Dr Mark Walker, Interim Executive Medical Director

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1 Remuneration and Terms of Service Committee Item R16/40 Title: Author: Responsible Director: Public or In Committee Strategic Goals To improve health and provide excellent care Proposal to Increase Hourly Rates Paid to Substantive Medical Staff Undertaking Additional Duties Internal Locums Mrs Patricia Foster, Head of Medical Workforce Dr Mark Walker, Interim Executive Medical Director Public (Indicate how the subject matter of this paper supports the achievement of BCUHB s strategic goals tick all that apply) 1. Improve health and wellbeing for all and reduce health inequalities 2. Work in partnership to design and deliver more care closer to home 3. Improve the safety and outcomes of care to match the NHS best 4. Respect individuals and maintain dignity in care 5. Listen to and learn from the experiences of individuals 6. Use resources wisely, transforming services through innovation and research 7. Support, train and develop our staff to excel. Approval / Scrutiny Route Purpose: Significant issues and risks None To highlight the difficulties in securing internal locum doctors; outline the need to review / agree increased remuneration for these doctor and consider specific action to address this. Levels of remuneration for substantive doctors undertaking additional duties / shifts within the Health Board are set by the Health Board. The rates currently in payment were originally set by the Health Board in Although they have been reviewed since then they have not been increased. There are increasing workforce gaps in medical rotas and whilst there continues to be an active focus on recruitment this is against a background of national shortages of doctors at all grades in those specialities. Since 2010 several requests to vary / increase internal locum rates have been made by various specialities in particular General Medicine; Emergency Medicine; Paediatrics and several surgical specialities. A

2 Equality Impact Assessment Recommendation/ Action required by the Committee comparison of the hourly rates paid for internal locums by BCU HB and the hourly rates paid by Locum Agencies suggests that amounts actually paid to the doctors is not significantly different. There is some evidence to suggest that some specialities have occasionally gone outside of the HB agreed internal locum rates to maintain continuity of service and patient safety. There is evidence to indicate that using internal locums, who are already familiar with the organisation and its processes, is safer for patients than the use of external agency locums, particularly for locum episodes of short duration. Decisions by operational managers to pay in excess of the agreed HB internal locum rates are influenced by an analysis of other options to maintain patient safety and continuity of service which include requiring and remunerating Consultants to be resident on call. The Wales Consultant Contract attracts remuneration of three times the sessional payment at Point 6 of the Consultant salary scale, excluding commitment awards and Clinical Excellence awards, with compensatory rest the following day. A number of substantive doctors from BCU HB are already signed up with external locum agencies and will work for these agencies in other hospitals e.g. Countess of Chester because they believe they receive increased remuneration. Increasing internal locum rates may mean that these doctors would be more willing to undertake additional duties in BCU HB thereby improving patient safety and reducing financial costs.. It is recommended that: Internal locum rates are increased as outlined in the attached paper Key specialities such as Emergency Medicine; Paediatrics including Neonatology and Mental Health be given some additional flexibility to vary these rates with the agreement of the relevant Area Director or Secondary Care Director Where this flexibility is used by these specialities a record of the reason for doing so, together with the written authorisation of the Area /Secondary Care Director and the relevant Management Accountant is retained for audit purposes. These actions will encourage substantive doctors to undertake internal locum duties / shifts. This will provide a greater degree of assurance in respect of patient safety. It will reassure clinical managers; clinicians and their representatives that the HB has heard and acknowledged their views.. The proposals benefit all individuals. To note, endorse and approve the paper Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

3 Proposal to increase hourly rates paid to substantive medical staff undertaking additional duties internal locums 1. Purpose of report Set against a background of UK wide medical recruitment difficulties this paper examines the remuneration paid to internal locums i.e. doctors who are already substantively employed by the Betsi Cadwaladr University Health Board (BCU HB) who undertake additional duties / shifts and submit timesheets for these hours. All grades of training and non training doctor may undertake additional duties / shifts as internal locums. The rates of payment were set by the Health Board in This paper seeks to establish whether these rates should now be increased, if so to what level, whether specific specialities should attract additional flexibility within agreed parameters and whether increasing internal locum hourly rates would improve the deployment of substantive staff thereby reducing reliance on agency locum doctors. 2. Introduction/Context 2.1 The difficulties experienced in recruiting to medical training and non training posts by the Health Board, whilst not exclusive to BCU HB, continue to be significant. Despite active recruitment against a backdrop of UK wide national recruitment difficulties BCU HB has therefore become increasingly reliant on agency locum doctors to maintain medical staffing rotas and service delivery. Other influences including European Working Time requirements; problems in attracting Non Consultant Career Grade doctors to HB posts and stringent Wales Deanery requirements that junior doctors should not be working a less than 1 in 11 rota (i.e. during an 11 week period the doctor will work a maximum of seven hour night shifts and a maximum of seven long day shifts including weekends) have added to these difficulties. 2.2 There is evidence to suggest that where care is provided by doctors who are already familiar with the HB sites and processes i.e those doctors who are substantively employed by BCU HB, patient outcomes are better. Whilst Agency Locum doctors can be very skilled and their assistance can be helpful in maintaining high quality patient care inevitably they are unlikely to have the same familiarity with people; processes and environments that substantive staff will have. 2.3 The Health Board, in line with other Health Boards in Wales, would always recommend seeking an internal locum to cover short term medical staffing absences in the first instance. However where it was once the norm for HB doctors to agree to undertake these short notice internal locum duties recent years have seen a decline in the number of substantively employed doctors agreeing to provide this internal locum cover. 2.4 In the majority of cases the refusal seems to be the result of substantive doctors comparing the hourly rate remuneration paid to them unfavourably with that paid to Agency Locum doctors. However comments from substantive doctors relate not simply to the perceived financial differentiation but also relate to the perceived value they consider their substantive employer (BCU HB) places on them. 1

4 2.5 The need to urgently cover medical staffing services can and does lead to individual employees attempting to negotiate higher hourly rates. Refusals mean that those doctors who are often already signed up with external Locum agencies will refuse to assist. They may work, as an agency locum, at other Health Boards in the Wirral and North West areas rather than on their own site as an internal locum. Whilst this may appear to be unethical there is nothing which prevents them from undertaking agency locum duties in their own time, as long as they comply with European Working Time requirements. 3. Issues 3.1 Current hourly rates of payment for internal locums Appendix 1shows the current rates of payment to internal locums by grade together with a comparison of Agency locum payment rates and a neighbouring Trust in England Within BCU HB these rates have been in payment since 2010 and have not been increased in line with normal salary scales since that date Some specialities, such as Emergency Medicine and Paediatrics, where medical recruitment is especially difficult are able to command much higher hourly rates because the demand for these doctors is higher than the numbers of doctors available to meet it Individual submissions have been made by these specialities at times of significant pressure e.g. Paediatrics December Whilst there is anecdotal evidence that departments have paid in excess of the agreed rates on occasion, enquiries with the departments and their management accountants have failed to confirm this Where the HB requires a Consultant to undertake resident on call the Wales Amended Consultant Contract provides him / her to be remunerated at 3 x the sessional rate (one session is 3.75 hours). Some departments have been able to negotiate lower remuneration rates but this is very much discretionary and outwith the Consultants contractual entitlement. 3.2 Agency locum costs The BCU HB has agreed rates with its agency locum service provider, Medacs Healthcare. Medacs are part of the UK National Framework for the provision of locum services. Agency locum costs are subject to on going scrutiny and reducing these costs is a priority for departments NHS England has recently capped the agency locum rates NHS Trusts in England are able to pay In placing this cap on NHS Trusts they have considered looking at different hourly rate levels depending on whether the locum is for core hours (7am to 7pm ) or for out of hours work (7pm to 7am). 3.3 Action to address this situation An analysis of agency rates together with the remuneration contractually payable to Consultants resident on call suggest the following hourly rates of payment for internal locums would be reasonable; 2

5 3.3.2 Core hours 9am to 5pm Monday to Friday Consultant 70 per hour 75 Specialist Registrar / SAS doctors working at middle grade level 55 per hour 60 FYI / FY2 / CMT Clinical Fellows / SAS doctors working at junior level 40 per hour 45 Out of hours 5pm to 9am evenings; weekends and bank holidays Key specialities (Emergency Medicine; Paediatrics; Mental Health) to have flexibility to exceed the out of hours rate by 10% in exceptional circumstances with the agreement of the relevant Area or Secondary Care Director and Executive Director. 4. Assessment of risk Financial risk - the Health Board will be increasing the monies paid to medical staff undertaking internal locum duties. This increase should attract more medical staff to undertake internal locums and reduce dependency and cost of agency locums. This risk could be managed by pro-active examination of internal and agency locum spend on a monthly basis. Financial risk the Consultants remain contractually entitled to their 3 times sessional rate. They may choose to exercise this right. There is also an organisational risk that medical staff will still choose to work elsewhere as agency locums rather than undertake internal locums. 5. Equality Impact Assessment The proposals benefit all individuals. 6. Conclusions / Next Steps By 1 May 2016 revised rates of internal locum rates for all grades of Medical staff will be agreed and implemented. 7. Recommendations The Remuneration Committee is requested to note, endorse and approve The proposed increases in hourly rates of payment to all grades of medical staff set out in 3.3.2: 3

6 The proposal that certain specialities have additional flexibility to increase rates by a maximum of 10% in exceptional circumstances on submission of a written request to their Area or Secondary Director and Executive Director. Where such requests are made written authorisation, setting out the reasons for the request and reasons for approval of the request, must be provided and retained for audit purposes 4

7 2015 Locum Payment Comparison Appendix 1 Grade of Doctor 2015 National NHS Locum Rate 2015 Rate paid to BCU Internal Locum Comparison of NHS and BCU Internal Countess of Chester rates Comparison of BCU Internal and Countess of Chester Agency Doctor Hourly rates Maximum * Agency Doctor Hourly rates Minimum * F hr 20 hr -76p hr 25 hr + 5 hr hr hr F hr 30 hr hr 40 hr + 10 hr hr hr SHO/STrL hr 30 hr -37p hr 40 hr + 10 hr hr hr SpR/STrH hr 45 hr hr 40 hr - 5 hr hr hr Specialty Doctor/Staff Grade hr 45 hr hr 50 hr + 5 hr hr hr Associate Specialist MC hr 45 hr hr 50 hr + 5 hr Associate Specialist MC42 (2008) hr 45 hr hr 50 hr + 5 hr Middle Grade A&E Only 45 hr 60 hr + 15 hr Consultant hr 65 hr hr Sessional rate hr hr hr * The amounts detail are the hourly rate received by the Doctor they do not include agency fee, WTR or VAT costs. Based at top of Consultant pay scale sessional rate per 3.75hr session Associate Specialists within an agency setting are not recognised would potentially work at middle grade or locum Consultant level.