For three decades a new form of doctors employment is common in Sweden – the “rental doctors”. They are loved by some, hated by others. It gives freedom, and most often a better economy, for the doctor. But it digs a hole in the budget of the public health.
It seemed to have happened out of nowhere. During the late 90’s, the possibility to work a week or two in some remote hospital or clinic for well-paid remuneration became an appealing option for many doctors. This phenomenon with temporary doctors, referred to as “locum physicians”, happened very suddenly. In the beginning it was restricted to a few clinics and for shorter periods of time.
With time, these clinics and hospitals began to consider the temporary locum physicians as a more long-term solution, due to the shortage of doctors. But of course, this came at a price. While medical competence was made available, what suffered in the process was continuity. Every week a new doctor needed to be acquainted with the routines of the clinic and taught to navigate the journal system. Patients could only hope to meet the same doctor more than once.
The wheels were set in motion. More and more doctors left their regular jobs to work in the more lucrative “locum positions”. It was possible to dictate one’s working conditions and with a flexibility of both time and place, this proved to be a very attractive option. Besides, the salary was most often double or more compared to the regular. The phenomenon gradually spread from the small towns to the big cities, and a lot of the clinics who had difficulty in recruiting doctors came to rely almost entirely on locum staff. Currently, in certain clinics the number of permanent employees is often less than half. The greatest need is mostly in outpatient general psychiatry clinics, but locum positions are also used to compensate for lack of doctors in both in-patient care and on-call and emergency services.
So how could the situation get like this? To get some answers I called up Christian Törnqvist at the Swedish Association of Local Authorities (SALAR), in Sweden known as Sveriges kommuner och Regioner, SKR. SALAR is the employers' organization that represents and advocates for the local governments of the regions in Sweden, including medical staff working in the public health system.
It all started in the 90s, when the law on private employment was opened up. Suddenly, it was possible for privately run agencies to employ and provide staff to public healthcare. This was a completely new phenomenon. To start with, this system was used to cover up for temporary vacancies, and these positions were mainly attractive to doctors nearing retirement. However, the character gradually changed from being a temporary to a more permanent solution.
Christian says that initially this form of employment was mainly used to cover for physician vacancies, but in the last decade it has also been extended to recruit nurses, who today cost the public health system as much as doctors do.
How could it get like this?
It is due to a combination of reasons. It is not just the higher salary alone that is the deciding factor, although many doctors are attracted by the opportunity to work through their own companies. Other aspects, such as control over one’s own work situation, are at least as important. Many doctors can feel like cogs in a wheel with a limited opportunity to influence their own circumstances and the system they operate in. Christian wonders if this notion can sometimes become a self-fulfilling prophecy. It is quite evident that doctors indeed have a profound impact on the healthcare system.
The system of locum doctors has its price, both monetarily and in that it has a negative impact on the quality of healthcare provided. With a constant flux of doctors, their interest and involvement in the development of their workplace decreases. There is lack of continuity and the work environment for the permanent doctors who remain deteriorates. With rising costs and budget constraints, the possibility to hire other medical staff also suffers consequently. Today, the cost of hired personnel is close to five percent (4.8%) of the regions' entire staff budget.
Various projects have been implemented to reduce these costs and were indeed quite effective a few years ago. But then the pandemic came, and in its wake, there was a large healthcare debt with the need to clear up the backlog. As a result, since 2022, we have seen costs skyrocketing again.
In addition, different strategies have been introduced to try and reduce the percentage of temporary hired personnel. It has been mainly about finding more individual solutions to increase the attractiveness of working in permanent positions. In addition, various regions have locally put a stop to hiring locum staff. This has sometimes worked, but has sometimes also had significant consequences, such as outpatient clinics and wards having to close as a result of staff shortages.
Can't there be a decision at a national level to stop locum positions?
It is, of course, an appealing thought, but you must be clear that all regions are self-governing. The regional governments have negotiated a national agreement concerning the employment of locum medical staff to assure quality at a reasonable cost. The private actors and companies who provide these locum medical staff, have constantly appealed against this agreement to the Administrative Courts ending up in a long-drawn process.
In the midst of it all, Christian Törnqvist is optimistic. He thinks that we must get better at communicating the benefits of being permanently employed. Likewise, care providers must get involved locally in finding individual solutions to increase the attractiveness of being permanent staff. SALAR's goal is not to remove the system of locum doctors entirely. It will always be a valuable tool to solve short-term vacancies. But it would be ideal to reduce this type of dependence, not the least financially speaking. Perhaps reducing the cost by half to about two percent of the personnel budget, would be a reasonable goal. □