Locum doctors and patient safety

No “tangible progress” has been made to curb the reliance on locum doctors despite a 190 per cent increase in expenditure in the last seven years, a report by the Auditor and Comptroller General (A&CG) has found.

In follow-up examinations into two key areas (locum doctors and patient safety) of the health and social care sector previously reviewed by the Northern Ireland Audit Office (NIAO) and the Public Accounts Committee (PAC), Kieran Donnelly revealed that expenditure on locum doctors had increased from £28.4 million in 2010-11 to £83 million in 2017-18.

Donnelly revealed some Trusts are still not carrying out necessary pre-employment checks before offering locum appointments. The Department of Health has not been routinely monitoring the usage of ‘non-contracted’ agencies by the Trusts, which have not reduced. The Department has also not been monitoring data gathered by the Trusts to determine if locum doctors are presenting increased risks to patient safety.

The A&CG outlined that while reliance on locums has increased across all trusts, a significant increase was most acute in the Northern and Western Trusts, which account for over 22 per cent of the total medical pay bill. He also points to evidence that this trend is placing significant strain on Trust budgets.

Pointing to a failure to implement effective solutions, Donnelly highlights that despite an elocums booking system being introduced in 2012 to minimise Trust reliance on agency staff by maximising the amount of locum work performed by internally employed doctors, expenditure on agency doctors has still increased from £23.2 million in 2011-12 to £73.5 million in 2017-18.

The Comptroller and Auditor General criticised the level of development of workforce planning solutions to identify the necessary number of local trainee doctor places required and described an “urgent need for more strategic, innovative and forward-thinking” initiatives to reduce future reliance on locum doctors.

The second of Donnelly’s reports focussed on improvements in patient safety, the context being that in 2013, a PAC report informed by work by the C&AG declared that no reliable evidence existed that HSC patients were any safer than they had been 10 years before and that the Department could still not accurately track progress in improving patient safety.

Fast forward to the follow up report and the C&AG outlines positives moves by the Department and Trusts in several areas to enhance patient safety culture across the HSC sector and adds that the public is now better informed about patient safety and performance and standards across HSC Trusts.

Other positives include an increase in the involvement of patients, carers and families in the investigation of serious adverse incidents (SAI), increased staff appraisal levels and a reduction in the time taken to settle clinical negligence claims.

However, Donnelly points to a number of existing challenges including evidence from the Hyponatraemia Inquiry findings that indicate improvements are still required in aspects of SAI “reporting and investigations, and in disseminating learning”.

The report states that under-reporting of SAIs by acute settings may still exist and that further work is required to enhance staff confidence that incidents reported will be properly investigated, and to identify why many HSC staff still consider that learning is not being properly disseminated.

Progress in developing a regional learning system has been “limited” and resource constraints raise uncertainty over whether such a system will ever be introduced.

Finally, Donnelly states that as well as the need for further analysis behind increased costs in settling clinical negligence claims, the Department should assess whether “staffing shortfalls in key clinical disciplines are heightening patient safety risks and, if so, how these can be mitigated by stronger workforce planning”.

The issue of locum doctors and the need for a strategic approach to addressing a doctor shortage in Northern Ireland is the focus of this issue’s cover story with new BMA Chair Dr Tom Black on page 12.

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