Scotland’s health boards have paid up to £837 an hour for locum psychiatrists to help cope with a deepening staff shortage crisis in mental health services.
They have been charged more than £130m by dozens of private health care companies to provide temporary psychiatrists over the past five years, including one firm now owned by two billionaires from Texas.
The Royal College of Psychiatrists and NHS executives said mental health services in Scotland were now at breaking point because of severe staff shortages, which was damaging patient care and causing experienced consultants to quit.
Scottish hospitals are now so reliant on agency locums to ensure their mental health services function, that health boards are forced to pay hourly rates significantly higher than the salaries of NHS consultants.
Dr Jane Morris, chair of the college’s Scottish arm, said adult psychiatry was the worst affected branch of the NHS, with a 25% vacancy rate across Scotland. “There simply aren’t enough of us,” she said. “I think the whole agency locum question is a reflection of a real crisis in the Scottish psychiatric workforce.”
The soaring costs of locums led to a “vicious circle”, she said. It put NHS consultants under greater pressure to manage services and take on heavier caseloads; they felt overworked and undervalued, so resigned, worsening the crisis.
A joint investigation by the Guardian and BBC Scotland has found:
Annual spending by Scotland’s 14 health boards on locum psychiatrists reached nearly £35m last year, up from £20m five years ago.
NHS Tayside has spent more than £30m since 2019, and NHS Fife nearly £26m.
One company charged NHS Lothian nearly £350,000 for 416 hours of cover in 2019, at an average hourly cost of £837.
NHS Western Isles paid £27,000 for one week of round-the-clock cover in April 2023.
NHS executives said hospitals and GP surgeries often needed locums to cover staff holidays or sickness, or in emergencies. In some cases, that was provided by NHS staff who were paid overtime or for working during their holidays.
Agencies charge hourly rates ranging from £85 to as much as £473. That included administration and professional fees, and VAT at 20%. By comparison, a junior NHS consultant would earn about £50 an hour.
One company, Brookson Solutions, which was bought by two US billionaire investors, David Bonderman and James Coulter, in 2022, has earned more than £19m from providing locums to NHS Tayside and NHS Fife.
It said it provided payroll and compliance services, and did not directly recruit the locums Tayside used.
Morris said Scotland’s hospitals were so dependent on locums in some cases they hired psychiatrists who were not fully qualified or who were not members of the Royal College of Psychiatrists, the profession’s governing body.
Some locums gave remote consultations online from cities outside Scotland, in Britain or abroad, including in India – a service the royal college regards as substandard unless it includes face-to-face follow-ups.
Dr Amanda Cotton, the associate medical director for mental health in NHS Borders and a spokesperson for the Senior Medical Managers in Psychiatry group, said the shortage of staff psychiatrists raised serious questions about hospitals’ ability to provide cover.
“The cracks are absolutely starting to show,” she said. “That’s one of the reasons that we are seeing the locum bills increase, because we’re faced with a stark choice. Do we see posts go unfilled and then see services aren’t sustainable, or do we bring these doctors into post despite that enormous cost?”
Gordon Jamieson, the chief executive of NHS Western Isles, one of Scotland’s smallest boards, said locums were the single greatest pressure on his budget and his board had diverted money from other parts of its budget to pay for them.
Some charges were “eye-wateringly high”, he said. “If you go into the locum market, then it’s such a volatile market that really you find yourself at the mercy of the market,” he said. “If you don’t respond to the market cost you have no service.”
Cotton and Morris said it was essential the Scottish government reversed its cuts to mental health funding. In 2021, ministers promised to ensure 10% of NHS spending went on mental health, but it had instead fallen to about 8%.
In August’s emergency budget, the Scottish government cut a further £19m from its national mental health spending. Cotton said this had led to standards and quality “being eroded over time … We’re going backwards rather than in the right direction”.
The Scottish government said it was convening a working group to discuss solutions to the locums crisis with the royal college and Cotton’s group later this month, and was providing more psychiatry training places.
“Ensuring the provision of high quality and safe patient care is our priority, and it is also critical that we ensure best value on delivering mental health services, which allows us to maximise the impact of investment,” said Maree Todd, the mental wellbeing minister.
“To support wider recruitment and retention issues facing psychiatry, we are exploring how we can attract new or existing psychiatrists to take up posts in Scotland.”
