With performance targets being missed by many, it makes sense for A&E departments to look to European doctors to reduce their reliance on costly locums, writes Harry Harron

I read every week about the concern of accident and emergency departments not meeting targets and how March’s poor performance was perhaps due to the bad weather and the publication of the Francis report. I’m sure there is a lot of truth in that, and it is widely accepted that the pressure on A&E departments could be eased somewhat by looking at the out of hours GP services and using the thousands of community pharmacies as endorsed by NHS England in its urgent care review.

What I am not reading about is the link between running A&E departments on a high percentage of locum cover (if not 100 per cent) and the issue of trying to run an already stretched department in that way efficiently. Surely it must be tough. HSJ’s A&E performance tracker is a regular reminder many are missing the targets.. Who can be surprised?

‘Why would any A&E doctor wish to take on a salaried position when they can earn many times more working as a locum?’

I spend my life meeting with medical directors and HR directors talking about the ever growing problem of the amount of money spent on locums. A study published in the BMJ in 2011 found that locum doctors received lower scores of perceived professionalism than those doctors with a permanent employment contract. Anecdotally, I hear complaints that when some locums do turn up they are not of the calibre that was hoped for.

One would think that hospitals would gladly employ more full-time staff and break out of the increasingly expensive locum cycle. But why would any A&E doctor wish to take on a salaried position when they can earn many times more working as a locum? It would seem the time is right and appetite is there to fix the staff problem. Or is it?

This issue is not isolated to the UK. The Health Service Executive in Ireland experiences much the same problems.

Forward planning

In Ireland, it is common for the Irish Medical Council to inform doctors who wish to register that the process may take up to 12 weeks. Ireland changes over doctors’ contracts every July and January, and in every July and January predictable shortages appear throughout the country. Should, therefore, one wish to bring in “new to Ireland” doctors to meet the predictable shortfall, then one would start to do that at least four months before.

Some do, avoiding disastrous realisations closer to the changeover date that they do not have enough doctors. They should be commended for their forward planning and saving the taxpayer millions of euros from the “let’s manage it with locums” strategy.

Some hospitals don’t forward plan in the same way. It is called “panic recruitment” and is normally done with the words of “don’t send anyone unless they have IMC registration”. 

No UK experience

Similar comments can be heard in the UK. One of them being: “If they don’t have any UK experience then we don’t want them.” This is normally heard from the mouths of consultants, the future leaders of the NHS.

The situation as I see it is that there are not enough A&E doctors in the UK or in Ireland. There is a deficit. Be that true, then we need more. If we need more, then we need to find them from somewhere other than the UK or Ireland… and they probably don’t have UK experience.

‘The UK and Ireland have emergency departments set up in a unique way to the rest of Europe’

It is amazing how many A&E departments say there is no other alternative. The result is that lots of A&E departments are run on locums, costing the hospitals many times more than if they were paid as normal full-time staff.

The last “recession years” have taught businesses to be flexible, experiment, and do things differently if you want a different result. While there are hospitals and departments through the UK and Ireland that are being more flexible in their way of thinking, and they do experiment and aim for different results, I think it is fair to say that, all too often, they are in the minority.

Why no UK experience?

In defence of the clinicians who do not want to work with A&E doctors without previous UK experience, A&E doctors outside of the UK (and Ireland) don’t exist – well, not in Europe anyway.

The UK and Ireland have emergency departments set up in a unique way to the rest of Europe. Therefore finding a straight fit, ie: someone who can move from one EU country to work in an English speaking A&E department, is a challenge.

Even if they find a doctor who is “nearly there” in terms of skills and experience it is often a bigger challenge to get clinical development time for those doctors. Often, the consultants are too pushed to have time to train these doctors and the rest of the team.

Ban the locum?

No, this isn’t the message. It is right and appropriate that there is a flexible workforce and crucial that this exists in A&E. That said, there is a balance to be had and to get right and at the moment it isn’t.

I strongly believe that the solution to the A&E staffing locum issue must lie in our European doctors: a workforce willing to work as full-time staff and to be part of the team. Economic turmoil in Europe, as well as the UK and Ireland having the highest salaries in Europe for doctors, means that there is a large pool of doctors looking for work. Many apply for A&E positions and without the right experience few are getting the jobs.

‘If we believe that UK and Irish doctors are the only ones to grasp the role of an A&E doctor then we are being arrogant’

The answer lies in recruiting the right person in the right way with the right skills mix. Then develop them. If we believe that UK and Irish doctors are the only ones to grasp the role of an A&E doctor then we are being arrogant. We have the opportunity to work with other well trained European doctors who, while they do not have the much-desired “UK experience”, have the right basic skills set and are able and willing to be trained to the right standard.

Someone may shout: “But who is going to pay for that?” and the simple answer is: “How much has been spent running the service on locums, and when and why is it going to going to get better any time soon?” Hospitals must invest now to save later. In any other area of life, by investing in the “team” we expect to get desirable results. We will expect to get better teamwork, and good will resulting in more flexible staff.

By moving away from employing people by the hour and having a team, we will see more efficiencies and get closer and closer to hitting those targets more and more often. With more people working together and becoming more cohesive, maybe even the patients will notice? Who knows, when the balance of A&E doctors moves from there being more full-time staff than locums, maybe the locum positions won’t be as attractive? By having more full-time paid members of staff could we see job security creeping in and more doctors choosing a salaried job over a locum one? This has happened in pharmacy over the past few years due to the overproduction in pharmacists. Perhaps the same could happen in A&E.

Bite the bullet

While there will be pain in the beginning, it has to be worth it. The effort needs to be put in now, for the results to pay out later. We are working with a number of clients who are taking a fresh approach to recruitment and solving the A&E issue.

At the moment we have a course being developed by leading NHS A&E consultants to create “bridging training” − a boot camp for European doctors wishing to work in A&E in the UK and Ireland. UK and Irish A&E doctors in a hospital setting will deliver the training and the aim is to develop the skills and awareness of carefully selected EU doctors wising to work in the UK and Ireland.

In other parts of the UK, we are working with clients who have chosen a much more robust and enhanced set of procedures for recruitment.  Everything from professional language screening, which one would expect, to bespoke clinical screening labs in Europe − and on home ground too.

‘We are working with a number of clients who are taking a fresh approach to recruitment and solving the A&E issue’

More and more of this type of recruitment and development of doctors with the right skills mix is needed if we are to change the way things are in terms of A&E and locums. True, there are costs now in doing this, but the long-term benefits are also true with hundreds of thousands of pounds to be saved per doctor over a short period of time.

Roll on the good times

In the meantime, recruitment agencies focusing on the locum solution alone are making hay while the sun is shining, and who can blame them? Even with the best will in the world to reduce the locum spend, often the system seems to be set up against this happening. While there are those who wait for the bigger-picture events to happen, long may the agencies reap their reward for offering the solutions they do.

For those who get on with it and do something different, well done, and I am sure soon we will be reading about your increased team efficiencies, improved patient outcomes and, perhaps most importantly in these times, the millions of pounds that have been saved.

Harry Harron is managing director of A-Team Health Recruitment