The only way to protect consultants and preserve their services is to ensure absolute transparency in consulting staffing arrangements, writes Martin Elliott

Martin Elliott

Martin Elliott

Martin Elliott

It is clear from recent publicity that nursing and medical staffing represent a significant challenge for the NHS. There are widespread staff shortages including at both junior doctor and consultant level, and locum and agency costs have become a major burden for the system.

Jim Mackey, chief executive of NHS Improvement, has said locum pay caps, introduced in 2015, are often not being enforced rigorously enough, leaving trusts with excessive costs.

In-house bank systems are cheaper, and Mackey said NHSI will be identifying trusts and services that are over-reliant on locums, especially from agencies.

More recently, in a letter sent to trusts by NHSI, Mackey said greater transparency is needed around the pay of locum staff earning in excess of £150,000.

NHSI will give more details of proposed actions in coming weeks, but it may ask providers to publish rates paid to high earning locums.

This is not about holding consultant’s ‘feet to the fire’. It simply means a putting in place a fairer deal for the consultant workforce.

Similar transparency measures already exist in government, where the names and pay-bandings of civil servants and senior officials earning £150,000 and above are published.

The reason for the high demand for locums, and hence high costs can be traced back to a longer term staffing challenge and the way the consultant workforce is used.

On the one hand, NHS hospital trusts are finding it impossible to fill key posts. According to a Royal College of Physicians annual audit of doctors working in hospitals in 2016, 40 per cent of posts were unfilled.

On the other hand, anyone who has first hand knowledge of consultant staffing will tell you it remains one of the least transparent areas of workforce planning in the NHS.

Rotas are often opaque, leave and study leave plans not shared, and duty swaps poorly communicated with management. These problems are especially marked for consultants who work across multiple sites, different trusts, or in academic environments.

As you would expect, consultants value their independence, but trusts under financial pressure and with huge demand on their services, can also reasonably expect that consultants to be where they should be, providing the services according to their agreed job plans.

This is not about holding consultant’s ‘feet to the fire’. It simply means a putting in place a fairer deal for the consultant workforce.

There are widespread staff shortages including at both junior doctor and consultant level, and locum and agency costs have become a major burden for the system.

It is often impossible to keep track of last minute duty swaps and frequently it is the same colleagues who pick up the extra duties because their work life balance can accommodate last minute changes.

Many consultants are working ridiculously hard, not only doing their own work, but covering for absent colleagues. They need to be protected and services need to be preserved.

The only way to do this is to ensure absolute transparency in consultant staffing arrangements, including the details of rotas.

Rules about taking leave are often ‘forgotten’ especially around the times of national or international society meetings, and it can be difficult for managers and executives to keep the show on the road.

In small units, or hospitals, direct conversations may suffice to keep things working at the levels of efficiency that current demand requires. However, in complex organisations in which consultants work on larger, or multiple sites, and in situations with many consultants on the rotas, sorting all this out can become very difficult.

As an academic consultant, working on several sites, I had to rely on three different diaries, a secretary and the patience of my wife to make sure I was in the right place at the right time.

My secretarial support was shared with six others and in common with other colleagues, diary management became increasingly done by me (and hence often badly). If I made changes and especially tried do it on the move, or at busy times, it was too easy fail to communicate any changes.

Modern IT systems linking job planning, rostering and populated rotas could solve these problems, and create the transparency trusts need to optimise service delivery and keep costs under control.

The reason for the high demand for locums, and hence high costs can be traced back to a longer term staffing challenge and the way the consultant workforce is used.

Making sure the right people are in the right place at the right time is core to efficient service delivery.

Consultant independence need not be threatened; let them organise duty swaps between themselves on their mobiles and let the software inform everyone else of the changes, thus assuring compliance with leave and cover rules.

It is not difficult to see why changing consultant working patterns presents a significant challenge as staff shortages bite.

Further, Sustainability and Transformation Plans will inevitably have an additional impact on the consultant workforce, especially if multi site working increases.

These are not insignificant problems, but we are well equipped to overcome them. My biggest concern is that we leave it too late to have effective systems in place.

Martin Elliott is chief medical officer at Allocate Software and professor of paediatric cardiothoracic surgery at University College London.