The use of locum doctors by Northern Ireland …Locum doctors provided to Trusts by external...

The use of locum doctors by Northern Ireland Hospitals

REPORT BY THE COMPTROLLER AND AUDITOR GENERAL1 July 2011

BELFAST:TheStationeryOffice £5.00

ReportbytheComptrollerandAuditorGeneralforNorthernIreland

TheuseoflocumdoctorsbyNorthernIrelandHospitals

ThisreporthasbeenpreparedunderArticle8oftheAudit(NorthernIreland)Order1987forpresentationtotheNorthernIrelandAssemblyinaccordancewithArticle11ofthatOrder.

KJDonnelly NorthernIrelandAuditOfficeComptrollerandAuditorGeneral 1July2011

TheComptrollerandAuditorGeneralistheheadoftheNorthernIrelandAuditOfficeemployingsome145staff.HeandtheNorthernIrelandAuditOfficearetotallyindependentofGovernment.HecertifiestheaccountsofallGovernmentDepartmentsandawiderangeofotherpublicsectorbodies;andhehasstatutoryauthoritytoreporttotheAssemblyontheeconomy,efficiencyandeffectivenesswithwhichdepartmentsandotherbodieshaveusedtheirresources.

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Contents

Executive Summary 1

Part One Introduction and Background 7

LocumdoctorsareusedinNorthernIrelandhospitalstoensure 10 continuityofcareforthepatient

Wehaddifficultyobtainingdetailsofthetotallocumspendacrosstrusts 10

Theuseoflocumsmustbemonitoredcarefullyifthecostandquality 14 ofcareistobemaintained

ThisreportconsiderstheeffectivenessofTrustcontrolsovertheuseof 15 locumdoctorsinhospitals

Part Two Managing the demand for locum cover 17

Workforceplanninginthehealthserviceattemptstobalancethe 18 availabilityofsuitably-qualifiedmedicalstaffagainstpatientneeds

ThelatestReviewofthemedicalWorkforcewaspublishedin2010 18

Changestothehospitalenvironmenthavehadanimpactonthe 18 availabilityofstaff

Managementinformationisinsufficienttoenableeffectivemonitoring 20 andcontroloftheuseoflocums

The2010WorkforcePlanningReviewwascompletedintheabsence 20 ofdetailedinformationonspecialtyplanning

Usinglocumdoctorscancreateconsiderablefinancialrisks 21

Part Three Safeguarding the quality of care provided to patients 25

TrustsandtheDepartmentmustmanageriskstoprovidesafe,high-quality 26 caretopatients LocumdoctorsprovidedtoTrustsbyexternalagenciesarenotregulated 26 bytheRegulationandQualityImprovementAuthority

TheCodeofPracticeinLocumDoctorAppointmentandEmployment 27 (thecode)wasintroducedinNorthernIrelandin1998andsetsoutkey controlsfortheuseoflocums

TheCodesetsouttherequiredpre-employmentchecksforeachlocum 27 episode

Weidentifiedseveralweaknessesinproceduresforemployinglocums 28 fromexternalagencies

TheCodesetsoutproceduresforassessingthequalityofservicefor 29 eachlocumepisode

Thelimitationsofexistingmanagementinformationcancreatedifficultiesfor 31 TrustsattemptingtoverifycompliancewiththerequirementsoftheEuropean WorkingTimeDirctive(EWTD)

TheConfidenceinCareprogramme,introducingrevalidationofalllicensed 32 doctors,isintendedtoimprovethequalityofpatientcare

WhereTrustsdonotundertaketherequiredpre-employmentchecks, 33 completeappraisalsforeachlocumepisodeorenforcecompliancewith theEWTD,thereisariskthatpatientsafetywillbecompromised

Contents

Appendices 37

Appendix 1: Structure of Northern Ireland Health and Social Care Trusts 38

Appendix 2: Health and Social Care Hospitals in Northern Ireland 39

Appendix 3: The Cost of Agency and Internal Locums in Northern Ireland 41 2007-08 to 2010-11

Appendix 4: Audit Methodology 43

Appendix 5: Implications of the EU Working TIme Directive 44

Appendix 6: Medical Demand and Supply Problems Identified by the 45 Department – Review of Workforce Planning for the Medical Profession (September 2006)

Appendix 7: Good Practice Examples identified from the NHS Employers 47 publication “Controlling the use of temporary staff through large scall workforce change”

Appendix 8: Regionally Managed Medical Locum Service for Northern Ireland 52

Abbreviations

A&E AccidentandEmergency

AHP AlliedHealthProfessional

BSO BusinessServicesOrganisation

DHSSPS DepartmentofHealth,SocialServicesandPublicSafety

ENT Ear,NoseandThroat

EWTD EuropeanWorkingTimeDirective

GMC GeneralMedicalCouncil

GP GeneralPractitioner

HR HumanResources

HSC HealthandSocialCare

IT InformationTechnology

LDA LocumDoctors’Association

NIAO NorthernIrelandAuditOffice

NIMDTA NorthernIrelandMedicalandDentalTrainingAgency

NHS NationalHealthService

PASA PurchasingandSupplyAgency

RMMLS RegionallyManagedMedicalLocumService

RQIA RegulationandQualityImprovementAuthority

RST RevalidationSupportTeam

SAI SeriousAdverseIncident

SHO SeniorHouseOfficer

USA UnitedStatesofAmerica

Executive Summary

2TheuseoflocumdoctorsbyNorthernIrelandHospitals

Introduction

1. Properly-manageduseoflocumdoctorsallowsHealthandSocialCare(HSC)Truststorespondflexiblyandefficientlytovaryingactivitylevelsandtocovershort-termabsencesorvacancies.However,inordertosafeguardthequalityofpatientcare,Trustsmustnotonlycontrolcostsbutmusttakestepstoreducetheclinicalrisksassociatedwithlocumdoctorswhomaybeunfamiliarwiththeircolleagues,theirsurroundings,thepatientsundertheircare,orwithlocalproceduresandpractice.

2. ThisreportexaminestheuseoflocumdoctorsinhospitalsacrossNorthernIreland.ItconsiderswhethertheDepartmentofHealth,SocialServicesandPublicSafety(theDepartment)andTrustshavedevelopedaplannedapproachtocontrollingandmanagingthesupplyofanddemandforlocumdoctors.Thereportalsoexploresthesafetyandqualityissuesassociatedwiththeuseoflocumdoctors.

On average, Trusts spend around 8 per cent of total medical staffing expenditure on locum doctors

3. Inthefouryearsto31March2011,Trustsspentover£100millioncoveringdoctorshortagesinhospitals.In2010-11alone,locumcostsamountedto£22.5million,almost8percentofallmedicalstaffingexpenditure.WithintheWesternTrustthepercentagewasmorethandoublethisrate(at17percent).IfitwerepossibleforallTruststomaintain

locumcostswithintheregionalaverage,thismightyieldpotentialsavingsof£5millioneachyear.LocalcircumstancesmaymakethischallengingtoachievebutTrustsshouldbecapableofmakingsavingsbymoreeffectivemanagementofthedemandforlocumsandimprovingpurchasingprocedures.

Better information on the use of locum doctors is needed to identify where efficiency can be improved

4. ThequalityofmanagementinformationusedacrosstheHealthandSocialCaresectorvariesconsiderablyand,asaresult,itcanbedifficulttoobtainanoverallpictureoflocumdoctoractivityandcosts.Costsrelatingtolocumsemployedthroughrecruitmentagenciesareroutinelyidentified.However,informationontheuseandcostofinternallocums(i.e.doctorsemployedwithinTrustsworkinghoursadditionaltothosestatedintheircontract)tocovergapsinrotasisnotcapturedinthesameway.Inordertomanagetheuseoflocumdoctorseffectivelyandmakesavings,Trustsneedaccurateandcomprehensivesummaryinformationonhowmuchisbeingspentonlocums,thegradesandspecialtiesbeingusedandthetypeoflocum–internaloragency.MonitoringexpenditureinthiswaymayhelpTruststotargetareaswheretheycouldbemoreefficientintheiruseoflocumsandtobenchmarklocumuselocallyandagainstotherUnitedKingdomcomparators.

Executive Summary

TheuseoflocumdoctorsbyNorthernIrelandHospitals3

Managing the demand for locum doctors could be improved

5. ConsultantmedicalstaffworkforcecomplementsarefixedbyTrustsincollaborationwiththeHealthandSocialCareBoard.Inrelationtojuniordoctors,theNorthernIrelandMedicalandDentalTrainingAgency(NIMDTA)isresponsiblefortherecruitmentofdoctorsintraining.Trustshavenoauthoritytopermanentlyappointjuniordoctorstofillpostswhichcreategapsinrotas.

6. Demandforlocumdoctorsismainlydrivenbytheneedtoprovideasafeandeffectiveservicewheretherearehard-to-fillvacanciesandwheremedicalstaffarerequiredtocomplywiththe48-hourweekEuropeanWorkingTimeDirective(EWTD).Periodicreviewsofthemedicalworkforce,producedbytheDepartment,provideahighleveloverviewoflikelystaffingneedsbutarenotdesignedtoidentifygapsatmedicalspecialtylevel.WeacknowledgethattheDepartmenthascommencedworkaimedataddressinghowitcanstrengthenplanningandintelligenceatmedicalspecialtylevel.

7. ItisimportantforTruststohavethekeymanagementinformationavailablelocallytoinformdecisions.ThereforeTrustsshoulddevelopstrategiestoimprovetheirunderstandingandmanagementofdemandforlocumdoctors.Trustsshoulduseastandardsystemforrecordingthereasonswhyemployinglocumdoctorswasdeemednecessary;thegradeandspecialtyinvolved;thetypeoflocum(internaloragency);andthetimeand

durationofshift.Trustmanagersshouldthenusethisinformationtoimproveworkforceplanningarrangements.

Improved procurement could lead to more efficient use of locum doctors

8. AccordingtoTrustprocedures,onlywhentheoptionsofcoverbymedicalteamsortheappointmentofinternallocumshavebeenexhaustedwillTrustsgrantapprovaltoapproachexternalrecruitmentagencies.AllTrustshavecontractsinplacewithanumberofagencies,throughtheBusinessServicesOrganisation(BSO),forthesupplyoflocumdoctors.Truststoldusthatwherethecontractedagenciesareunabletoprovidelocums,theywillmoveoutsidethecontract.

9. Inordertofurthergenerateefficiencysavingsandreduceclinicalrisk,weconsiderthatTrustsneedtoexploreandadoptbetterpracticeintheprocurementoflocumhoursbyimprovingcollaborationandpartnershipworking.Towardsthisend,weacknowledgethatTrustsaretakingstepstodeveloparegionally-managedmedicallocumserviceforNorthernIreland.Wheninplace,theregionalserviceshouldenabletheTruststoplanlocumusemoreeffectivelyandtodemonstratethatlocumsarebeingusedappropriately.Inaddition,therisktopatientsafetyoflocumdoctorscouldbereducedifalllocumsavailableundertheservicereceivedappropriateinductionsandhadtheirperformancefullyassessed.

Improvements need to be made to assure the quality of locum doctors

10. Controllingthescaleandcostoflocumuseisonlypartofthechallenge.Perhapsmoreimportant,isthedutytoprovidesafe,effectiveandqualitycaretopatients.Trustsmustaddresstheirresponsibilitytoensurethatlocumsarecompetenttoundertakethedutiesrequiredofthem.WhileeachoftheTrustshasproceduresinplaceforprocuringlocumdoctors,InternalAudithasidentifiedseveralinstanceswherecheckstoensurethecompetenceoflocumdoctorshadnotbeenundertakenorwerenotproperlydocumentedandwhereTrusts’arrangementswithagenciessupplyinglocumsexposedthemtorisk.

11. In2006,theDepartmentintroducedInterim Arrangements for the Appraisal of Locum Doctors.Thesearrangementsrequiredthatalllocumepisodesshouldbesubjecttoastandardperformancereviewassessingtheclinicalskillsofthelocum.However,areviewin20081indicatedthat,incertainareas,therewasasignificantshortfallinthenumberofconsultants(andpossiblylocums)appraised;thattherewerenoformalsystemsforthereviewandperformancemanagementofappraisers;andthattherewaslittleevidenceoftheevaluationoftrainingoroftheoutcomesoftheappraisalprocess.Amorerecentseriesofreviewsin20102reportedimprovementoverallbutnotedthatTrustsdonotalwaysreceiveendofplacementreportsfromlocumagenciesorpreviousemployersandthatnotallTrustshavesystems

inplacetoprovideexitreportsforalllocumdoctors.TheneedforTruststomaintainrecordsoftheperformanceofindividuallocumswillbecomeevenmoreimportantastheGeneralMedicalCouncil(GMC)movesforwardwithaprocessofrevalidationwhereadoctor’slicencetopracticewillbereissuedeveryfiveyearssubjecttothesatisfactoryassessmentoftheirfitnesstopractise.TheDepartmenttoldusthatitispreparingforrevalidation.

12. Whilethedetailedaspectsoftheemploymentoflocumdoctorsare,inpractice,delegatedtostaffwithinthespecialtyrequiringcover,eachoftheTrustsoperatesacentralaccountabilitysystemthroughwhichseniordoctors(AssociateMedicalDirector/ClinicalDirectorlevel),areaccountableforthedemandandtheassociatedsafetyandqualityissues.Itisimportantthatcompliancewithsuchproceduresismonitoredandthatactionistakentoimprovecompliancewherenecessary.

13. TherearenosystemsandsafeguardsinplacetoenableaTrusttoroutinelyidentifywhetheralocumdoctorhasexceededthesafelevelofhourssetundertheEuropeanWorkingTimeDirective.Longworkinghourscanplacerisksonthehealthandperformanceofthelocumsandcanaffectthesafetyofpatientsintheircare.WhileGood Medical Practice3requiresindividualdoctorstoberesponsiblefortheirownwork,inourview,intheinterestsofpatientsafety,Trustsneedtoestablishsystemstoenablethemtocontrolandmonitorthetotalnumberofhoursworkedbyeachlocumdoctor.We

Executive Summary

1 TheRegulationandQualityImprovementAuthority(RQIA)ReviewofMedicalConsultantAppraisal,August20082 TheRegulationandQualityImprovementAuthority(RQIA)ReviewofHSCTrustReadinessforMedicalRevalidation,

December20103 GoodMedicalPractice–FrameworkforAssessmentandAppraisal,TheGeneralMedicalCouncil,November2006

acknowledgethatthecurrentregionaldiscussionsandscopingexerciseonthepotentialtodeveloparegionallocumservicecitesthisasapotentialbenefit.

14. IntheDepartment’sview,locumdoctorsprovideanentirelysatisfactoryserviceinthevastmajorityofepisodesinwhichtheyareemployed.However,giventheweaknessesweidentifiedinthearrangementsformanagingtheworkoflocums,webelievethattheTrustsandtheDepartmentneedtoroutinelymonitortheperformanceoflocumdoctors.Truststoldusthattheirmanagementinformationsystemshavethecapacitytoprovideinformationonadoctor-specificbasis,althoughsomealterationstothewayinwhichdataisrecordedmayberequiredtospecificallyidentifylocums.

Part One:Introduction and Background

1.1 InNorthernIreland,theDepartmentofHealth,SocialServicesandPublicSafety(theDepartment)isresponsibleforimprovingthehealthandsocialwell-beingofthepeopleofNorthernIreland.Partofitsresponsibilitiesinvolveensuringtheprovisionofappropriatehealthandsocialcareservices,bothinclinicalsettings(suchashospitalsandGeneralPractitioners’(GPs’)surgeries)andinthecommunitythroughnursing,socialworkandotherprofessionalservices.

1.2 Inrecentyears,thehealthandsocial

caresectorhasbeensubjecttomajorstructuralreforms4.On1April2007,fiveintegratedHealthandSocialCareTrustsreplaced18ofthe19Trusts(seeAppendix1).TheremainingTrust,theNorthernIrelandAmbulanceServiceHealthandSocialCareTrust,stayedinplace.OtherchangeswithinthesectorhaveincludedthecreationoftheHealthandSocialCareBoard(HSCBoard),fiveLocalCommissioningGroups,theBusinessServicesOrganisation(BSO),thePatientandClientCouncilandthePublicHealthAgency.

1.3 ManagementofhospitalservicesfallstothefiveHealthandSocialCareTrusts.Therearecurrently39hospitalsinNorthernIreland.Ofthese,13provideacutehospitalserviceswhiletheremaining26provideeithercommunity-basedservices5ormentalhealthservices.Thereportingstructuresforhospitalservicessince1April2007aresetoutinFigure1below.

1.4 NorthernIrelandhospitalsprovideawide-rangingprogrammeofcaretopatients.Somehospitalsoperate24hourseachday,365daysayear(acuteandmentalhealthhospitals).Othersprovidecarewithinspecifiedperiods(communityhospitals).Hospitalscanonlymaintaincrucialserviceswheretheyensurethatappropriatenumbersofdoctorsareavailableforeachshift.

1.5 Inrecentyears,anincreasingnumberofdoctorshaveelectedtoworkfewerhours,reflectingbroadercommunitypreferencesforbalancingworkandprivatelife.Inaddition,newimmigrationlawshaveledtoadeclineinthenumberofinternationalmedicalgraduatesandtheEuropeanWorkingTimeDirective(EWTD)hasintroducedrestrictionsonthenumberofhoursdoctorscanwork.Thesechangeshavemadeitdifficultforhospitalstoensurethattheoptimalnumberofdoctorsisavailabletocovershiftsatalltimes.

1.6 Whereahospitalhasinsufficientnumbersofdoctorsavailabletoprovidetherequiredservices,itwilleither:

a. payexistingstaff(internallocums)tocovertheadditionalhours;

b. recruitadditional(temporary)staffwherethepostistolastseveralmonths;or

c. whereneither(a)or(b)isfeasibleorsuccessful,approachanexternalagencytoprovidestaff(agencylocums).

4 ThestructuralreformsprimarilyreflectedchangesrequiredthroughtheReviewofPublicAdministrationandtoaddressthefindingsoftheApplebyReview.

5 AlistofNorthernIrelandhospitalsisincludedatAppendix2.

Figure 1: Structure of the Northern Ireland Health and Social Care sector

*LurganandSouthTyroneHospitalsprovideinpatientservicestonon-acutepatients,aswellasofferingdaycareandoutpatientsinarangeofspecialitiesSource: DHSSPS and various other health and social care websites

Hospitals

Acute:Belfast City

Mater Infirmorum

Royal Group of Hospitals

Musgrave Park

Non-acute:Forster Green (Neurology & Elderly)

Shaftesbury Square (Drugs and Alcohol Counselling)

Knockbracken Mental Health Services (Acute Psychiatric)

Muckamore Abbey (Learning Disability)

Hospitals

Acute:Antrim Area

Causeway

Non-acute:Dalriada (Community)

Mid-Ulster (Community)

Moyle (Community)

Robinson (Community)

Whiteabbey (Community)

Holywell Hospital (Mental Health)

Hospitals

Acute:Altnagelvin Area

Non-acute:Tyrone County (Community)

Gransha (Mental Health)

Tyrone and Fermanagh (Mental Health)

Lakeside (Mental Health)

Hospitals

Acute:Craigavon Area

Daisy Hill

Non-acute:Armagh (Community)

Banbridge (Outpatients/Day cases)

Lurgan*

Mullinure (Geriatric Medicine)

South Tyrone*

Bluestone Unit (Mental Health)

St Luke’s (Mental Health)

Longstone (Learning Disability)

Hospitals

Acute:Downe

Lagan Valley

Ulster

Non-acute:Ards (Community)

Bangor (Community)

Thompson House (Physical & Sensory Disability)

Downshire (Mental Health)

Belfast Health and

Social Care Trust

Northern Health and Social Care

Western Health and Social Care

Southern Health and Social Care

South Eastern Health and Social Care

Northern Ireland

Ambulance Service

Health & Social Care Trust

Business Services Organisationproviding support to health and social

care bodies

Public Health Agencyresponsible for health improvement and health

protection

Patient and Client Councilrepresenting the interests of, and promoting

the involvement of the public

RQIA(Regulation and Quality Improvement Authority)

non-departmental public body responsible for monitoring and inspecting the availability and

quality of health and social care services

Local Commissioning Groups5 groups overseeing the activities of

individual Trusts

Health and Social Care Boardcommissioning, resource management, performance

management and improvement

DHSSPSresponsible for the provision of health and

social care services in Northern Ireland

Locum doctors are used in Northern Ireland hospitals to ensure continuity of care for the patient

1.7 ‘Locum’,fromtheLatinphraselocum tenes,referstoapersonwhotemporarilyfulfilsthedutiesofanother.A‘locum doctor’isaprofessionally-qualified,medicalpractitionertemporarilycoveringforstaffshortagesorunexpectedpeaksinworkload.Locumsassistinhospitalsintwokeyareas.Forinstance,theycanprovideshort-termshiftcoverfordoctorswhoaretemporarilyunavailableforwork,ortheycanbeappointedonalongertermbasistofillvacantpostsorascoverforstaffonextendedabsence,suchasmaternityleave.

1.8 Therewillalwaysbeaneedforlocumstafftocoverperiodsofsickormaternityleave,toovercomeshortagesinthenumberofdoctorsintrainingwithinsomespecialtiesand,increasingly,tocompensateforthedesireofstafftoworkmoreflexiblehours.However,Trustsacknowledgethateffectiveplanningcanhelpcontroltheextenttowhichlocumsarerequired.

1.9 DoctorsprovidinglocumservicesareeitherTrustemployeesworkingoutsidetheirnormalhoursoraresuppliedbyLocumAgencies.

• Internal Locums –Hospitalsusetheirowninternalstaffaslocums.StaffareusedtocoverabsencesandarenormallyremuneratedatnationallyagreedratesasspecifiedinDepartmentalcirculars.The

Departmenthasacknowledged,however,thatsincetheseratesaresubstantiallylowerthantheratesavailabletoAgencylocums,internallocumsoftenrefusetheadditionalhoursunlessanincreasedrateisoffered.ApartfromtheBelfastTrust,theotherfourTruststoldusthatinternallocumsoftenbarterforratesabovethoseapprovedbytheDepartment.

• Agency Locums –TherearecurrentlynineLocumAgenciesinNorthernIrelandwhosupplylocumdoctorstohospitals.TheseAgenciesrecruitdoctorsfromwithintheNorthernIrelandHealthandSocialCaresector,indeedmanyofthestaffsuppliedbytheseAgenciesarealreadyworkingforTrusthospitals.Thepaymentrates,althoughinlinewithagreedcontractrates,tendtobesignificantlyhigherthanthesalariespaidtohospitalstaff.Forexample,ratesforsomeofthelargerAgenciesrangebetween£31to£72perhourcomparedagainstsubstantivepostratesofbetween£26to£31perhour.

We had difficulty obtaining details of the total locum spend across Trusts

1.10 Attheoutsetofouraudit,weaskedeachTrusttoprovidedetailsofthetotalpaymentsmadeinrespectoflocumdoctors.Informationonpaymentstoexternalagencies(foragencylocums),hasbeencollectedbytheDepartment’sWorkforcePlanningUnitsinceOctober2006andwas,therefore,readily

available.Informationonthevalueofpaymentstointernallocumsprovedmoredifficulttoobtain.Throughoutouraudit,individualTruststoldusthatitwasnotpossibletoextractthisinformationfromtheirmanagementinformationsystems.

1.11 Sometimelater,duringthelatterstageofthereportingprocess,theDepartmentprovidedtheinformationwehadpreviouslyrequested(seeAppendix36).TheDepartmenttoldusthattheinformationcouldbeextractedfromthemanagementinformationsystemsofTrusts,albeitwithsomeinterrogationofsystems.

1.12 Figure2belowshowslocumdoctorexpenditurewithinNorthernIrelandTrustsovertheperiodfrom1April2007to31March2011.Overall,inthefouryearfrom2007to2011,NorthernIrelandTrustspaid£109milliontocoverstaffshortages.Expenditureonagencylocumsrosesteadilyovertheperiodfromalmost£14millionin2007to£22.5millionin2010-11.Since2007,thecostofagency-suppliedlocumdoctorshasamountedtojustunder£74millionforprovidinglocumdoctorstoTrusts.Overthesameperiod,Trustspaidjustover£35milliontointernalstaffforhoursworkedoverandabovetheircontractedhours.

6 WehavenotundertakenanyvalidationworktoassesstheaccuracyofthecostinformationprovidedtousbytheDepartment.

40Total Locum CostsAgency Locums

Directly Employed (Internal) Locums

2010-112009-102008-092007-08

Figure 2: Total Locum Expenditure within Northern Ireland hospitals over the period 2007-2011

Source: Department

1.13 Figure3shows(inpercentageterms)theleveloflocumexpenditurecomparedtopaymentstopermanentdoctorsforcontractedhours.Themajorityofexpenditure(around92percent)in2010-11relatestopaymentstodoctorsfortheircontractedhourswithintheTrust.

1.14 Onaverage,8percentofoverallspendonemployingdoctorswithinhospitalsrelatestotheuseoflocums-6percentofthisbeingpaidtoexternalagencies.A2010reportbyAuditScotland7identifiedthatlocumexpenditureinScottishNHSBoardsin2008-09accountedfor4.3percentofmedicalstaffingexpenditure.

7 UsingLocumDoctorsinHospital–AuditScotlandJune2010

1.15 IfitwerepossibleforallTruststomaintainlocumcostswithintheregionalaverageof8percent,thismightyieldpotentialsavingsof£5millioneachyear.Theoretically,thiswouldinvolveallTrustsminimisingtheuseoflocumdoctorsbydeployingamoreoptimalnumberandmixofpermanentdoctors.Inpractice,however,werecognisethatforsomeTruststhisisnoteasy.Forexample,theWesternandNorthernTrustshavefaceddifficultiesinrecruitingstaffinsomespecialtiesandgrades.Despitethepressurestouselocumscreatedbysuchastrategicworkforceissue,Trusts,inourview,shouldbecapableofgeneratingsavingsbymoreeffectivemanagement

Internal Locums Cost Agency Locum Costs Cost of hospital doctors working contracted hours

AverageSouthernWesternSouth EasternNorthern Belfast

Figure 3: Percentage split of total NI hospital doctor costs between contracted hours, Agency locums and internal locums over the period 2007-2011, by Trust

Source: Department

ofthedemandforlocumsandimprovingprocurementprocedures,particularlyaroundthepaymentofpremiumratestolocumdoctors.

1.16 FurtheranalysisofthefiguresfromTrustseachyear(Figure4above)shedssomelightonthespecificdifficultiesfacedbyTrusts.LocumexpenditurewithintheBelfastTrusthasremainedfairlyconstantoverthefouryearperiodto31March2011ataround5percentoftheoverallcostofhospitaldoctors.LevelswithintheSouthEasternTrustalsoremainedrelativelyconstantataround5percent,apartfromaslightincreasein2008-09whichsawthelocumlevelrisetojustunder7percent.

WesternNorthern Southern South Eastern Belfast

2010-112009-102008-092007-08

Figure 4: Trends in Locum Expenditure over the period 2007-2011

Source: Department

1.17 ThepercentageoflocumexpenditurewithintheSouthernTrusthadbeenhigher,withtheaverageforthefouryearsofaround9percent.However,thishasfalleninthelastthreeyearsandnowstandsatjustunder8percent.

1.18 PercentagelevelsintheNorthernTrustandtheWesternTrusthavebeenthehighestoverthefouryearperiod.WithintheNorthernTrust,thelevelstoodatalmost16percentin2008-09,althoughlevelshavefallenineachofthesubsequentyears.

1.19 WithintheWesternTrust,ontheotherhand,thepercentageoflocumuse

hasrisensteadilyoverthefouryearsfromalmost11percentin2007-08tonearly17percentin2010-11astheTrustbecomesmorereliantonlocumstomaintainservices.The2010-11levelwithintheWesternTrust(ofalmost17percent)isthehighestforanyTrustoverthefouryearsexamined.TheWesternTrusthadalwaysplacedrelianceonInternationalMedicalGraduates(IMGs)andtherecentchangestoimmigrationlawshasresultedinthisdisproportionateuseoflocumcover.

The use of locums must be monitored carefully if the cost and quality of care is to be maintained

1.20 LocumdoctorsprovidecoveratalllevelsinmedicalspecialtiesacrossNorthernIreland’shospitals.Althoughmostmedicalandhealthandsocialcarepersonnelagreethattheuseoflocumdoctorswithinhospitalsprovidesflexibility,thepracticealsocreatesspecificchallenges.Forinstance,followingourpreviousreportonacutehospitalservicesin19938,thePublicAccountsCommitteeatWestminster9concludedthat,whiletherewasarecognisedneedforlocumdoctorstobeusedonoccasions:

“.....the Department must monitor carefully the quality of service provided in such situations on a regular basis so as to assure itself that quality of care is not being compromised.”

1.21 Asubsequentreportbyus10in2007highlightedthecircumstancessurroundingtheemploymentofalocumconsultantradiologistwhowaspaid£240,000forworkduringtheperiod2003-04.Apermanentstaffmemberwouldhavecostapproximately£71,000.Whenthepermanentpostwasfinallyadvertised,thelocumdidnotapply.Thereportalsoidentifiedaseriesofweaknesseswhichexistedinthemanagementoflocumdoctors(andagencynursingstaff)suchas:

• inadequateTrustguidanceonagency/locumstaffengagementprocedures;

• failurestouseformalcontracts;

• theappointmentofstafffromnon-contractedagencies;and

• weaknessesinvouchingprocedures.

1.22 Onthebasisofthesefindings,theComptrollerandAuditorGeneralmadeacommitmentinhisreporttoundertakeaseparatereview“.....into the use of locum doctors, with particular focus on the effectiveness of management arrangements in this area.”

1.23 ThecostoftemporarystaffinghasalsobeenthefocusofattentionintheNationalHealthServiceinGreatBritain.InDecember2005,theDepartmentofHealthlisted“managing temporary staffing as a major source of efficiency”11

8 Department of Health and Social Services: The Provision of Acute Hospital Services in Northern Ireland,NIAO,4November1993

9 Department of Finance and Personnel, Memorandum on the 12th and 13th Reports from the Committee of Public Accounts,Session1993-94,Cm2555,London,HMSO

10 Financial Auditing and Reporting: 2003-04 and 2004-05, Combined General Report on the Health Sector by the Comptroller and Auditor General for Northern Ireland, NIAO,NIA66/06-07,6July2007

11 A National Framework to Support Local Workforce Strategy Development,DepartmentofHealth,December2005

asoneofitstenhighimpactworkforcechanges.Whilefindingssuchasthesesupportthecaseforadetailedstudyoflocumuseandcosts,therearealsopotentiallymoreimportantissuesconcerningclinicalriskandstandardsofpatientcare.

1.24 Truststakeadvantageoftheflexibilitythatusinglocumdoctorsaffordssothattheycanensurethatservicesaresafelymaintainedandthattheycanaddresstheclinicalrisksoffailingtofillgapsindoctors’rotas.Ifthedoctorsappointedarecompetentinallrespectstodotheworkrequired,theywillprovidethesamequalityofcareasadoctorinapermanentpost.However,thecircumstancesunderwhichlocumdoctorsareappointedandcarryouttheirdutiesmayposecertainrisks.Forexample,wherealocumisbroughtinonashort-termbasis,theirinductionmaybelimited.TheirlackoffamiliaritywiththeTrustworkingenvironmentandotherstaffcancreatearisktopatientsafety.Further,theirlimitedstayonawardraisesconcernsoverthecontinuityofcare.

1.25 Trustshaveacknowledgedthatitwouldbepreferabletohaveamorerobust‘bank’oflocumstaff,whoprogressthroughaformaltrainingupdateprogramme,onanannualbasis.Withthisinmind,Trustsareengagingwitheachotherwithaviewtodevelopingaregionally-managedlocumsystem(seeparagraph2.16).

This report considers the effectiveness of Trust controls over the use of locum doctors in hospitals

1.26 ThisReportconsiderstheeffectivenessofmanagementarrangementsovertheuseoflocumdoctorsbyTrusts;

• Part2examinesthearrangementsinplacetomanagethedemandforlocumdoctors;and

• Part3considersthearrangementsinplaceforsafeguardingthequalityofcareprovidedtopatients.

MoredetailonourmethodologyissetoutatAppendix4.

Part Two:Managing the demand for locum cover

Workforce planning in the health service attempts to balance the availability of suitably-qualified medical staff against patient needs

2.1 Workforceplanningprovidesorganisationswithanopportunitytoidentifytrendsandanticipateshortfallsinstaffinglevels.Medicalworkforceplanningisacomplexprocess.InNorthernIreland,theexerciseconsistsofamajorreviewofserviceseverythreeyearsandinvolvesseveralorganisations,notablytheDepartment,theMedicalSchoolatTheQueen’sUniversityofBelfast,theTrustsandtheNorthernIrelandMedicalandDentalTrainingAgency12.Theobjectiveofmedicalworkforceplanningistobalancetheavailabilityofsuitably-qualifiedmedicalstaffagainstpatients’needs.

The latest Review of the Medical Workforce was published in 2010

2.2 InApril2010,theDepartmentpublisheditslatestReviewoftheMedicalWorkforce13.Thepurposeofthereviewwastoprovidecomprehensive,currentinformationonthemedicalprofessionalgroupinNorthernIrelandtobeusedbytheDepartmenttoforward-plantrainingoverafivetotenyearperiod14.

Changes to the hospital environment have had an impact on the availability of staff

2.3 Theenvironmentinwhichhospitalservicesaredeliveredhasgonethroughaperiodofsubstantialchange.Thishasimpactedontheavailabilityofstaffandthereforeontheneedtouselocumsifcrucialservicesaretobedelivered.GiventhecomplicatedinterplaybetweenworkforceplanningattheregionallevelandindividualTrusts’overallmedicalstaffingarrangements,inevitablythesupplyoftraineddoctorswillnotalwaysmatchdemand.Wheredemandforclinicalservicesoutstripsmedicalworkforcesupply,keyservicesmayhavetobewithdrawn.Forinstance,duringSeptember2009,theobstetricsandgynaecologyserviceattheErneHospitalwassuspendedfortwoweeksduetoagapintheserviceprovisioncreatedbyalackofjuniordoctors.In2010,AccidentandEmergencyservicesattheWhiteabbeyandMid-UlsterHospitalswereclosedandtransferredtoAntrimAreaHospitalforanumberofreasons15.Onereasonwasthelossofseniorclinicalstaffattheformertwolocationsandtheimpactthiscouldhaveonthequalityofclinicaloutcomes.

2.4 Primaryresponsibilityforplanningstaffingneedsinrelationtoservicedeliveryrestswiththeemployer–asdoessuccessionplanning.ThisisdoneatTrustlevel,andtheresultsprovidedto

12 TheNorthernIrelandMedicalandDentalTrainingAgencyisresponsibleforfunding,managingandsupportingpostgraduatemedicalanddentaleducationwithinNorthernIreland.Itisresponsiblefortheorganisation,developmentandqualityassuranceofPostgraduateMedicalandDentalEducationandforthedeliveryandqualityassuranceofContinuingProfessionalDevelopmentforgeneral,medicalanddentalpractitioners.

13 The2010Reviewrelatedto2008whilethepreviousreview,publishedin2006,relatedto2005.14 The2010WorkforcePlanningReviewrelatedtothetenyearperiodfrom2008.15 OtherreasonsfortheclosureincludedtheabsenceofcriticalcarefacilitiesandapaediatricserviceatWhiteabbey

Hospital,thelackofaccessateitherhospitalstoacutesurgicalinpatientservices,theabsenceofintensivecareunitsatbothsites;andthelimitationsmoderntechnologiesincardiologyhaveplacedoncardiologists’abilitytocovertwositessimultaneouslyout-of-hours.

theDepartment,sothatregionalgaps/shortages/trendscanbeidentifiedandremedialactiontaken.Theregionalpositionisanoverallsummarywhichcannotreplacecloseplanninginrelationtoserviceneeds.TheDepartmenttoldusthatworkiscurrentlyunderwaytopromptimprovementsinthisarea.

2.5 Severalfactorshavecontributedtothelimitedavailabilityofsuitablyqualifiedstaffacrossthehealthandsocialcaresectorasfollows:

a. Changes to the immigration rules:InFebruary2008,anewpoints-basedimmigrationsystemwasintroducedsettingouttheconditionsunderwhichoverseasdoctorscouldqualifyforentrytoworkintheUK.ThenewregulationsrestrictthenumbersofoverseasdoctorseligibletoworkintheUK.

b. Introduction of the European Working Time Directive (EWTD):TheEWTDwasintroducedinNorthernIrelandin1998toprotectthehealthandsafetyofworkersbyintroducingminimumrulesforrestperiods,leaveentitlements,lengthofworkingweekandnightwork(additionalinformationontheimplicationsoftheDirectiveissetoutatAppendix5).FromAugust2004,thelegislationlimitedjuniordoctors’workinghoursto58perweek.Thiswasfurtherreducedto56hoursperweekfromAugust2007andto48hoursfromAugust200916.

c. Individual specialty and location preferences of staff: HospitalslocatedoutsideBelfastoftenexperiencedifficultyattractingandretainingstaff.Small,ruralsitescanstruggletoconsistentlyprovideadequatecoverforpatients.Withinthesehospitals,thelossofevenonememberofstaff(throughsickleave,resignationorotherreason)canhaveamajorimpactontheabilityofthesitetomaintainitsservices.Inevitablythisputspressureonremainingconsultantsandstaffandmakestheirpositionslessattractive.

d. Flexibility of working hours and early retirements:Doctorsofbothsexesareincreasinglyelectingtoworkfewerhoursduringtheircareerandtoretireearly.ThisreflectsbroadercommunitypreferencesforbalancingworkandprivatelifebutplacespressureonTrustsasexperiencedstaffareavailableforareducedperiodoftime.

e. Change in the female to male ratio of students:Anincreasingnumberoffemalesarechoosingmedicineasacareer.ThecurrentfemaletomaleratioamongmedicalstudentsatQueen’sUniversity,Belfastisalmost60:4017.Thiswillultimatelyimpactonthecompositionoftheworkforce-overthelasttwoyearsfemalerepresentationhasincreasedby3percentand,infutureyears,thisisexpectedtorise.Theemploymentofadditionalfemalescanplacefurther

16 ResearchundertakenbytheDepartmentin2008identifiedthatdespitethepotentialimpositionofheavypenalties,non-compliancewithEWTDishighacrossthefiveNorthernIrelandHealthandSocialCareTrusts.TheresearchidentifiedthatlevelsofcompliancecouldbesignificantlyimprovedbytheimplementationofinternalmeasuresbyeachoftherespectiveTrusts.

17 QUBMedicalSchoolData–January2009-Femaletomaleratiois57:43

pressureonTrustswherecoverisrequiredforperiodsofmaternityleave.

2.6 TheDepartmenttoldusthatithastakenstepstoaddresstheshortageofjuniordoctors.In2005,fundingwasprovidedtoincreasethenumberofmedicalstudents.Theextenttowhichtheseadditionalgraduatesreducetheuseoflocumswilldependontheirchosencareerlocationandtheirchoiceofspecialty.

2.7 Whilelocumappointmentsareintendedtofillgapsresultingfromtheunavailabilityofpermanentdoctors,thereisevidencethatthelocalsupplyoflocumsisalsobecomingaconcern.TheDepartmentrecentlydrewattentiontothehighcostsofbringingindoctorsfromoutsideNorthernIrelandtoprovidecoverinAccidentandEmergencydepartments,commentingthat,insomecases,temporaryreplacementdoctorswerebeingpaidalmostthreetimesmorethanstaffdoctors18.Trustsneedtobeabletodemonstratethatsuchpracticeisanappropriateandcosteffectiveuseofresourcesinthelongerterm.

Management information is insufficient to enable effective monitoring and control of the use of locums

2.8 IndividualTrustscollectinformation,tovaryingdegrees,ontheusageandcostsoflocumdoctorsandreportthistomanagementperiodically.However,theinformationcollectedisnotcomprehensivenorisitbroughttogetherinasystematicmannertoprovidethebasisforanalysing

themostappropriatewaytouselocumsthroughouttheTrusts.Failuretocollateandanalysecomprehensivemanagementinformationmakeseffectivestrategicplanningandcontroloflocumsverydifficult.TheabilityofTruststoplanstrategicallyandworkflexiblybecomesincreasinglyimportant,iftheyaretoaddressmedicalworkforcechanges.

2.9 TheTruststoldusthatitisessentialthatinformationisavailabletoassistinplanninganduseoflocums.TheTrustsseegreatmeritinthedevelopmentofaregionalmanagementinformationsystemwhichwouldbemanagedbyadedicatedresourceandwouldensurethatinformationiscollatedconsistentlyacrosstheregion.Thiswouldalsofacilitateregionalmonitoringofactivityandtrendsandinter-trustcomparisons,providinggreateropportunityformanagingtheuseoflocumsholisticallyacrosstheservice.

The 2010 Workforce Planning Review was completed in the absence of detailed information on speciality training

2.10 Iftheuseoflocumdoctorsistobeeffectivelyplanned,itisessentialtohavegoodqualityinformationonlikelystaffingdifficultieswithinthesector.TheworkforceplanningreviewpublishedinSeptember200619indicatedpotentialstaffingshortfallsinthefollowingspecialties(seeAppendix6forfurtherdetail):

• anaesthetics;

• communitypaediatrics;

18 InformationwasextractedfromanarticlewhichappearedintheIrishNewson2April2010.19 ReviewofWorkforcePlanningfortheMedicalProfession,September2006

• orthopaedics;

• psychiatry;and

• radiology.

2.11 ThenextWorkforcePlanningReview,publishedin2010,statesthat“...detailed specialty planning will be required to address specialty specific training and recruitment needs”.WhiletheDepartmenttoldusthatplanningforallspecialtieshadbeencompletedbeforeApril2009,theReviewteamwouldnothavehadallofthisinformationatthetimeofitsfieldwork.Inourview,tobemosteffective,itisimportantthatworkforceplanningshouldbebasedonananalysisofthestaffnumbersandgradesthatareneededsothatbothtrainingrequirementsandserviceneedsaremet.ItisonlywhensuchplansareagreedthatTrustswillbeinapositiontoconsiderhowtheirdependenceonlocumsmightbereduced.

2.12 Inordertomaximiseuseoftheworkforceplanningwerecommendthat,forallsubsequentexercises,specialtyplanningiscommissionedandundertakeninsufficienttimetoenabledetailedanalysispriortopublicationoftheten-yearWorkforcePlanningReview.

Using locum doctors can create considerable financial risks

2.13 Therecanbeconsiderablefinancialrisksinappointinglocumdoctors.Trustsarechargedwithensuringthatthey

havesufficientsubstantivepoststomeetforeseenservicedemands,includingplannedabsences.TheDepartmenttoldusthatTrustsmustbalancethisrequirementagainsttheirstatutoryobligationtobreak-eveneachyear.Theuseoflocumsisgenerallyonlypermissibletocovertemporaryabsences(suchasmaternityabsence)fromsubstantiveposts.Locumappointmentsareexpectedtobeprecededbyanassessmentoftherelativecost-effectivenessandviabilityofengagingadditionalpermanentstaffasopposedtoengaginglocumstaff.TheDepartmentassuredusthateachTrustreviewstherelativemeritsofeachcaseandassessescost-effectivenessbeforemakingdecisions.

2.14 WeexaminedInternalAuditreportsontheuseoflocumsproducedsince2005.Thesemadeanumberofcommentsinrelationtopaymentsmadetolocumagencies20:

• itwasoftendifficulttoverifytheratespaidtoexternalagenciesbecausespecificlocumgradeswerenotrecordedonthedocumentation;

• instanceswereidentifiedwhereTrustswereusinglocumsregisteredwithAgencieswhichdonothaveacontractwithTrusts.Inthesecases,Trustswerenegotiatingpaymentratesonanad-hocbasis;

• itwasnotedthatexistingTrustmedicalemployeeswerealsoregisteredwithlocumAgencies(onoccasionmorethanoneagency).Inthesecases,

20 Itisnotpossibletoquantifytheactualextentofnon-complianceidentifiedbyInternalAuditduetothesummarynatureoftheirreports.

Trustsarepayinghigherratestotheirownemployeesthroughexternalrecruitmentagencies;and

• instanceswererepeatedlyidentifiedbyInternalAuditwheretheratespaidforlocumworkwereinexcessoftheDepartment’sagreedremunerationrates.Inaddition,otheroccasionswerehighlightedwhereTrusts,needingashiftcoveredatthelastminute,negotiatedpaymentsrateswithlocumsratherthanofferingtheratesstipulatedbytheDepartment(seeCaseExample1).TheDepartmentconfirmedthatinordertofillgapsinrotastomaintainsafeandeffectiveservicesitissometimesnecessarytonegotiatehigherratesthanthoserecommendedinDepartmentalguidance.ThemanagementinformationheldbytheDepartmentandTrustsisnotsufficientlydetailedtoallowidentificationoftheproportionandvalueoflocumpaymentswhichexceedstipulatedrates.

2.15 Giventhecurrentdrivefordeliveringefficiencysavingsacrossthehealthandsocialcaresector,Trustsmusttakeactiontocontrolcostswhenengaginglocumdoctors.DrawingontheexperienceoftheNationalHealthService(NHS)inEngland,wehavesetoutinFigure5,twoexamplesofgoodpracticewhichhavebeendevelopedandimplementedbyparticipatingteams(fulldetailsareprovidedatAppendix7).Eachexamplehasapositiveimpactonproductivity,improvesefficiencyandgeneratescost-savings21.Inparticular,thecollaborationofhospitalsandTrusts,applyingagreedstandardsandrates,hasbeenshowntocontributetomorecost-effectiveuseofmedicallocums.AnumberofTrustsworkingtogetherhavegreaterleveragewithexternalagencies,andeconomiesofscalecandelivermorecompetitiveagencyrates.Additionally,collaborationacrossTrustsenablesthesharingofgoodpracticeandlearning.

21 ThegoodpracticeexampleshavebeentakenfromtheNHSEmployerspublication“Controlling the use of temporary staff through large scale workforce change”.

Case Example 1

Inoneinstance,anInternalLocumConsultanthadbeenpaidaremunerationratearbitrarilydeterminedbytheClinicalDirectorateratherthanthatspecifiedinDepartmentalguidance.TheConsultantwaspaidatotalof£1,500(£500per3-4hoursession).Weestimatethathadadoctorinasubstantivepostundertakenthework,thelikelycostwouldhavebeenaround£100to£125foreach3-4hoursession).ItwasalsonotedthatpaymentforonesessionwasdisallowedbyFinancesinceithadbeenpaidbefore.

Figure 5: Summary of Good Practice Purchasing Initiatives identified by NHS Employers

Issues similar to those identified in our report were identified in hospitals across UK Trusts as follows:• theuseofagenciesoutsidethoseoutlinedinthenationalframeworkwereregularlybeingused;• individualdepartmentsweredevelopingandusingtheirownsuppliersandproceduresforbookinglocums;• absenceof(orlimited)centralcontroloverexpenditureontemporarystaff;• anabsenceofusefulintelligenceonmedicallocumusageandspend;• insufficientcheckingofinvoicesformedicallocumsepisodes;and• anumberofpositionsreliedonhigh-costmedicallocumstofillvacancies,andthesehadnotbeenreviewed

forsometime.

A range of potential solutions were generated and piloted to address these issues as follows:• useofaconsortiumoftrustswithsharedgoalsandcommitments,todrivedownagencycoststhrough

combinedspendingpower;• developmentofamastervendornetworkallocatingresponsibilityforsupplyingtemporarystafftoasingle

supplier;• introductionofprotocolsandimprovedfinancialcontrolsoverthebookingofmedicallocums;• directphonecallstoagenciesfromwardswerebanned,thephonenumberwasblockedthroughthe

switchboardandout-of-hoursbookingsweredonethroughon-callexecutivedirectors;• useofcentralisedbookingarrangements(forallmedicalstaff)throughonesourcewithinindividualTrusts;• improvedmanagementinformationtoallowmanagerstocontroltheuseoftemporarystaffmoreeffectively;• reviewofrota-planningarrangements;and• postswhichtendedtorelyheavilyonagencylocumswerere-advertised,NHSlocumswerefavouredover

agencylocumsandagencylocumswereencouragedtotransfertoNHScontracts.

Various benefits were secured through these initiatives including:• abilitytosecuremorefavourableratesandbettersharingofgoodpracticethroughcollaborativeworking;• increasedspendingpower,greaterleverageindrivingdowncosts,improvedservicetoTrustsandthe

provisionofimprovedmanagementinformationfromthesupplier;• improvedmonitoringoftheuseoflocums;• releaseofconsiderableclinicalstafftimebyuseofadministrativestafftoarrangelocumbookingsandasingle

supplier;and• improvedstaffmoralebyincreasingfillratesonshifts.

Actual savings were secured as follows:• InoneTrust,theuseofthemastervendorsystemreducedspendonmedicallocums(nursingandmedical)by

justover£2millioneachyear.• InthatTrust,theintroductionofacentralisedbookingsystemreleasedsavingsofaround£0.8million.• WithinanotherTrust,theintroductionofimprovedproceduresreducedtheuseandcostofmedicallocumsby

over£278,000permonth,equatingtoanestimatedannualsavingofover£3.3millionperyear.

2.16 GiventhesuccessoftheseexamplesintheNHS,itisencouragingtonotetherecentdecisioninNorthernIrelandtotakestepstointroduceaRegionallyManagedMedicalLocumServiceforNorthernIreland(seeAppendix8).WealsowelcomeassurancesfromtheBusinessServicesOrganisationthatithastakenstepstoimprovecollaborativeworkingandimprovepurchasingarrangements.

2.17 TrustsacrosstheUnitedKingdomexperiencesimilarproblemsmanaginglocumcosts.SuccessfulpilotsinTrustsacrosstheUnitedKingdomgeneratedsubstantialsavingsandthiscouldbereplicatedwithinNorthernIrelandTrusts.WerecommendthatTrustskeepuptodatewithdevelopmentselsewhereintheUnitedKingdomandexplorethesuccessorotherwiseofthevariousinitiativesundertakenasameansofidentifyingimprovedpractices.

Part Three:Safeguarding the quality of care provided to patients

Trusts and the Department must manage risks to provide safe, high-quality care to patients

3.1 Asdemandforlocumsincreasesandpressureonworkloadgrows,TrustsandtheDepartmentmustensurethat,alongwithcontrollingcosts,doctorsappointedonalocumbasisarecompetenttoundertakethedutiesrequiredofthem.Riskmanagement,therefore,isincreasinglyimportantinensuringthatTrustsprovideasafeandhighqualityservicetopatients.Patientsareentitledtoexpectappropriatestaffinglevelsandprofessionalcompetence.Theuseoflocumdoctorsbothavertsandcontributestotherisk,byenablinghospitalstomaintainappropriatestaffinglevelseventhoughthismightinvolveappointingdoctorswithlessexperienceorskillsthanthosetheyarereplacing.

3.2 Therecanbeotherpotentialrisksforthehealthcaresysteminengaginglocums:lackofcontinuityofcare;orlackoffamiliaritywithahospitalanditsprocedures.Inaddition,therecanbesignificantpotentialdisadvantagesfordoctorswhochoosetoworkonalocumbasis,forexample,thelackofongoingeducationfrompatientfollow-up;andtheabsenceofmentorandpeersupportorinadequatesupervisionofadherencetoconditionsoftheEWTD(seeparagraph2.5b).

3.3 Thepresenceofriskisnotanargumentagainsttheuseoflocums,butthosemakingthedecisionsneedtobeable

toidentify,measureandcontrolthedegreeofriskinvolved.ThecorporategovernancestructureswithinthehealthandsocialcaresectorrequiretheManagementBoardsofindividualTruststoevaluateinternalcontrolsandreporttheresultstotheDepartment.Inrelationtostaffing,theHumanResources(HR)ControlsAssuranceStandard22setsoutkeycriteriaandcontainsguidanceonhowManagementBoardsshouldestablishwhethersystemsaresound.OneofthestatedcriteriaoftheHRStandardistoensurethatallstaffarerecruitedandemployedinaccordancewithrelevantstatutoryemploymentlegislationandanyotherrelevantrequirements.

Locum doctors provided to Trusts by external agencies are not regulated by the Regulation and Quality Improvement Authority

3.4 TheRegulationandQualityImprovementAuthority(RQIA)23isresponsiblefortheregulationofawiderangeofhealthandsocialcareservicesincludingNursingAgencieswhichprovidetemporaryregisterednurses,healthvisitors,andmidwivestothehealthandsocialcaresector.However,itsremitdoesnotextendtoAgenciesprovidinglocumdoctors.

3.5 WeunderstandthatarrangementsinScotlandandWalesalsoexcludetheregulationoflocumagencies.InEngland,unlessthelocumagencyhasadirectroleinmanagingordirectingthecarethenitisexemptfromregulation.

22 HSCControlsAssuranceStandard–HumanResources(latestversionApril2009)23 RQIAistheindependentbodyresponsibleformonitoringandinspectingtheavailabilityandqualityofhealthandsocial

careservicesinNorthernIreland,andencouragingimprovementsinthequalityofthoseservices.

3.6 AlthoughwenotethatthecurrentregulationarrangementsinNorthernIrelandmirrorthoseelsewhereintheUnitedKingdom,inourview,externalagenciessupplyinglocumdoctorsshouldbesubjecttothesameregulationasnursingagencies.WerecommendthattheDepartmentconsidersextendingRQIA’sroletocoverexternalagenciessupplyinglocumdoctorstoTrusts.Formaximumbenefit,theDepartmentshouldconsiderliaisingwiththeotherregionsintheUnitedKingdomwithaviewtodevelopingajoined-upapproachtosuchregulation.

The Code of Practice in Locum Doctor Appointment and Employment was introduced in Northern Ireland in 1998 and sets out key controls for the use of locums

3.7 ItistheclearresponsibilityofTruststoensurethatalldoctorstheyemployarecompetent,appropriatelyqualified,experiencedandcapableofundertakingthedutiesrequiredofthem.ToassistTrusts,inJuly1998,theDepartmentintroducedTheCodeofPracticeinLocumDoctorAppointmentandEmployment.

3.8 TheCodewasdevelopedbytheLocumsWorkingGroupwhichwascommissionedbytheChiefMedicalOfficerinEnglandbecause:

“... the health service, the medical profession and the Health Departments all expressed concerns over the quality of some locum doctors and the apparent ease with which some unsatisfactory

doctors are sometimes able to move between locum posts within the Health Service ...”

The Code sets out the required pre-employment checks for each locum episode

3.9 Theguidanceoutlineskeycheckstobecompletedpriortotheappointmentoflocumdoctorsandrequiredmonitoringandrecordingofthequalityofeachlocumepisode.TheCodeclarifiesthatalllocumappointmentsshouldcomply.ItremindsTruststhat,asemployers,theyhaveultimateresponsibilityforpre-employmentscreening,whetherornotthelocumdoctorhasbeensuppliedbyanagency.Theobjectiveoftheguidanceistosafeguardthequalityofpatientcare.Asanadditionalcontrol,inlinewithDepartmentalguidance,TrustsarerequiredtouseonlylocumssuppliedbycontractedAgencies.

3.10 Followingadecisiontoappointalocumdoctor,eachTrusthasresponsibilityfordeterminingthemostsuitableapplicant.Locumappointmentsshouldbemadewiththesamecareassubstantiveappointments.Priortoofferingtheappointment,Trustsareresponsibleforensuringthatthelocumdoctor:

• hastherequisitequalificationsandexperiencetoundertakethework;

• isnotsubjecttoreservationsaboutthestandardorcompetenceinpreviousemployment;

24 Again,itisnotpossibletoquantifytheactualextentofnon-complianceidentifiedbyInternalAuditduetothesummarynatureoftheirreports.

• identifiesandprovidesawrittenreportfromtheirmostrecentlocumemployerand/orrelevantreferences;

• hasbeensubjecttoaformalhealthassessmentandhassignedahealthdeclarationform;and

• disclosesdetailsofanyconvictions–spentorotherwise.

3.11 Inpractice,whereAgencylocumsareused,pre-employmentchecksarecompletedbytheAgency.Internallocums,asTrustemployees,willalreadyhavebeenappointedusingproceduresforsubstantiveposts.

We identified several weaknesses in procedures for employing locums from external agencies

3.12 Aswellasexaminingasampleof30locumappointmentswithintheBelfastTrust,wereviewedpreviousinternalauditreportsontheuseoflocumsproducedsince2005.Wefoundevidenceofproblemswiththewayinwhichchecksonlocumdoctorshavebeenconducted24:

• inoneTrust,Agencieshadnotbeenrequiredtoprovidewrittenconfirmationthatpre-employmentcheckshadbeencompleted;

• inoneTrust,qualificationchecksweremadeonaninformalbasis,increasingtheriskofinappropriateandpossiblyunder-qualifiedstaffbeingused;

• someTrustsusednon-contractedAgenciestoprovidestaff.Thisraisesissuesrelatingtothequalityandsafetyofservicewhereassuranceislimitedthatappropriatevalidationcheckshavebeencompleted.TheDepartmenttoldusthat,wherecontractedagenciesareunabletoprovideappropriatestaff,Trustshavenooptionbuttousenon-contractedAgencies;and

• someTrustshadfailedtocarryoutanyauditoflocumAgenciesforanumberofyears.Undercontractualarrangements,Trustshavetherighttoconductanauditoftheexternalagencyatanytime,toensureitcomplieswithitspre-employmentvettingobligations.SuchauditsshouldincludechecksthatthelocumdoctorregisteredwiththeAgencyhasthenecessaryqualifications/experience/skillsforthepost,hasasatisfactoryhealthassessment,andproperjobreferences.AssuchtheygiveassurancetoTruststhatAgenciesareprovidingproperlyvettedlocums.WeunderstandthatnoauditshavebeenperformedsincetheinceptionofthenewHealthTrustsinApril2007.

3.13 ItisamatterofconcernthatTrustsonsomanyoccasionsdidnotcomplywiththeapprovedproceduresforemployinglocumsfromexternalagencies.Inmanycases,InternalAudit’sconcernsresultedinanassessmentof“partial”or“limited”assurance.

3.14 WerecommendthatallTrustscomplywiththeexistingproceduresforemployinglocumdoctorsfromexternalagencies.Foralllocumappointments,Trustsmustbesatisfiedthatappropriatevettingofapplicantshasbeenundertaken.Intheabsenceofappropriatevetting,Trustsriskcompromisingpatientsafetyandmayfaceseriousfinancialconsequencesifclaimsforclinicalnegligenceweretoresultfromaninappropriateappointment.

3.15 Trustsalsoneedtocarefullyweigh,andfullyaddress,theaddedrisksofusinglocums,especiallywheredoctorsarenewtothehospital,areunfamiliarwithcolleagues,thepatientsundertheircareandlocalproceduresandpractices.WerecommendthatTrustsreviewtheirinductionarrangementsforlocumstafftoprotectpatientsafety.

The Code sets out procedures for assessing the quality of service for each locum episode

3.16 Inadditiontopre-employmentchecks,Trustsneedtohaveproceduresinplacetoensurethatthequalityofserviceisassessedforeachlocumepisode.InOctober2006,theDepartmentintroduced Interim Arrangements for the Appraisal of Locum Doctors in Trusts. Thisenhancesguidancecontainedinthe1998CodeofPractice(paragraph3.7).TherequirementsoftheguidancearesetoutinFigure6.

3.17 InAugust2008,RQIAconductedaReview of Medical Consultant Appraisal.Aspartofthereview,Trustswereaskedtosupplyinformationonthepercentageofconsultantlocumswhohadnotbeenappraisedduringtheperiod1April2006-31March2007.RQIAnotedinthereportthat

Figure 6: Appraisal of Locum Doctors

- wherealocumdoctorisemployedforlessthanoneweekhe/sheshouldbesuppliedwithasuitablereferenceor‘statementofsatisfactoryemployment’

- wherealocumdoctorisemployedforperiodsofmorethanoneweekbutlessthansixmonthsandcannotbeincludedinroutineappraisalprocesses,anend-of-placementreport,whichshowsthattherearenosignificantunresolvedconcernsaboutthedoctor’sfitnesstopractise,shouldbecompleted

- ifthelocumpostisformorethansixmonthsduration,thedoctorshouldbeappraisedaspartoftheroutineappraisalprocess

- wherethelocumdoctorisemployedviaanAgencyandappraisalofdoctorsispartoftheservicesprovidedbythatAgency,theemployershouldensurethatappropriatestandardsandqualityassurancemechanismsareinplacetoensurerobustappraisalmechanismsandpre-employmentchecks.

themethodologyledtolimitationsinthequalityofinformationsuppliedbytheTrusts.Thereviewmethodologywasnotconducivetoin-depthanalysisnordiditallowexaminationoftheimplementationofpoliciesandprocedures.Theviewsofappraisersandappraiseeswerenotsought.Therefore,theanalysisoftheeffectivenessoftheconsultantappraisalsystemislimited.ResultsarecontainedatFigure7.

Figure 7 – Percentage of Locum Consultants not Appraised

Trust % locums not appraised

Belfast Informationnotsupplied

Northern 42%

Southern 43%

SouthEastern Informationnotsupplied

Western Informationnotsupplied

Source: RQIA

3.18 OnlytwoTrustssuppliedtherequiredinformation.FortheseTrusts,asignificantpercentageoflocumconsultantshadnotbeenappraised.Reasonsgivenfornon-appraisalincluded:

• changesinmedicalpersonnelasaresultoftherestructuringwithinthehealthsectorhadadverselyaffectedthecompletionofappraisals;

• lossofmomentumasaresultofthedelayinfinalisingarrangementsforrevalidationofhospitaldoctors(seeparagraph3.27below);

• doctorsappraisedbutpaperworknotreturnedtoHumanResources;

• postsnotfilledpermanentlyandhighturnoveroflocumstaff;and

• sickleave.

3.19 Inadditiontotheapparentlowincidenceoflocumappraisal,RQIAidentifiedanumberofotherconcernswiththemedicalappraisalsystem,including:

• therewaslittleevidencesubmittedthatTrustscarryoutanannualauditofmedicalappraisalsystems.Inthemain,Trustsdescribedanaspirationtomeetgoodappraisalcriteria;and

• onlyoneTrust(theSouthernTrust)indicatedithadaprocessinplacetoreviewtheskillsofappraisers.RQIAconcludedfromitsanalysisofinformationfromTrusts,thatthereappearedtobenoformalprocessforreviewandperformancemanagementofappraisers,andlittleevaluationoftheeffectivenessoftheappraisaldiscussion.

3.20 Inamorerecentreviewin201025,RQIAconcludedthattherewasstrongcommitmentinallHealthandsocialcaresectorTrustsinNorthernIrelandtoensuringeffectiveappraisalsystemsareinplaceandthattherehasbeengoodprogresstowardspreparingforrevalidation.However,specificallyinrelationtolocums,thereviewteamobservedthatTrustswerenotalwaysreceivingendofplacementreportsfrom

25 In2010,RQIAworkedwiththeGeneralMedicalCouncil,theNHSRevalidationSupportTeam(RST),QualityImprovementScotlandandtheHealthcareInspectorateWalestopilotaapproachforindependentlyreviewingmedicalrevalidationprocedureswithinTrusts.

locumagenciesorpreviousemployersandthatnotallTrustshadsystemsinplacetoprovideexitreportsforalllocumdoctors.ThereviewteamconsideredthatitwouldbeusefultostandardisearrangementsacrossNorthernIrelandandrecommendedareviewofthesystemsforgatheringandsharinglocumdoctorinformationtoensurethatthesecansupportrevalidation.

3.21 Failuretocarryoutlocumdoctorappraisalsinaconsistentandrigorouswayandtoregularlyauditappraisalproceduresisaseriousbreachofclinicalgovernance.Attheconclusionofeverylocumappointment,inlinewithbestpractice,theTrustspecialtyengagingalocumdoctorshouldprepareabriefstandardisedreturntotheclinicaldirector,providingfeedbackonperformanceandhighlightinganyconcerns.Trustsalsoneedtohaveproceduresinplacetoensurethatappraisers,whoarekeytotheprocess,areselected,trainedandsupportedappropriately.

3.22 Theplannedmovetowardsanewsystemofrevalidationasameansofassessingtheperformanceofstaffprovidinghealthcaretopatientsisapositivestep.WewelcometheassurancethatallHSCTrustsinNorthernIrelandarecommittedtoensuringeffectiveappraisalsystemsareinplaceandhavemadegoodprogresstowardspreparingforrevalidation.However,wenotetherecommendationsofthereviewteamthatworkisrequiredinrelation

totheappraisaloflocumdoctors.WerecommendthattheDepartmentaddressesthereviewteam’sconcernsinrelationtolocumdoctorsasamatterofurgency.

The limitations of existing management information can create difficulties for Trusts attempting to verify compliance with the requirements of the European Working Time Directive (EWTD)

3.23 TheDepartmenttoldusthat,compliancewiththeEWTD(seeparagraph2.5)hascontributedtotheneedtoemploylocums.However,wefoundthatthemanagementinformationsystemsinplacedonotfacilitatemonitoringofthenumberofhoursworkedbyinternallocums.Byimplicationthisthereforeprecludesidentificationofthenumberofhoursresttakenbyinternallocums.AcrucialelementoftheEWTDistheneedfordoctorstotakeaminimumof11hoursrestinany24hourperiod.Whileitisuptoindividualdoctorstobehaveinaprofessionalmanner,itisalsoappropriatetohavesystemsinplacetoensurethatlocumdoctorsdonotworkexcessivehours.AlthoughTrustsmustensurethatthestaffwhomtheyemploydonotbreachthetermsoftheEWTD,whereadoctorchoosestoworkadditionalhoursinanotherTrust,itcanbedifficultforindividualTruststomonitorcontinuedcompliancewiththeDirective.

3.24 AccordingtoresearchundertakenbytheDepartmentin200826,non-compliancewiththeEWTDwashighacrossthefive

26 ResearchwasundertakenbytheDepartment’sImplementationSupportGroupinAugust2008

NorthernIrelandHealthandSocialCareTrustsdespitethepotentialimpositionofheavypenalties.TheresearchidentifiedthattheaveragelevelofcompliancewiththeDirectiveacrossTrustswas40percent.

3.25 TheDepartmenttoldusthatamorerecentself-reportingexerciseundertakeninOctober201027indicatedthatthelevelofcompliancewas77.5percent.Theexerciseidentifiedthatnon-complaintpostsweremainlyinspecialtiessuchasMedicine,Surgery,ObstetricsandGynaecology,PsychiatryandPaediatricswheresolutionsremaindifficult.

3.26 WeacknowledgetheimprovementthattheTrustshavemadeintherateofcompliancewiththeEWTD.WealsorecognisethedifficultyfacedbyTrustsanddoctorsincomplyingwiththeDirectivewhileseekingtomeetthedemandsofhospitalservices.However,failuretomeettherequirementsofEWTDcouldresultintheimpositionofsignificantfinancialpenaltiesbytheEuropeanUnion,ormoreseriously,couldcompromisethehealthandsafetyofdoctorsandpatients.Itisimportant,therefore,thatTrustsworkcloselytogetherandwiththeDepartmenttoagreewhatneedstobedonetosupportcompliance.

The Confidence in Care programme, introducing revalidation of all licensed doctors, is intended to improve the quality of patient care

3.27 The2007WhitePaperTrust Assurance and Safetyhaspositionedappraisalasthecornerstoneofaprogrammeofrevalidation.Whentheprogrammeisfullyimplemented,everydoctorwhowishestopractise(eitherasasubstantivestaffmemberorasalocum)willberequiredtoholdalicenseandwillberequiredtoparticipateinrevalidation.Revalidationistheprocessbywhichdoctorswilldemonstratethattheirknowledgeisuptodateandthattheyarefittopractise.

3.28 Undertheprocess,eachdoctorwillmaintainafive-yearportfolioforreviewagainststandards(setbytheGeneralMedicalCouncil)atanannualappraisal.Thisapproachaimstoensuremoreconsistentclinicalgovernanceandthefairerassessmentofdoctors’medicalpracticeagainststandards.ItisimportanttonotethattheLocumDoctors’Association28hasexpressedconcernovertheabilityoflocumdoctorstocollateenoughevidenceofpracticetowarrantrevalidation.

3.29 Wewelcometheplanstomovetowardsanewsystemofrevalidationasameansofassessingtheperformanceofstaffprovidinghealthcaretopatients.

27 TheBoardLiaisonGroup(BLG)withintheHealthandSocialCareBoardactsinanadvisorycapacitytoTrusts,theHSCBoardandtheDepartmenttohelpdevelopEWTDnon-compliancesolutions.TheBLGestimatedtheOctober2010levelofcompliancewiththeEWTDonthebasisoftheresultsofaself-reportingexerciseacrosstheTrusts.

28 TheLDAisatradeunionwhichwasfoundedinJune1997andrepresentshospitallocumdoctors.

3.30 Whenrevalidationisfullyoperational,itssuccesswilldependtoalargeextentontherobustnessofTrustarrangementsandthequalityofchallengeexercisedbyTrustswherethereisanyevidenceoflackofcompliance.Intheperiodpriortotheintroductionofrevalidation,werecommendthatTrustsintroduceinterimarrangementstoassesstheperformanceofhospitallocums.

Where Trusts do not undertake the required pre-employment checks, complete appraisals for each locum episode or enforce compliance with the EWTD, there is a risk that patient safety will be compromised

3.31 Duringourauditwefoundevidencethatpre-employmentchecksandappraisalsarenotcompletedforalllocumepisodes.WealsonotedfromresearchundertakenbytheDepartmentthatTrustswerenotcomplyingwiththerequirementsoftheEWTD.Theseareimportantcontrolsdesignedtoprovideassurancethatpatientsreceivequalitycare.WhileweacknowledgethattheDepartmenthasintroducedclinicalandsocialcaregovernanceandriskmanagementprocessesacrossthehealthandsocialcaresector,inourviewthefailuretocomplywithkeycontrolsincreasestheriskthatcareisnotofsufficientquality.

3.32 Inanattempttoestablishwhetherlocumdoctorsposeagreaterclinicalriskthantheircounterpartsinsubstantiveposts,weexaminedtherecordsheldbytheDepartment29forevidenceastowhether

theincidenceofseriousadverseincidentsinvolvinglocumdoctorswashigherthanthoseinvolvingonlypermanentstaff.Wefoundhowever,thattheDepartment’srecordsdidnotconsistentlyrecordwhetherthedoctorinvolvedwasemployedpermanentlyorwasalocum.

3.33 TheDepartmenttoldusthatsuchareviewofseriousadverseincidentswouldnotproduceanobjectiveassessmentoflocumperformance.WhiletheDepartmentacceptsthat,asaresultoftreatment,somepatientsmaysuffersomeformofharm,maycomplainormayseekcompensation,ittoldusthatevenwhereitisclearthatanadverseeventhasoccurred,itisnotalwaysanindicationofthepoorperformanceofstaff.Rather,adverseeventscanariseasaresultofsystemsorproceduralfailuresaswellasbecauseofhumanerror.

3.34 TheDepartmentadvisedusthattheSupportingSaferServicesReport30isdesignedtosharethelearningfromtheSeriousAdverseIncidentReportingSystem.The2007Report,forexample,detailstheissues,identifiedbyHSCorganisationsforlearning,intheareasofrecruitmentandtraining.Thisincludedguidanceoninductionforallnewlyappointedstaff(whethersubstantiveorlocum)andarrangementstoensurelocumsarefamiliarwithTrustprotocolsandprocedures.

3.35 Whilethelackofdetailedinformationontheextenttowhichlocumswereinvolvedinreportedseriousadverseincidentspreventedcomprehensiveanalysis,we

29 SeriousAdverseIncidentReportingArrangementstransferredfromtheDepartmenttotheHSCBoard(workinginclosepartnershipwiththePublicHealthAuthorityandRQIA)witheffectfrom1May2010.

30 DHSSPS(2006and2007)SupportingSaferServices:AnalysisofSeriousAdverseIncidents

wereabletoidentifysomecaseswherelocumsprovidedunsatisfactorycaretopatients.Inourview,theseillustratethepotentiallyveryseriousconsequencesoffailingtooperatepre-employment,appraisalandEWTDcontrolseffectively.Failingsreportedinthesecasesinvolved

unprofessionalbehaviour,breachesofdepartmentalmedicalpoliciesandpracticeandaninabilitytoperformthework.CaseExamples2-4belowprovidesomeindicationoftheimpactofpoorlocumperformanceonpatientcareandsafety.

Case Example 2

Followingconcerns,areviewofexaminationsperformedbyalocumconsultantradiologistwasundertaken.Thereviewidentified“seriousfailureinstandardsinbreastscreeningassessment”.Intotal,44casesrequiredurgentre-assessment.Ofthese,eightwomenwerediagnosedwithbreastcancer.Thelocumradiologistwassuspendedfromclinicalpracticependingdisciplinaryprocedures.AsaresultofthesefindingstheHealthMinistercommissionedanindependentgovernanceinvestigationbyRQIA.InMarch2006,RQIAconcludedthat:• chronicshortagesofradiologistscontributedtothecircumstanceswhichledtothelocumworkingin

adegreeofisolation,withoutpeersupport;

• concernsovertheclinicalcompetenceofthelocumradiologistwerenotraisedordiscussedwiththeindividual;and

• management’sdecisiontocontinueprovidingbreastscreeningservicesdespiteconcernsoverthecompetenceoftheconsultantradiologistwasflawed.

Case Example 3

ConcernswereraisedaboutthequalityofMRIscansundertakenbyalocumradiologistduringtheperiodApril2007toOctober2007.Thelocumhadbeenemployedforfouryears,untilJune2007.

Theaccuracyof620scansundertakenbythelocumradiologistwasindependentlyassessedbyanaccreditedmedicalcompany.Halfoftheindependentassessmentsdifferedsubstantiallyfromthelocum’sresults.Ineachofthesecases,patientrecordswerereviewedtoensurethevalidityofdiagnosisand,wherenecessary,patientswererecalled.

3.36 TheneedforTruststouselocumdoctorstomaintaincrucialservicesinNorthernIrelandhospitalsisnotdisputed.Weacceptthataverylargenumberoflocumsprovidequalitycover.However,theweaknessesinproceduresidentifiedacrossTrustsinrelationtopre-employmentchecks,appraisalprocessesandregulationoflocumsandtheconsequentincreaseinriskexposuremeansthatitisallthemoreimportantthattheDepartmentshouldroutinelymonitortheperformanceoflocumdoctors.

Case Example 4

InJune2008alocumconsultantobtainedapost.Afterafewmonthshiscolleaguesexpressedconcernaboutsomeaspectsofhisgynaecologicalpractice.AfterdiscussionswiththeMedicalDirectorandHumanResources,hewassuspendedfromgynaecologicalworkbutcontinuedinobstetricpracticeatthehospital.Subsequently,furtherissueswereraisedand,followingdiscussion,hiscontractwasterminated.

AnexercisebytheChiefExecutiveoftheTrustidentified25patientswhowerehavingtreatmentwhichmaynothavebeenofasufficientstandard.Thesepatientswereofferedarevisedtreatmentplan.Thedoctorinquestionwasinhisfirstyearofconsultantpractice.TheTrusthasdecidedtodevelopaninductionprogrammefornewconsultants.

Appendices

Appendix 1: Structure of Northern Ireland Health and Social Care Trusts

Current Trust Trusts prior to 1 April 2007

BelfastTrust BelfastCityHospitalTrust

GreenparkTrust

MaterHospitalTrust

NorthandWestBelfastTrust

RoyalGroupofHospitalsTrust

SouthandEastBelfastTrust

NorthernTrust CausewayTrust

HomefirstCommunityTrust

UnitedHospitalsTrust

SouthEasternTrust DownLisburnTrust

UlsterCommunityandHospitalsTrust

SouthernTrust ArmaghandDungannonTrust

CraigavonAreaHospital

CraigavonandBanbridgeCommunityTrust

NewryandMourneTrust

WesternTrust AltnagelvinTrust

FoyleTrust

SperrinLakelandTrust

Appendix 2: Health and Social Care Hospitals in Northern Ireland

ACUTE:

1. AltnagelvinAreaHospital

2. AntrimAreaHospital

3. BelfastCityHospital

4. CausewayHospital

5. CraigavonAreaHospital

6. DaisyHillHospital

7. DowneHospital

8. ErneHospital

9 LaganValleyHospital

10. MaterInfirmorumHospital

11. MusgraveParkHospital

12. TheRoyalGroupofHospitals:

–RoyalJubileeMaternityService;

–RoyalDentalHospital;

–RoyalBelfastHospitalforSickChildren;

–RoyalVictoriaHospital.

13. UlsterHospital

Non Acute:

14. ArdsCommunityHospital

15. ArmaghCommunityHospital

16. Banbridge–(OutpatientsandDaycases)

17. BangorCommunityHospital

18. BluestoneUnit(MentalHealth)

19. DalriadaHospital(Community)

20. DownshireHospital(MentalHealth)

21. ForsterGreenHospital(NonAcute–Neurology&Elderly)

Appendix 2: Health and Social Care Hospitals in Northern Ireland

Non Acute (Continued):

22. GranshaHospital(MentalHealth)

23. HolywellHospital(MentalHealth)

24. KnockbrackenMentalHealthServices(AcutePsychiatric)

25. LakeviewHospital(MentalHealth)

26. Longstone(LearningDisability)

27. Lurgan-Non-AcuteInpatients,DayCareandOutpatients

28. MidUlsterHospital

29. MoyleHospital(Community)

30. MuckamoreAbbey(LearningDisability)

31. Mullinure(GeriatricMedicine)

32. RobinsonHospital(Community)

33. ShaftesburySquareHospital(Drugs&Alcohol,Counseling)

34. StLuke’sHospital(MentalHealth)

35. SouthTyrone-Non-AcuteInpatients,DayCases,DayCareandOutpatients

36. ThompsonHouse(Physical&SensoryDisability)

37. TyroneCountyHospital(Community)

38. Tyrone&FermanaghHospital(MentalHealth)

39. WhiteabbeyHospital

Appendix 3: The Cost of Agency and Internal Locums in Northern Ireland 2007-08 to 2010-11

2010/11

HSC Trust Agency Locum

£ million

Internal Locum£ million

Total Locum Costs

£ million

Cost of permanent doctors working contracted hours

£ million

Total Doctor Costs

£ million

Agency Locum costs as % of Total Medical

costs£ million

Total Locum costs as % of Total Doctor

costs£ million

Belfast 5.6 1.8 7.4 145.3 152.7 3.67% 4.85%

Northern 4.0 2.0 6.0 46.9 52.9 7.56% 11.34%

SouthEastern

1.8 0.5 2.3 47.1 49.4 3.64% 4.66%

Western 7.9 1.1 9.0 45.0 54.0 14.63% 16.67%

Southern 3.2 1.2 4.4 51.8 56.2 5.69% 7.83%

Total 22.5 6.6 29.1 336.1 365.2 6.16% 7.97%

2009/10

£ million

Total Locum Costs

£ million

Total Doctor Costs

£ million

costs£ million

Belfast 5.5 2.6 8.1 148.0 156.1 3.5% 5.19%

Northern 5.4 2.7 8.1 44.7 52.8 10.23% 15.34%

SouthEastern

2.2 0.5 2.7 47.4 50.1 4.39% 5.39%

Western 5.1 1.9 7.0 44.6 51.6 9.88% 13.57%

Southern 2.4 2.5 4.9 43.5 48.4 4.96% 10.12%

Total 20.6 10.2 30.8 328.2 359.0 5.74% 8.58%

Appendix 3: The Cost of Agency and Internal Locums in Northern Ireland 2007-08 to 2010-11

2008/09

£ million

Total Locum Costs

£ million

Total Doctor Costs

£ million

costs£ million

Belfast 4.5 2.9 7.4 137.0 144.4 3.1% 5.12%

Northern 4.9 2.7 7.6 41.4 49.0 10.00% 15.51%

SouthEastern

2.4 0.7 3.1 43.0 46.1 5.21% 6.72%

Western 3.3 1.9 5.2 43.0 48.2 6.85% 10.79%

Southern 1.9 2.8 4.7 41.6 46.3 4.10% 10.15%

Total 17.0 11.0 28.0 306.0 334.0 5.09% 8.38%

2007/08

£ million

Total Locum Costs

£ million

Total Doctor Costs

£ million

costs£ million

Belfast 3.6 2.9 6.5 126.0 132.5 2.7% 4.91%

Northern 4.7 37.1 41.8 11.24% 11.24%

SouthEastern

1.4 0.8 2.2 40.0 42.2 3.32% 5.21%

Western 2.4 2.3 4.7 39.6 44.3 5.42% 10.61%

Southern 1.5 1.4 2.9 37.0 39.9 3.76% 7.27%

Total 13.6 7.4 21.0 279.7 300.7 4.52% 6.98%

Appendix 4: Audit Methodology

ThisreportconsidersthearrangementsinplaceacrossTruststomanagethedemandforlocumdoctorsandthoseforsafeguardingpatientsafety.

OurreportfocusesontheuseoflocumdoctorsbyacuteandcommunityhospitalsbutdoesnotextendtotheuseofGPlocumsintheprimarycaresector.

AttheoutsetoftheauditwewrotetotheDepartmentoutliningourinterestinthefollowingareas:

• theexpenditureincurredineachoftheacuteandcommunityhospitalsinNorthernIreland;

• theusageoflocumdoctorswithinTrusthospitals;

• theworkforceplanningmethodologiesoperatedbyTrusthospitals;

• theextentofTrustcompliancewithlocumpre-employmentprocedures;and

• thequalityofappraisalproceduresinplacetoassesstheperformanceoflocumdoctors.

WeundertookarangeofinterviewswithkeypersonnelwithineachTrust.

InformationprovidedtousbyindividualTrustsinrelationtothecostofinternallocumswaslimited.TheinformationwassubsequentlyrequestedfromTrustsbytheDepartment.FollowingtherequestfromtheDepartment,Trustscarriedoutsomeinterrogationoftheirmanagementinformationsystemsandprovidedtheinformationrequired.GiventhetimetakenfortheDepartmenttoproducethecostinformation,itwasnotpossible

forustoundertakeanyvalidationworktoassesstheaccuracyoftheinformationcontainedintheTrustspreadsheets.

WeexaminedvariousDepartmentalpoliciesrelatingtotheemployment,monitoringandappraisaloflocumdoctorsinhospitalsandwereviewedrelevantInternalAuditworkacrosstheTrusts.

WealsoreviewedthedetailofthoseSeriousAdverseIncidentswhichinvolvedlocumdoctors.

Appendix 5: Implications of the EU Working Time Directive

TheEuropeanCommissionintroducedtheWorkingTimeDirectivetoNorthernIrelandin1998toworkalongsidememberstatesemploymentlaws.Itisprimarilydesignedtosafeguardworkersrightsbyputtingalimitonthenumberofhoursthatshouldbeworkedeachweek.Somegroupsofworkerswereinitiallyexcludedfromtheseregulations,howeverfromAugust2004theprovisionsoftheDirectivehavebeguntobeappliedtodoctorsintrainingintheUK.Legislationlimitedjuniordoctorsworkinghourstoa58hourweek,withstrictarrangementsforrestrequirements.FromAugust2007theworkingweekwasfurtherlimitedto56hoursofworkperweekuntilthefullimplementationofthedirectiveinAugust2009,limitingtheworkingweekto48hours.

Inthepast,hospitalsusedjuniordoctorsextensivelyformedicalcoverduringunsocialhours.TheconsensusofallNorthernIreland’sTrustswasthattheprogressiveimplementationoftheWorkingTimeDirectivehashad,andwillcontinuetohave,profoundeffectsonthedeliveryandcontinuityofmedicalcare,andondoctorsintraining.Thereisalargedegreeofpressurenowtoprovideextracover(includingusinglocums)toensurejuniordoctorworkinghoursandrotapatternsarecompliantwiththeDirective.Consultantsreportedthattheyhavehadtoprovidemoreservicecoverduringunsocialhours,thusreducingavailabilityduringthedayandinturnrequiringfurtherexpansionofconsultantnumbers.

Appendix 6: Medical Demand and Supply Problems Identified by the Department

Review of Workforce Planning for the Medical Profession (September 2006)

Speciality Demand and Supply Problems

Anaesthetics TherearealargenumberofunfilledpostsinNorthernIrelandandthereisaneedforincreasedconsultantnumbers.

Ear,NoseandThroat(ENT)

ConcernwasexpressedattheunevengeographicdistributionofENTconsultantsrelativetothepopulationserved.Earlierretirementsarepredictedforthefutureandthereareincreasesinlevelsofmaternityleave,familyleaveandrequestsforpart-timeworking,attributedtoahighratiooffemalesinthisarea.IncreaseddemandforENTserviceswasresultingfromGPsnotbeingadequatelytrainedinENT.Itwasestimatedthatatleast30%ofoutpatientsdonotneedtobeseen,resultinginalargenumberofunnecessaryreferralscloggingout-patientlists.

MedicalPaediatrics

ThereisahighfemaletomaleratiowithinPaediatricsanditislikelythattherewillbeanincreaseddemandforflexibleworkingpatterns.Duetothehighlevelofon-callrequirement,itispredictedthatmanyconsultantswillnotworkmuchpasttheageof55.Peripheralhospitalsarefacingdifficultiesinfillingposts.Forexample,theErnehospitalhashadtorecruitincreasingnumbersofnonNorthernIrelandtraineddoctorswhoonlyintendtoremaininpostforashortperiodoftime.

CommunityPaediatrics

Significantdepletionoftheworkforceispredictedgiventheageprofileofthecurrentworkforceandexpectedretirementswithinthenext10years.ThemajorityofTrustshavehaddifficultyrecruitingstaffoverrecentyears.Aneedwasidentifiedtoincreasetrainingatbothundergraduateandpostgraduatelevel.

Neurology FindingsfromtheAssociationofBritishNeurologistshashighlightedshortagesofneurologistsinNorthernIreland:- intheUSAthereisoneconsultantper20,000ofpopulation- inNorthernIrelandthereisoneconsultantper100,000ofpopulation- therearefewerconsultantneurologistsperheadofpopulationinNorthernIreland

thaninmanyotherpartsoftheUnitedKingdom.

Oncology ThedemographictrendswithinNorthernIrelandmeanthattherewillbeagreaternumberofpeopleaged70yearsplusandthereforeahigherfrequencyofcancerincidents.Therewillbegreaterdemandforoncologyconsultantsinthefuture.TheWorkforcePlanidentifiedhaematologyasunder-resourced.TheDepartmentisworkingtotheRoyalCollegeofPhysiciansrecommendationofoneconsultantper250patients.TheUSAratioisoneconsultantper100patients.

Appendix 6: Medical Demand and Supply Problems Identified by the Department

Speciality Demand and Supply Problems

Ophthalmology AgeingpopulationisasignificantfactorforOphthalmology.TheRoyalCollegeofOphthalmologistshaverecommendedoneconsultantper50,000to70,000ofpopulation.NorthernIrelandcurrentlysitsatoneconsultantper100,000ofpopulationandwouldneedtoincreasefrom23.5to30tomeetthisratio.TheretirementageofconsultantOphthalmologistshasdecreasedby2-3yearsoverrecentyears.Inadditionthereisahighnumberoffemaleswithinthespeciality,withanincreaseddesiretoworkpart-time,therebycreatingdemandsforextrastaff.

Orthopaedics AnageingpopulationonceagaincreatesgreaterdemandforOrthopaedicservices.NorthernIrelandsitsasaregionwithintheUKwiththelowestConsultantorthopaedicnumbersperheadofpopulation.TheWorkforcePlanidentifiedashortageof40%fromthetargetnumberofconsultants.

Pathology Pathologyisperceivedasalessattractivespecialitythanotherswithnotenoughtraineescomingthroughthesystem.

CommunityCare

ThePlanidentifiedsupplyissuesatTrustlevelandcontinuingrecruitmentdifficultieswerereportedinthewestofNorthernIreland.

Psychiatry ThePlanestimatedthatapproximately120consultantswillberequiredoverthenextfewyears.Thereisahigherproportionoffemalestaffwhichimpactsonworkforcelevelswithhigherlevelsofbreaksofemploymentduetocaringresponsibilities.TheEuropeanWorkingTimeDirectiveishavinganimpactontheabilityoftheprofessiontoprovidenightcoverduetotherelativelysmallsizeoftheworkforce.

Radiology Thereisagreaterdemandforradiologyservicesandthereisasignificantworkforcedeficit.Itisestimatedthattherewillbe80consultantvacanciesoverthenext10years.

Appendix 7: Good Practice Examples identified from the NHS Employer’s publication “Controlling the use of temporary staff through large scale workforce change”

Example 1: Kingston Hospitals NHS Trust

KingstonHospitalisanacutegeneralhospitalservingapopulationofaround320,000insouth-westLondon.Itfacessimilarpressurestomanycitycentrehospitalsinhighdemand(ithasoneofthehighestlevelsofdaysurgeryinthecountry)andatransientworkforce.

Issues identified• ahighexpenditureonmedicallocumsacrossthetrust,notablyseniorhouseofficers(SHOs)inthe

AccidentandEmergency(A&E)department• agenciesoutsidethoseoutlinedintheNHSPurchasingandSupplyAgency(PASA)national

frameworkwereregularlybeingused• excessivedelaysintherunningofCriminalRecordsBureaucheckswerecausingpotentialrecruits

tobelosttootheremployers• lackofappropriateauthoritylevelsinthebookingofmedicallocums-bookingswerenot

challengedorvetted• lackofcentralcontrolinbookingmedicallocumsandcontrollingexpenditure-eachdepartment

wasusingitsownsuppliersandproceduresforbooking• lackofusefulintelligenceonmedicallocumusageandspend.

Aims• todevelopamastervendorsystemincollaborationwithothertrusts• toreducespendonmedicalandAlliedHealthProfessional(AHP)agencystaff.

Implementation• establishedaconsortiumwithothertrustswithsharedgoalsandcommitments,todrivedown

agencycoststhroughcombinedspendingpower• pilotedtheuseofapreferredagency(mastervendor)inA&Etoassesstheimpactonexpenditure

andfurtherdeveloptheconcepttorolloutacrossthetrust• establishedprotocolsforbookinglocumsandmeasuringcomplianceagainstexpenditure/use.• establishedfinancialcontrolsforbookingofmedicallocums(forexample,higherlineofauthority

for‘requesting’signatureandfor‘authorisingpayment’signature)• centralisedbookingarrangementsthroughonesourcewithinthetrust-andcombinedthiswiththe

operationforbookingnursebankstaff• developedtheHarlequinITsystem(alreadyusedforthenursebank)andintroduceditfor

managingmedicallocumandAHPbookings• improvedmanagementinformationonmedicallocumusetoallowmanagerstoauditandquery

useofmedicallocumsmoreeffectively

• recruitedstaffbookedthroughtheagencyontothetrustbank• educatedthecoordinatorsofrotasandrotaplanning.

Improvements delivered:

Collaborative workingThetrustnegotiatedwithexternalagenciesincollaborationwiththreeothertrusts.Aswellassecuringmorefavourablerates,trustssharedgoodpracticewitheachotherandenhancedtheirprojectwork.

Developing a master vendorIncollaboration,thetrustdevelopedamastervendornetworkacrossthestrategichealthauthoritytoprovideapreferredsupplierfornursingagencies(andlaterforotherstaffgroups).Theincreasedspendingpoweroffourtrustsprovidedgreaterleverageindrivingdowncosts,improvingtheservicetothetrustand,inaddition,thesupplierwasabletoprovidevaluablemanagementinformationonuse.Themastervendorguaranteestofillvacanciesrequested(againstanagreedfillrate)andwillcontactsecondaryagenciesifunabletofilltheshiftthemselves.Inaddition,becausetheycanrelyonaguaranteedincomefromthetrust,thesupplierisabletojustifyprovidingdedicatedstaffsupportfordealingwiththetrustsneeds.Asaresultofthesechangesthespendingonagencynurseswasreducedfromapproximately£2.8mtoaround£1.0mperannum-asavingof£1.8mforthetrustacrosstheyear.

FromJanuary2006thefirst‘true’mastervendoragreementstarted,withasinglesupplierfornursing,medicalandAHPs.Thisgaveafurtherreductionof26percent,whichequatesto£260,000perannumacrossthetrust.

Management control for medical locums and AHPsThetrustintroducedtightercontrolsontheauthorisationforbookingtemporarystaffandchangedthecultureofacceptancefortheneedforabooking.BookingsarenowcentralisedthroughasinglefunctionandthetrusthasdevelopeditsHarlequinITsystemtomanagemedicallocumandAHPbookings.Agencyspendonthesestaffgroupsreducedfrom£1.8mperannumtolessthan£1.0m.

Clinical and administrative staffByhavingasinglepointofcontactandasingleexternalsupplier(ratherthanmorethan20agencies),clinicalstaffsavedconsiderabletimeonbookingshifts.Clinicaltimepreviouslyspentcontactingfiveorsixagenciestosecureabookingisnowsavedbycontactingthemastervendoronly.Sincethemastervendorpayssecondaryagenciesandtheninvoicesthetrustforallcosts,thissavesadministrativetimeinprocessingmultipleinvoices.Inaddition,themanagementinformationthatthemastervendorwasabletoprovidesavedonadministrativetimeforthetrust.

Improving working livesItisanidentifiedfactorthatshiftfillrateshaveamarkedeffectonstaffmorale.Whenstaffareexpectedtodeliverservicesinashiftwithareducednumberofstaffonduty,moraleoftenfallsasaresult.Themastervendorschemesetupguaranteesa90percentfillrateforthetrustandthisratehasinfactbeenbetteredsincetheschemewasintroduced.Thisledtoincreasedstaffmorale.

Kingston Hospital. Annual spend on medical locums and Allied Health Professionals 2005-06

After master vendor agreement implemented (Jan 06)

After controls in placePrior to project

Example 2: East Kent Hospitals NHS Trust

EastKentHospitalsNHSTrustisoneofthelargesthospitaltrustsinEngland,withfivehospitalsandseveraloutpatientfacilities.Thetrusthasundergoneamajorservicereconfigurationprogrammeinvolvingextensivebuildsatthreeofitssites.

Issues identified

• thetrusthadarisingspendonmedicallocumusage• somelocumsweresuppliedthroughhigh-costagenciesandoutsideofthePASAframework• therewasalackofcontrolinsomedirectorateswithconsultantsbookingtheirownmedicallocums

withoutauthorisation• therewaslittleornocheckingofinvoicesformedicallocumsoncesubmittedforpayment• anumberofpositionsreliedonhigh-costmedicallocumstofillvacancies,andthesehadnotbeen

reviewedforsometime.

Aims• tocentraliselocumbookingarrangementsindirectorates,withtheexceptionofA&E,anaesthetics

andradiology,witheffectfrom1September2005• torevieweachhigh-costagencylocumwithaviewtoidentifyingthebestwaytoreducecostsby

oneoracombinationofactions

Implementation

Locum bookingArevisedpolicyforemploymentoflocummedicalstaffwasapprovedbytheclinicalmanagementboardandwasimplementedon1September2005.Bookingswerecentralisedthroughareportingmechanismtoasinglepointofcontact.Bookingsarenowmadeforclinicalcareonlyandmustbecapableofclinicaljustification.

Directphonecallstoagenciesfromwardswerebanned,thephonenumberwasblockedthroughtheswitchboardandout-of-hoursbookingsweredonethroughon-callexecutivedirectors.Theseon-calldirectorsadheredtoastrictprotocolinlinewithanewbookingpolicyagreedatboardlevel.Administrativeguidancenoteswereissuedtoallstaffforimplementingthenewpolicyanduniquereferencenumberswereissuedtoeachauthorisedbooking-onlyinvoicesbearingthisnumberwerepassedforpayment.

Thejobplansofsubstantivedoctorswereanalysedandlocumswerenotauthorisedwherethetrust’sowndoctorswereduty-boundtoprovidecover.

Thecoreprojectteamreviewed,studiedandactedonissuesraisedonafortnightlybasistotheendoftheproject.Thiswasespeciallyimportantintheearlyphases.

Individual high-cost agency locumsEachhigh-costlocumplacementwasreviewedandastrategytoreducecostwasadopted.Poststhathadreliedonagencylocumsforseveralmonthswerere-advertisedandNHSlocumsfavouredoveragencylocums.AgencylocumswereencouragedtotransfertoNHScontracts.NHSProfessionalswassoughtasacheaperalternativeifthetrustwasunabletomakesubstantiveappointments.

Annualandstudyleaveperiodswereimposedforlocumswhereprospectivecoverarrangementsapplied.Invoiceswerecarefullyscrutinisedtoensurehoursworkedandclaimedwereconsistentwiththeoriginalhoursbookedwiththeagency,andcostswerecappedtotheratesagreedundertheagencyframeworkagreement.

Dataonlocumusagewascollectedandanalysedandafortnightlyreviewcarriedout.Directorateswithhighusageweretargetedforinterventionandactionplanswitheachdirectoratewereagreed.

Improvements delivered• decreaseinbothuseandoverallspendonmedicallocumssinceSeptember2005,whenchanges

werefirstimplemented.Previousyear’saveragemonthlycostswere£548,400(September2004toAugust2005)

• thetargettoreduceexpenditureto£490,000permonthwasbettered.Spendreducedtounder£270,000permonth(September2005toMay2006)-asavingofover£278,000permonth

• ifthissavingweresustainedacrosstheyear,itwouldequatetoanannualsavingofover£3.3millionfortheyear(seegraph)

• thetrustidentifiedseasonalfluctuationsandcannowplantocoveranyknownandpredictabledemand(suchasmedicalexaminations).

East Kent Hospitals NHS Trust: monthly spend on medical locums 2005/06

Target Mothly average Sept 2005to May 2006

Monthly averageSept 2004 to Aug 2005

Monthly agencyspend Sept 2005to May 2006

Monthly agency spend Sept 2004to Aug 2005

AugJulJunMayAprMarFebJanDecNovOctSept

Appendix 8: Regionally Managed Medical Locum Service for Northern Ireland

TheRegionallyManagedMedicalLocumService(RMMLS)representsacollectiveeffortbyTrustswithinHSCNItomoreeffectivelymanageexpenditureassociatedwiththeuseoflocumdoctorsinNorthernIreland.

IndividuallyHSCTrustshavebeentakingforwardinitiativestoseektomoreeffectivelymanagetheuseandexpenditureassociatedwithlocumdoctors.ThisprojectpresentsanopportunitytopoolthecollectiveinputsofTrustsandtheBSOtodeveloparegionallyco-ordinatedandmanagedapproachtolocumcoverwithinthecontextofsharedservices.

DiscussionshavetakenplaceacrosstheHSConhowtoregionallytackletheincreasingspendonLocums.TheoutcomeoftheseconversationswastheformationofaHumanResourceledRegionalMedicalLocumGroupcomprisingrepresentativesfromeachTrust(usuallythemedicalHRorrelevantrecruitmentstaff)totakethisforward.

TheRegionalMedicalLocumGrouphasproducedaplantoaddresstheescalatingagencyLocumspendwhichreflectstheneedforacoordinatedregionalapproachtothemanagementoflocumdoctors.Intheshorttermtheimmediateactionistheestablishmentofaregionaldatabasetorecordthedetailsoflocumdoctors,pre-employmentchecks,shiftsworked,anyidentifiedperformanceissuesetc.

Inthemediumtermopportunitiesexistthroughthisprojecttoutilisetheregionaldatabaseasatooltosupportthemanagementoflocumsonaregionalbasisi.e.thesourcingandplacingoflocumdoctorsviaasharedservice.

Inthelongertermthisprojectalsoprovidesavehicletosupporttheprocessesassociatedwith

themanagementofrevalidationofmedicallocumsandthedischargingoftheResponsibleOfficerfunctionforlocumdoctorswhoarenotemployedonafull-timebasisbyaTrusti.e.careerlocums.Thepurposeofrevalidation,whenitisintroduced(currentprojectionsaremid-2012),willbetoassurepatientsandthepublic,employersandotherhealthcareprofessionalsthatlicenseddoctorsareuptodateandarepractisingtothestandardsdefinedby Good Medical Practice31.

Thedevelopmentoftheresponsibleofficerrole(whichwasimplementedinNIinOctober2010)ispartofwiderangingregulatoryreformsetoutintheWhitePaperTrust, Assurance and Safety32.InNorthernIreland,thesereformsarebeingtakenforwardthroughtheDHSSPSConfidence in Care programme.

ThetermsofreferencefortheRegionallyManagedMedicalLocumService(RMMLS)havebeeninformedbytheMedicalLocumRegionalWorkingGroupandreflectthestreamingandpriorityofactivitiestobeundertaken.Thetermsofreferenceundereachoftheprojectworkstreamsaresetoutbelow.

Workstream 1 – Development of the Regional Locum Registration Process and Database (Timescale-Short Term)

• Definethestrategy,scopeandoperationalrequirements/arrangementsofthecentralmedicallocumregistrationprocessanddatabase.

• Developthegovernance,accountabilityandadministrationarrangementsforsame.

31 GoodMedicalPractice–FrameworkforAssessmentandAppraisal,TheGeneralMedicalCouncil,November200632 Trust,AssuranceandSafety:TheRegulationofHealthProfessionalsinthe21stCentury:TSO,February2007

• Securefundingfordevelopmentofthecentraldatabase.

• AgreethehostingorganisationandtheoperationalframeworkfortheRegionalLocumRegistrationprocessandDatabase

• Designthespecificationintermsofcontent,operationalrequirementsandcapabilitiesoftheregistrationsystemanddatabase,togetherwiththepracticalaccessarrangementsinaccordancewithdataprotectionrequirements.

• Commissiontheconstructionofthesystem.

• Producetheoperationalregistrationprocessanddatabasewithaccompanyingmechanismsforfeedbackandreviewtocontinuallyensureserviceimprovement.

• PlanimplementationarrangementsensuringthatbothlocumsjoiningtheschemeandtheTrustsusingtheschemeareclearonoperationalarrangements,haveaccesstoinformationonoperationalarrangements,haveaccesstooperationalinstructionsanda‘helpdesk’facility(likelytobeoneforeachTrustinitially).

• CommencethephasedregistrationofLocums.

• ‘Golive’withtheregionallocumdatabase.

Workstream 2 – Shared Service Model for Employment and Management of Locums and service provision to the HSC stakeholders (Timescale-Medium Term)

• DeveloptheoperationalmodeltosupportthemanagementoflocumsundertheumbrellaofBSO,SharedServicesensuringthat

thereisclarityregardingtheemploymentarrangementsofmedicallocumsincludingallrelatedissues(suchassafeguardingchecks,paymentetc)andhowTrustswillaccess,useandpayforthisservice.

• Developthegovernance,accountability,andperformancemanagementarrangementsfortheproposedsharedservicesmodelforthemanagementoflocums

• Developandseekapprovalforthebusinesscasefortheprovisionofsharedservicesforlocumdoctors

• Implementthemodelforsharedservicesforlocumdoctors

Workstream 3 – Development of Regional Contract for the Provision of Locum Services from Agencies (Timescale-Medium Term)

• TheBSOwillworkwithTrustcolleaguesinthegrouptowardsthedevelopmentofasingleregionalcontractwithAgenciesthroughwhichagencylocumservicescanbesecured(shouldtherequiredlocumcovernotbeavailableviatheSharedServiceforlocums).Thiswillinvolvethedevelopmentofadraftcontractandtheassociatedcontentofsame.

Workstream 4 – Revalidation/RO Support for Locums (Timescale-Medium/Long Term)

• InconjunctionwiththeDHSSPSConfidence in Care ProgrammedevelopandimplementthearrangementstosupportthedischargeofResponsibleOfficerfunctionsforthoselocumdoctorsnotemployedbyaTrust

• InconjunctionwiththeDHSSPSConfidence in Care Programmedevelopandimplementthearrangementstosupportrevalidation(includingappraisal)forthoselocumdoctorsnotemployedbyaTrust

Appendix 8: Regionally Managed Medical Locum Service for Northern Ireland

Title Date Published

CampsieOfficeAccommodationandSynergye-BusinessIncubator(SeBI) 24March2010

OrganisedCrime:developmentssincetheNorthernIrelandAffairs 1April2010CommitteeReport2006

MemorandumtotheCommitteeofPublicAccountsfromtheComptrollerand 1April2010AuditorGeneralforNorthernIreland:Combatingorganisedcrime

Improvingpublicsectorefficiency-Goodpracticechecklistforpublicbodies 19May2010

TheManagementofSubstitutionCoverforTeachers:Follow-upReport 26May2010

MeasuringthePerformanceofNIWater 16June2010

Schools’ViewsoftheirEducationandLibraryBoard2009 28June2010

GeneralReportontheHealthandSocialCareSectorbytheComptroller 30June2010andAuditorGeneralforNorthernIreland–2009

FinancialAuditingandReporting-ReporttotheNorthernIrelandAssemblyby 7July2010theComptrollerandAuditorGeneral2009

SchoolDesignandDelivery 25August2010

ReportontheQualityofSchoolDesignforNIAuditOffice 6September2010

ReviewoftheHealthandSafetyExecutiveforNorthernIreland 8September2010

CreatingEffectivePartnershipsbetweenGovernmentandtheVoluntaryand 15September2010CommunitySector

CORE:Acasestudyinthemanagementandcontrolofalocaleconomic 27October2010developmentinitiative

ArrangementsforEnsuringtheQualityofCareinHomesforOlderPeople 8December2010

ExaminationofProcurementBreachesinNorthernIrelandWater 14December2010

GeneralReportbytheComptrollerandAuditorGeneralforNorthern 22December2010Ireland-2010

NIAO Reports 2010-2011

Title Date Published

CompensationRecoveryUnit–MaximisingtheRecoveryofSocial 26January2011SecurityBenefitsandHealthServiceCostsfromCompensators

NationalFraudInitiative2008-09 16February2011

UptakeofBenefitsbyPensioners 23February2011

SafeguardingNorthernIreland’sListedBuildings 2March2011

ReducingWaterPollutionfromAgriculturalSources: 9March2011TheFarmNutrientManagementScheme

PromotingGoodNutritionthroughHealthySchoolMeals 16March2011

ContinuousimprovementarrangementsintheNorthernIrelandPolicingBoard 25May2011

Goodpracticeinriskmanagement 8June2011

UseofExternalConsultantsbyNorthernIrelandDepartments:Follow-upReport 15June2011

ManagingCriminalLegalAid 29June2011

NIAO Reports 2010-2011

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