Resident doctors finishing their foundation training, looking ahead to see daunting competition for training posts and low pay in locally employed jobs, used to have another option during ‘FY3’.

Doctors could usually secure enough locum shifts to get by – giving them a decent hourly rate and the opportunity to help fill gaps in rotas, sample different specialties and build their portfolios with a reasonable work-life balance for a career in medicine.

But trusts on government-sanctioned cost-cutting drives have increasingly put a stop to this option, which resident doctors often used as either respite or a fall-back.

Across the country, resident doctors report that locum shifts are harder to come by and trusts' banks are paying lower rates – which in turn is leaving hospitals with dangerous gaps in medical rotas and doctors scrabbling around to make ends meet.

‘I wasn’t getting enough work as a locum,’ says Molly Nobes, who took a job as a clinical fellow at Manchester University NHS Foundation Trust in October 2024. ‘Now, if I wanted to try and bump up my earnings [by taking locum work on top of her contracted hours], shifts are harder to find.

‘The rates were better for locums [than her substantive post] but I wasn’t getting the work. People are under pressure to pay rent, mortgages, bills and the shifts that were there are being paid less. So, options are limited.’

Dr Nobes says there were hundreds of applicants for each available clinical fellow role when she applied. Meanwhile, competition for a place on an emergency medicine specialty training programme is at a ratio of more than 14 applicants to every post.

For those who find neither a substantive post nor a training place, the ‘FY3’ locum shifts that otherwise would have provided a fallback are no longer a sustainable option. There are also growing reports of unfilled shifts being staffed by non-doctors such as physician assistants, anaesthetist assistants and advanced care practitioners.

‘I’m feeling despondent about the pay erosion we’ve all faced but then I’m exceptionally lucky to have got my job,’ says Dr Nobes, speaking to The Doctor on the picket line during recent industrial action by resident doctors. ‘But imagine the people who have been unable to get jobs. They must be very worried.’

In Mersey, the BMA is receiving ‘worrying reports’ of doctors being asked to act down to cover shifts, or work with uncovered gaps, which the association says is ‘impacting patient safety and doctors' wellbeing’.

Owing to the short-staffing, doctors are facing extreme levels of burnout, with some off sick as a result, further exacerbating the rota gaps. This is pulling doctors in training out of precious educational opportunities and causing anger among those who feel moral injury from providing sub-standard care.

A letter from the BMA to Cheshire and Merseyside ICB (integrated care board) in September, seen by The Doctor, says: ‘You have imposed impossible cost-improvement targets on our hospital leaders and have demonstrated complete disdain for staff across the region.

‘Your heavy-handed approach has resulted in effective recruitment freezes across the region with many vital services cut to unsafe levels. Not only has this had a significant detrimental impact on the quality of patient care, it has also damaged the health and well-being of staff who are being forced to work under intolerable pressure.’

Locum rates – for SAS doctors, as well as residents – have been ‘harmonised’ across the region. This has left some doctors facing steep cuts and others seeing slight rises in locum rates.

At LUHFT (Liverpool University Hospitals NHS Trust), specialty trainee 3s have seen their hourly locum rate fall from £75 to £55 and foundation year 2s have faced a drop from £42 to £40. But foundation year 1s have seen an increase from £30 to £35 and ST1/2 rates are up from £42 to £45. At Mersey Care NHS Trust, ST1/2 rates have come down from £58 to £45 and ST3 rates from £65 to £55.

Unsocial ST3 rates had been set at £70 per hour, meaning a drop from £85 at LUHFT and a rise at Mersey Care from £65, but LUHFT has now rowed back on this imposition after pressure from the BMA amid concerns around increased costs, consultant step-downs and uncovered shifts.

The BMA is demanding an end to imposed rates and a removal of barriers to recruiting additional staff where vacancies exist and that the board eases its deficit-reduction targets to fund safe staffing.

The association is organising locally and says staff ‘will have no choice but to take a stand’ if concerns are not addressed.

Katerina Efstathiou, co-chair of the BMA resident doctors committee in Mersey, told The Doctor how she began locuming after finishing her foundation years in 2020, partly to test out which specialties she might want to pursue, but also to have a break from the intensity of medical training after foundation year 2 and before embarking on gruelling specialty training.

That started off ‘quite well’ until ‘suddenly’ the trust started cutting rates.

‘Every trust started lowering their rates locally,’ she says. ‘Cutting rates means rota gaps. Slowly, we began not having full rotas. Now, we always need more doctors.’

Dr Efstathiou explains how, with the level of burnout so high, doctors do not feel like they can take on locum shifts at the rates offered. The resulting level of rota gaps causes ‘a problem for patient safety’.

She says trusts in Mersey have been telling 'FY3' locums who work regularly in the same department that their shifts will no longer be available. In many cases, these doctors have been offered substantive 'FY3' roles, usually as clinical fellows, on lower pay and without the pathway to becoming consultants.

‘They are there for service provision,’ says Dr Efstathiou. ‘They see patients, do bloods, speak to relatives. There are no educational opportunities and little portfolio time. It’s a trap. Doctors fear they could be stuck in these jobs for a long time. Then you risk these doctors quitting medicine.’

Dr Efstathiou says cost-cutting trusts are naïve to think doctors work as a ‘FY3’ locums just because of pay compared with substantive roles at the same grade.

She says locuming for a year or two helps doctors gain knowledge of different specialties to help them decide which career paths they might go down or gives a welcome break from the demands of training after five or more years of medical school and two years of intense foundation training.

‘I don’t think people understand the importance of locum doctors,’ Dr Efstathiou tells The Doctor. ‘They might locum four days a week on the same ward, which creates continuity of care. And it reduces the burnout of doctors because locums are there to support the training doctors on rotation.

‘I worked in surgery for a year [as a locum] but realised it was not what I wanted to do. Then I went into stroke but settled in GP – which was the best choice for me. If I didn’t do locum I’d have gone into surgical training and that might have been a mistake. Now, as a GP trainee, I am much more confident if someone comes in with abdominal pain, or someone came in with a stroke, because of my locums. It will make me a better GP.’

In the Black Country, the BMA entered into dispute with four acute trusts in September over the planned imposition of cuts to medical bank pay rates for doctors doing extra-contractual work from October.

Locum rates had been slashed across the board for all types of doctor.

The ‘significant and unacceptable’ cuts to pay, ‘without any meaningful consultation or negotiation’ led doctors to take a stand, which resulted in withdrawals by each trust of the planned reduced rates. Further negotiations are due to take place where the BMA will push for better rates to help fill rota gaps.

One Black Country doctor, speaking anonymously, says: ‘This felt like an attack on the value of doctors, delivered at a time when unemployment among resident doctors is at record high – it was an opportunistic move exploiting desperation.’

BMA West Midlands resident doctors committee co-chair Erin Gourley says: ‘It is unacceptable that doctors who are already going above and beyond to provide care in challenging conditions are being treated so unfairly.

‘The proposed imposition of rates would have ultimately meant a cut in pay in extra-contractual work for many and would have been a real betrayal to hard-working resident doctors.

‘It would have clearly disincentivised doctors from taking up additional shifts and we're pleased that the trusts are reassesing their actions given the groundswell of discontent from doctors.’

Dr Nobes, in Manchester, describes a similar lack of incentive. Weekend locum rates are now set at £50 per/hour for specialty trainee 1, regardless of whether they are days or nights.

‘There is no incentive,’ she says. ‘Why would I work for the same rate on a Saturday night, with no consultant other than on the phone, as a day shift with consultant support? But with the lack of jobs out there, people have to take the shifts they can get.’

In London, doctors tell a similar story. Shivam Sharma, co-chair of the BMA North Thames Regional RDC, sent Freedom of Information requests to 23 London trusts which found that at least 32,576 shifts were offered to doctors but not filled in six months at the end of 2024.

Alongside this, pay rates were capped which led the BMA to conclude: ‘Trusts are colluding to keep the rates universally low across all sites and this means shifts are going unfilled as pay rates are not competitive enough.’

The BMA is campaigning to ‘scrap the cap’ in London, to stop a practice which it says is ‘artificially supressing rates’ and means doctors in London are paid less than in other parts of the country to work extra shifts.

The association argues that fair rates agreed through negotiation would attract doctors to take unfilled shifts and ensure safer and better care for patients.

Dr Sharma told The Doctor: ‘Culturally, it used to be the case that if you didn’t get into specialty training there were locum jobs available. People were taking a year or two out because they felt like there was nothing to lose, foundation years were quite tiring and it’s nice to have a bit of a break from training, do some locuming which is likely to give a lot more flexibility.’

He says things changed when industrial action on pay began in early 2023, when he was working an 'FY3' locum year.

‘That’s when we found out they were axing locums,’ he said. ‘They basically replaced me with a more long-term post – and they didn’t offer me that post, it was given to an international medical graduate.

‘Essentially, there’s been a shift to stop the locum jobs to replace them with more clinical fellow posts, which are generally cheaper for the Government. That’s been happening over the last two to three years. What they’re doing now, as well, is cutting locum rates. All of that together makes it [an 'FY3' locum year] unviable.’

Dr Sharma fears the rate caps imposed in London are now spreading across the country as trusts seek to ‘cut and slash’ locum rates.

‘In London, they are getting away with it because there are so many doctors without enough work that people just accept it.

‘The rates are too low. A senior registrar in Barts is £42 p/h for an overnight, which is ridiculous.’

Having experienced it, Dr Sharma understands the ‘trade-off’ that comes with working an 'FY3' locum, and an ‘understanding’ from both sides.

Shifts can be anti-social, or sporadic in nature, there might be significant periods without work at all. Rates, so therefore take-home pay, may have been higher per hour but would vary month to month.

For trusts, it means slightly higher hourly costs but flexibility on staffing with a steady stream of trained doctors ready to step in, in the event of sickness (which is higher among health professionals than average), maternity cover or annual leave (when approved).

However, Dr Sharma says that mutual understanding has evaporated.

‘Now, it’s as if they are purposefully cutting the rates, keeping the rates low, or not even putting out locums,' he says.

‘If someone calls in sick, or is not able to turn up, it seems that they don’t even try to sort out the locum shifts any more, or if they do it’s for measly rates. They used to email everyone on the rota.’

Dr Sharma wants to see trusts financially punished for making doctors work on understaffed rotas. Otherwise, the substandard care provided owing to a lack of staff ultimately falls on the consciences of doctors treating patients at the coalface.

‘There’s a lack of accountability and responsibility,’ he says. ‘When shifts go unfilled, the remaining doctors' work doubles. The NHS needs all hands on deck. We have such high waiting lists but then you have doctors who are unemployed or underemployed and it's difficult for them to find posts.’

While the drying up of locum shifts appears to be nationwide, The Doctor contacted the trusts relevant to the stories we have heard first hand.

Barts Health NHS Trust chose not to comment while trusts in the Black Country, and Cheshire and Merseyside ICB, did not respond.

Sohail Munshi, joint chief medical officer for Manchester University NHS Foundation Trust, says: ‘We have strong infrastructures in place to ensure rotas are safe, meet clinical demands and support the wellbeing of our doctors. We’ve taken significant steps to address rota gaps, including increasing funded posts, redesigning rotas and improving recruitment and retention. 

‘Where additional cover is needed, we use our internal bank with clinical oversight to maintain safety. 

‘In May 2025, we aligned bank rates across Greater Manchester to ensure fairness. While some rates decreased, others did increase, we’ve seen no rise in incidents related to medical staffing and continue to monitor this closely.’

Doctors staffing these rotas, however, are raising the alarm.

Dr Sharma says: ‘The need for locums will always exist because people will fall sick at short notice. Every time there is a locum it means you’re a doctor down and there’s a responsibility to fill that shift so that you’re properly staffed, but that’s not happening.

‘People have various reasons, be it short-term sickness, long-term sickness or people leaving posts – and there will always be doctors who want to work as locums, as long as the rates are fair.

‘They’re just trying to stop that completely, which is a patient safety issue.’

A recent study praised the 'crucial role' of locums but NHS England doesn't know how many there are. They seem only to be regarded as a cost, and not the vital benefit they bring to an under-staffed health service

A recent University of Manchester study into the use of locum doctors concluded: ‘Locum doctors play a crucial role in the NHS, across both primary and secondary care, by maintaining workforce capacity and flexibility… they are vital to the smooth running of health systems.’

It added: ‘Reliance on locum doctors is partly driven by challenges in recruiting and retaining permanent staff, particularly in rural areas. Addressing these underlying issues requires a comprehensive workforce plan that prioritises the recruitment and retention of permanent doctors.’

Data on locum use is not routinely published so, as a 2023 study in the BMJ found, ‘little is known about the extent of locum use in NHS trusts’ although it noted ‘large variations in demand for and use of locums’, with trusts with low Care Quality Commission ratings typically using them more.

NHS England responded to a Freedom of Information request from The Doctor asking for the number of locum doctors employed in secondary care to say there is ‘no agreed definition’ of a locum doctor and therefore it was ‘unable to supply any data’.

A BMA survey of nearly 4,000 responses, in 2022, found that some 71 per cent of resident doctors worked additional hours as locums in the NHS to help them keep up with the cost-of-living crisis amid eroding pay. On the ground reports suggest the availability of shifts has dried up since then.

The government appears to treat locum staff as a cost, rather than a benefit or a symptom of the wider pay erosion that doctors have faced since the onset of austerity in 2010.

The debate is muddied by the use of agencies providing temporary NHS staff and trusts using internal bank systems. NHS England reported in June that it had saved nearly £1bn by reducing fees paid to agencies. Freedom of Information requests to trusts in Liverpool and London show that, while agency spend has significantly decreased, bank spend has gone up. While most doctors agree that reducing the role of agencies to prioritise banks is preferable, they are now seeing bank rates slashed. 

It is worth noting that, on top of a target to reduce agency spend by 30 per cent, health secretary Wes Streeting also told trusts to ensure their banks were not paying beyond the ‘average equivalent agency rate’ – all while he remains unwilling to budge on headline pay for full-time resident doctors, the root cause of continued industrial action – stymying the retention drive recommended by the University of Manchester study.

An NHS Professionals report says it is promoting a ‘bank first’ approach to trusts but warns: ‘With rota gaps persisting, hiring locums becomes the only option to maintain safe staffing levels.’