Family Practice Vol. 17, No. 1, 53-55
© Oxford University Press 2000
GPs’ employment of locum doctors and satisfaction with their service
Department of Public Health Sciences, Guy's, King's and St Thomas' School of Medicine, Kings College London, UK.
Myfanwy Morgan, Department of Public Health Sciences, GKT School of Medicine, Kings College London, Capital House, Weston Street, London SE1 3QD, UK.
Morgan M, McKevitt C and Hudson M. GPs’ employment of locum doctors and satisfaction with their service. Family Practice 2000; 17: 53–55.
Received 23 April 1999; Revised 26 July 1999; Accepted 6 September 1999.
Abstract
Background. Locum doctors provide cover during normal working hours for GPs absent due to holidays, sickness, maternity leave or for educational purposes. However, there is little information on the extent of the use of locums or of GPs’ perception of their services.
Objectives. To examine the level of use of locum doctors by GPs, the ease of recruitment and satisfaction with their services.
Methods. A postal survey of all general practices in one of the six health regions in England was carried out. Logistic regression analysis was used to examine the independent effects on locum use of practice size and type of area, source of recruitment and GPs’ satisfaction with their services.
Results. A total of 935 (80.6%) general practices responded. Locum GPs were employed by 81.7% of practices in the previous 12 months. Two-thirds of practices reported problems obtaining locum cover, especially at short notice and for holiday periods. One-fifth of practices employing a locum in the previous 12 months were dissatisfied with the locum.
Conclusions. There are high demands for, but a considerable shortage of, locum doctors in general practice. Educational and other initiatives for GPs may contribute to increased demands for locum cover. Difficulties in recruitment may be reduced by measures to improve the conditions of employment for doctors working as locums on a longer term basis. New codes of practice for employing locums may increase satisfaction with locum services.
Keywords. Family practice, manpower, quality of health care, staffing, workload..
Introduction
Locum doctors support general practices by providing cover during normal working hours for absences due to holidays, sickness, maternity leave or for educational purposes. In the UK, there are 
4000 GP non-principals of whom the majority are locums.1 General practices recruit locums themselves, although Health Authorities reimburse practices towards the cost of locum doctors for both sickness and maternity leave subject to eligibility criteria (e.g. length of service and list size). However, there is some flexibility in reimbursement criteria where justified by local circumstances or when single-handed GPs require sickness absence.
A large number of studies have examined the organization and provision of ‘out of hours' care in general practice by deputizing services.2 However, little is known about the employment of locum doctors in general practice who mainly come to notice only when problems of the quality of their care are identified.3
This survey provides baseline data regarding general practices' employment of locum doctors, and examines their experiences of recruitment and satisfaction with the services provided by locum doctors. The study was undertaken in the South Thames Health region, one of the six health regions in England which extends from inner London to the south coast.
Methods
A short anonymous questionnaire with mainly pre-coded questions was developed and piloted by practices outside the South Thames region. Questionnaires were sent with a covering letter to the 1160 operational general practices in the region identified from health authority lists. Two reminders were sent.
Logistic regression was used to examine the independent contributions of practice area (urban, rural, inner London, other inner city) and practice size (single-handed, 2–3 partners and four or more partners) to use of locum doctors, source of recruitment and satisfaction with locum doctors.
Results
The overall response rate was 80.6% (935/1160 practices). Practice lists indicated that single-handed practices were under-represented, comprising 24.4% of responders but 42.7% of the 225 non-responders (chi-square = 29.23 P < 0.001). Practice characteristics showed a significant relationship between practice size and type of area, with inner city areas having the greatest proportion of single-handed practices and rural areas the smallest (Table 1
).
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Overall, 81.7% (764/935) practices had employed a locum in the previous 12 months (Table 2
). Altogether, 43.5% of practices ‘often' used a locum for annual leave, 12.5% for maternity cover, 13.8% for short-term sickness (<1 week), 16.6% for medium-term sickness (1–6 weeks), 16.0% for long-term sickness (6 weeks) and 13.2% practices for ‘other reasons' (mainly for educational activities and to cover an unfilled vacancy). Single-handed practices made greatest use of locums for annual leave but less use for maternity cover, long-term sickness and ‘other reasons'. Table 3 shows reasons for not employing a locum rated as ‘very important’.
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In response to an open question, "do you ever have problems getting locum cover?", 64.2% (600/935) of general practices reported difficulties, with problems being greatest in inner city areas (Table 2
). Regression analysis confirmed that location but not practice size had a significant effect on recruitment. Written comments identified problems of obtaining cover for individual sessions, arranging cover at very short notice and, in some cases, booking ahead because locum doctors did not want to commit themselves long in advance. Particular shortages were also reported during the holiday periods, especially of female locums.
Sixty-six per cent (504/764) of the practices who had used a locum in the previous 12 months identified personal contact/word of mouth as the most usual method of recruitment. Only 5.4% ‘usually’ used commercial locum agencies and 7.2% general practice co-operatives, while 22.0% had no single source of recruitment. Inner city practices made greatest use of commercial agencies (11.1% practices compared with 3.5% in other areas).
Altogether, 19.5% (149/764) of practices who had employed a locum in the previous 12 months reported dissatisfaction over this period. Thirty-nine per cent of practices who usually recruited through commercial agencies were dissatisfied, compared with 25.5% who ‘usually’ recruited from general practice co-operatives and 18.5% who ‘usually’ recruited by personal contact/ word of mouth. Dissatisfaction was also particularly common among general practices in inner London, with this remaining significant after the usual source of recruitment was entered into the regression model (odds ratio compared with urban areas 1.73, 95% CI 1.08–2.75, P = 0.02).
Responses to open questions identified causes of dissatisfaction as difficulties in recruitment and the limited choice available. Specific reasons for dissatisfaction were analysed for the 149 practices who had employed a locum in the previous 12 months and expressed dissatisfaction. Many (41.3%) were critical of locums' general attitude and approach to the job, including ‘not fitting in’ with the practice, ‘laziness’, non-punctuality and unwillingness to cover minimum surgery times and do a minimum of visits and paperwork. A further 31.1% of comments related to clinical competence, especially under- or over-prescribing, inappropriate referrals and being ‘out-of-date’; 17.3% of comments were critical of the locums' relationship with patients, in terms of having a poor ‘bedside manner’, being curt and abrupt; 8.5% related to problems of poor administration and overcharging the employing practice.
Discussion
This is the first large-scale survey of general practices' use of and satisfaction with locum doctors. The response rate was high, although single-handed GPs were relatively over-represented among non-responders, which may have slightly reduced the overall rates of locum use identified and over emphasized the dissatisfaction and concerns of larger practices.
Problems in the supply of locum doctors characterized all areas, but were particularly pronounced in inner London. This problem reflects increasing demands for locum cover, partly associated with new educational initiatives, as well as a general shortage of medical manpower, with both factors being especially characteristic of inner London.4 The shortage of medical manpower currently is being responded to nationally by increasing the intake of medical students and developing new roles for nurses in primary care.5 Special schemes and incentives have also been introduced in inner London to increase the numbers of GPs in these areas.6 Another approach is the need to improve the conditions of service of doctors (mainly female) who undertake locum work on a long-term basis, thus maximizing their availability.1,7
One-fifth of practices who had employed a locum in the previous 12 months expressed dissatisfaction with locum doctors' attitude or services. These problems may be reduced by a national initiative which requires that all doctors entering general practice in any capacity have a vocational training certificate or equivalent, except those working in general practice prior to 31 December, 1994. A national Code of Good Practice, endorsed by the Royal College of General Practitioners, and local codes have also been drawn up.8,9 These identify both the responsibilities of locums themselves and the requirements of employing practices in terms of providing appropriate information, organizational arrangements and conditions of service for locum doctors. The impact of these measures should be monitored, and requirements for locum cover taken into account in planning new educational schemes and other initiatives for GPs. More generally, although the study was based in the UK, it highlights what are likely to be widespread problems of providing cover for community-based doctors in situations of a shortage in medical manpower.
References
1 Standing Committee on Postgraduate Medical Education. The Educational Needs of General Practitioner Non-principals. London: SCOPME, 1998.
2
Hallam L, Cragg D. Organisation of primary care services outside normal working hours. Br Med J 1994; 309: 1621–1623.
3 Handysides S. Deplorable care prompts warning to doctors. Br Med J 1993; 307: 222.
4 Tomlinson B. Report of the Inquiry into London's Health Service, Medical Education and Research. London: HMSO, 1992.
5 Medical workforce standing advisory committee: third report. Planning the Medical Workforce. London: Department of Health, 1997.
6
Heyward J, Modell M. New initiatives for general practitioners in London. Br Med J 1995; 311: 1314–1315.
7 McKevitt C, Morgan M, Hudson M. Locum doctors in general practice: motivation and experiences. Br J Gen Pract 1999; 49: 519–521.[Medline]
8 Newsletter of the National Association of Non-Principals. The Non-Principal. 1998; 4.
9 Primary Care Support Force. Locums Without Tears. London: NHS, n.d.
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