The Bottom Line
- Locum agencies take a <strong>margin on top of your rate</strong> — the trust pays more than you receive. Understand the spread.
- <strong>Direct booking</strong> (via NHS locum banks, Patchwork, Locum's Nest) eliminates the agency margin — but requires more admin.
- Not all agencies are equal: check <strong>payment terms, compliance requirements, and hidden deductions</strong> before signing.
The UK locum market is a multi-billion pound industry with hundreds of agencies competing for your registration. For IMGs and new doctors, the agency landscape is confusing — rates vary wildly, payment structures differ, and some agencies have practices that significantly reduce your take-home pay. This guide explains how the market works so you can make informed decisions.
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Step 1 — Understand the agency model
A trust needs a doctor. The trust contacts agencies (or posts on its internal bank). An agency offers you the shift at an hourly rate. The agency charges the trust a higher rate. The difference (the 'spread' or 'margin') is the agency's revenue. Typical margins range from 10–30% on top of your rate. You are the product — the agency's customer is the trust.
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Step 2 — Compare PAYE vs umbrella vs limited company
Agencies typically offer different payment structures. PAYE: the agency acts as your employer, deducts tax and NI, simple but you cannot claim expenses. Umbrella: a third-party company employs you, handles tax/NI, and may allow some expense claims — but check the umbrella's fees. Limited company: you invoice the agency through your own Ltd company — highest potential take-home but with IR35 implications and accounting costs. Each has trade-offs — read our IR35 and Umbrella guides for details.
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Step 3 — Check payment terms before your first shift
Key questions: How quickly do they pay after a shift (weekly? monthly? 30 days after invoice)? What documentation do they need (timesheets, trust confirmation)? Are there any deductions you should know about (admin fees, compliance charges, insurance)? Late or unreliable payment is the #1 agency complaint.
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Step 4 — Consider direct booking as your primary strategy
NHS trust staff banks, and platforms like Patchwork, Locum's Nest, and BDI Resourcing, allow you to book shifts directly with trusts — eliminating the agency margin. Direct booking typically pays more per hour because there is no intermediary taking a cut. The trade-off: you manage your own compliance, bookings, and availability.
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Step 5 — Use agencies strategically, not exclusively
Agencies are useful for: first-time locums who need compliance support, accessing shifts at trusts where you have no direct relationship, and filling gaps in your schedule. Use 2–3 agencies maximum — spreading across too many creates admin chaos. Always compare the agency rate with the direct rate for the same trust before accepting.
Questions to ask every agency
Before signing: (1) What is your margin on this shift? (some agencies will disclose; others won't — the refusal itself is informative). (2) What are your payment terms? (3) Do you charge any admin, compliance, or processing fees? (4) What happens if the trust cancels the shift — do I get a cancellation fee? (5) Who is my contact if there is a problem?
Practice
Test your knowledge
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