on any doctors they employed from agencies. "The experience from this hospital raises serious questions about the role of locum agencies," Mr Dickson said.

"These are not matters for me, other than to stress that anyone who employs or contracts with doctors takes on major responsibilities for patient safety which they share with the individual practitioner."

Alan Robertson, a member of the British Medical Association's Scottish junior doctors committee, said: "The examples which this doctor highlights are quite concerning to read.

"The difficulty in getting good-quality locums is something that comes up frequently."

Dr Robertson said it was hoped that plans for an NHS "locum bank" in Scotland, where doctors could sign up and be checked before going into hospital, could help solve part of the problem.

But he said, depending on the number of people signing up, many hospitals could still be forced to used agencies for staff.

"Until this issue is resolved, hospitals will have to be vigilant in making checks before locums are allowed to see patients," Dr Robertson said.

A Scottish Government spokeswoman said: "It is the responsibility of health boards to ensure high-quality, safe and effective care. They have rigorous procedures in place."