What seems to be the problem? Locum doctors, liminality and concerns about performance

Doctors who work in temporary positions (usually termed locums) in healthcare organisations can occupy a liminal space - at the margins of both the organisation and the medical profession, often situated on the periphery of or even outside formal structures for governance and support and informal professional and social networks. Qualitative semi-structured interviews were conducted with 88 participants including locums, permanently employed doctors, nurses and others with governance and recruitment responsibilities for locums across primary and secondary healthcare organisations in the English NHS during 2021-22. Data was analysed using reflexive thematic analysis and abductive analysis. Three main themes were constructed: i) lack of trust in and 'othering' of locums results in a low tolerance for problems or concerns, and a tendency both to apportion blame to the locum and to escalate concerns into formal processes of scrutiny and review; ii) low level of reciprocity of effort and mutual benefit in relationships between locums and organisations means problems or concerns may remain unresolved despite such processes of review; iii) lack of structural assertions which encompass locums and the organisations where they work may mean that both they and organisations may avoid scrutiny and responsibility for problems which affect the quality and safety of patient care. The liminal space occupied by locum doctors fundamentally shaped the way that narratives about performance concerns were constructed and enacted, in ways that mean the locum doctor was likely to be seen as "the problem". The combined consequences of the forms of liminality experienced by locum doctors - organisational, professional and socio-cultural - have profound implications for these doctors' sense of professional identity as well as for their performance. Organisations should seek to reduce or mitigate liminality to improve not only the quality and safety of patient care but also locum identity and performance.