Portuguese national healthcare system providers are not unfamiliar with a constant influx of new, temporary team members. These new members may be there for the whole day, the whole week, forever, or even for just a few hours, who knows? They are mostly junior, unspecialized doctors, earning plenty of money with very high hourly wages. These locum doctors have increasingly become part of everyday life in the Serviço Nacional de Saúde ( SNS).
Locum doctors provide clinical services on a short-term, temporary basis, and are used worldwide as a rapid response to staff shortages and seasonal demand and supply fluctuations. However convenient, locum doctors result in higher costs for the healthcare system and reduce continuity of care, as these doctors seldom get the chance to establish doctor-patient relationships, provide follow-up care, or perform clinical handovers in a structured way. Locum doctors’ unfamiliarity with local protocols and teams also disrupts care and hampers long-term quality-improvement. Finally, locum doctors have also been accused of inconsistent clinical standards and limited accountability mechanisms, which can lower the standard of care.
The (over)use of locum doctors in Portugal has been widely discussed in the media, with concerns ranging from the SNS dependence on locums, to inappropriate accountability mechanisms, and wage disparities between permanent and temporary staff. Controversies regarding the use of locum doctors in Portugal have been reported in the media as early as 2009. Since then, there have been regular reports on the overuse of these short-term contracts. By way of example, daily expenditure on locum doctors is reported to be 727 thousand euros this year.
Hourly wages of these doctors are often above those of even the most senior high-responsibility positions within the SNS: they range from €22 to €60, while the highest possible hourly wage earned by a doctor employed full-time in the SNS is €36.1. Moreover, why would someone “choose” to receive €10,75 to €14,19 as a medical intern during their specialty training if they could be earning more than the head of service, with much less experience or responsibility, working fewer hours and with more flexibility? Yes, locums can also face hard working conditions, being pulled into various locations and facing uncertainty due to the temporary, needs-based nature of their job. But the increasing dependency on these doctors has reduced the uncertainty and inconvenience of their jobs, with some hospitals even establishing permanent locum subscriptions called “avenças”, providing locum doctors with the high pay of temporary work and the stability of permanent work. The best of both worlds, right?
These wage discrepancies, together with the increasing dependence of the SNS on locum doctors, create a strong incentive for young doctors to pursue a locum career instead of specialising. Although other factors also contribute to this phenomenon, the number of slots left unclaimed by medical interns has been rising in the past few years, with 82% of the slots taken in 2024, compared to 91% in 2023. This has a long-lasting impact on the SNS, as the decrease in specialised doctors may also lead to shortcomings in the education of future doctors, for generations to come.
Lately the Portuguese government has recognised the need to address the overuse of locums, but so far they’ve had little success in solving this issue. Hourly wage caps have been established, and now the government aims to cut over 10% of the cost of goods and services, with € 100 M savings on locum contracts projected for 2026. It’s not yet clear how this will be achieved, though. The government also considers lowering the rather high wage caps. However, for obvious reasons locum doctors currently have a lot of power in the SNS, and are threatening with strikes in case the cut is implemented, which would cause a national shutdown of urgent care.
Perhaps the best way to address this issue is to treat the disease causing the current situation, rather than its symptoms. The use of locums has increased due to shortages in the SNS workforce, but these shortages are surely not due to a low number of physicians as Portugal ranks among the EU countries with the highest density of doctors. Shortages in the public sector seem instead driven by broader economic factors, including brain drain, rising (and unfair) competition between the public and private sectors on human resource retention, regional imbalances, workforce ageing, and political instability (due to high government turnover, a continuous strategic vision for the SNS is lacking).
Instead of trying to cut the locums out of the system, the Portuguese health minister should thus find a way for the system not to need locums in the first place: by tackling the drivers of workforce shortages and offering better conditions to SNS workers so that shortages are not systematic. This is no easy task, it will take years to get there, and locums will always be needed to a certain degree. But as long as workforce shortages are structural, there will be locum dependency.