This paper addresses important issues and challenges that exist in providing the expected standard of care in rural and remote Australia and rural New Zealand where the geographical distances between health services and major metropolitan hospitals can be vast. Surgeons in isolated practice require regular holidays and study leave, with the responsibility for finding appropriate surgical locums usually resting with the health authority, not with the surgeon. Surgeons who are in private practice will usually assume the responsibility of finding a locum. Surgical locums need to be selected to appropriately fill the required need in the location and as such they should be appropriately remunerated for their services.


The following principles specifically address the surgical environment, model of care and provision of resources for effective locum engagement:


The quality of care provided by surgical locums must be comparable to the standard provided by the regular surgical staff


The use of orthodox procedures and practices is essential to ensuring that patient safety is prioritised


The provision of resources for locum surgeons should be the same as provided to the incumbent surgeon


The engagement of surgical locums should be made with consideration to the location, scope of practice, case mix and requirements of the health service. The locum must be able to provide services that are expected in that location.


Rural and regional patients have the right to expect appropriate access to high quality medical services. When their condition requires surgical care by a locum, they expect a surgical service appropriate to their needs and of a quality comparable to that usually available elsewhere in Australia and New Zealand, with allowance given for more limited local facilities and varying distances from major facilities. They also expect that, in critical or emergency situations, the system of surgical care will support their care. Ensuring consistent quality of service relies upon the development of systems to ensure that surgical locums are appropriately engaged and prepared to care for all eventualities in the location. Because rural and remote health services are encouraged to develop relationships with large regional or city hospitals, some of these larger hospitals may provide occasional locums. The use and provision of locum services may also occur in the context of combined operating lists and co-located clinics where there is an outreach service: this assists surgical locums in having access to initial support and enhances the rapport between the surgeons. The sharing of protocols, inclusion in multi-disciplinary disease based meetings and participation in specialty or multi-institutional audits should be encouraged as a mechanism of ensuring patient care standards and safety.

Surgical locums should have consistent access to key support persons relevant to their context and there is value in the development and use of partnerships between health services and tertiary care units who can provide advice when necessary. Locum surgeons who are engaged for short periods of cover should ensure that their instructions for post-operative care are unambiguous and clearly recorded so that care can be maintained by another doctor after their posting has ended. Locum surgeons should give special consideration to their ongoing CPD requirements. If a surgeon expects to be engaged in locum work then his or her personal development and CPD plans should reflect this. It may be that the locum surgeon’s CPD activities relate to a broader range of clinical activities compared with substantive appointments because he or she needs to maintain a broader range of practice in order to obtain locum work. RACS offers CPD compliance through the Locum Logbook evaluation process available on the college website through the MALT system.


In order to ensure patient safety within locum care situations health services, there should be appropriate guidelines and models of care in place. These guidelines should at a minimum include initial orientation and introduction; full handover of current cases; appropriate support services and expectations and clear information on the hospital’s scope of practice. Locums should receive orientation or preparation for local practice prior to commencing their locum placement, avoiding a range of difficulties arising from the potential delivery of culturally inappropriate care or lack of continuity of care. Hospitals and health services must have established handover documentation, checklists, and record systems that can be readily accessed by locums. Appropriate procedures and processes should be established to ensure that locums have timely access to pathology, equipment, pharmaceutical prescription and other usual hospital services. Health services, hospitals and governments are encouraged to consider where equipment, pathology and other facilities can be standardised across locations. Examples of a lack of consistency may be seen in variations in booking and consent process; on call hours; availability of usual and critical equipment; networking of theatre staff in more remote areas.


Access to Locum surgeons is an essential component of supporting surgical services across geographical locations. Careful workforce planning and early recruitment to planned vacancies can help avoid the need for locum staff. Employers should consider the relative cost-effectiveness of engaging permanent versus locum staff. Ideally, there should be sufficient substantive posts within the hospital to meet predictable service demands, including planned absences; however, in remote locations this may not be possible.


All remote, rural and regional hospitals will have their own individual needs and requirements. The credentialing of a locum for a particular location will be best determined by an assessment of the locum’s scope of practice, the local needs and the facilities available. Selection of an appropriate locum will be location-specific and depend on the training and skill set of surgeon. The surgeon to be replaced must ensure that the locum is appropriately briefed regarding the routines and practices of the surgical team, knows whom to approach for advice on clinical or managerial matters, and is not required or expected to work outside his or her field of expertise.


Chong A, Kiroff G. Preparing surgeons for rural Australia: the RACS Rural Surgical Training Program. ANZ Journal of Surgery. Wiley-Blackwell; 2014 Oct 7;85(3):108–12.

Halverson AL, Hughes TG, Borgstrom DC, Sachdeva AK, DaRosa DA, Hoyt DB. What Surgical Skills Rural Surgeons Need to Master. Journal of the American College of Surgeons. Elsevier BV; 2013 Nov;217(5):919–23.

Maddern G. Rural surgery: challenges and solutions for the rural surgeon. Wichmann M, Borgstrom DC, Caron NR, editors. Berlin: Springer-Verlag Berlin and Heidelberg GmbH & Co. K; 2011.

O’Sullivan BG, Joyce CM, McGrail MR. Rural outreach by specialist doctors in Australia: a national cross-sectional study of supply and distribution. Human Resources for Health. Springer Science + Business Media; 2014;12(1):50.

Green A. Maintaining surgical standards beyond the city in Australia. ANZ Journal of Surgery. Wiley-Blackwell; 2003 Dec;73(12):1061–2.

Campbell NA, Kitchen G, Campbell IA. Operative experience of general surgeons in a rural hospital. ANZ Journal of Surgery. Wiley-Blackwell; 2010 Dec 23;81(9):601–3.

Halverson AL, Hughes TG, Borgstrom DC, Sachdeva AK, DaRosa DA, Hoyt DB. What Surgical Skills Rural Surgeons Need to Master. Journal of the American College of Surgeons. Elsevier BV; 2013 Nov;217(5):919–23.

Wakerman J, Humphreys JS. Sustainable workforce and sustainable health systems for rural and remote Australia. The Medical Journal of Australia. Australasian Medical Publishing Co. Pty Ltd. (AMPCo); 2012 Jul 23;1(3):14–7.

Skinner C, Buchanan J, Goulston K. The Medical Locum Challenge: Understanding the Impact of Locum Working Arrangements on the NSW Public Hospital System.

National Rural Health Alliance, ‘Locums and short term contractors in the health workforce, August 2012.

Department of Health. Locum Consultant Appointments. London: DH; 2010.

NHS Employers. The Use of Locums: Advice for Employers. Leeds: NHS Employers; 2009.

NHS Executive. Code of Practice In the Appointment and Employment of HCHS Locum Doctors. Leeds: NHS Executive; 1997.

Locum Surgeons – Principles and Standards, Professional Standards and Regulation Directorate, The Royal College of Surgeons of England 2011.