‘The use of locum doctors in the NHS: understanding and improving the safety and quality of care’ needs GP locums’ experience.
A new NIHR study is looking for locums, including GP locums, to share their experiences of working as a locum in the UK. Prof Kieran Walshe explains how their research might affect GPs, and how to get involved.
NASGP: Tell us a bit about where GP locums sit in the research that you’ve done and the research that you’re doing.
Prof Kieran Walshe: Sure. The project we’re doing, ‘The use of locum doctors in the NHS: understanding and improving the safety and quality of care’, which is funded by the National Institutes of Health Research, arose out of prior research we did into revalidation.
One bit of work was about trying to understand revalidation, what impact it had and what doctors thought about it. One of the things that came up was that revalidation seemed to work quite well for doctors who were in conventional employed relationships with organisations. But those doctors were those who were already best covered by systems of clinical governance. It seemed to work less well both for doctors and for organisations for those who have more distanced or more transitional or transactional relationships in organisations, including locums and portfolio doctors. To some degree it works less well for people who took career breaks.
We were particularly interested in what it told us about locum doctors and we did a little bit of further work, primarily in secondary care, looking at the experience of locums, so we had lots of interviews with people like responsible officers, medical directors, medical staffing, people in NHS organisations, and we did some further interviews with with locums. That revealed that the way locums get portrayed in the press is often quite negative. They will be stereotyped and to some degree blamed for being locums.
It also highlighted both the reasons why people could move into working as locums and the heterogeneity of the locum population. When people talk about locums, you’ve got everything – from somebody who’s got a substantive position but does a bit of locuming on the side, to somebody who’s locuming between job A and job B, to someone who’s chosen locuming as their their career (for flexibility and control over their working life), to people who are locums who would prefer a permanent position somewhere. It’s a really heterogeneous population.
When you go into an organisation as a locum, often the first thing people see is not your clinical experience or your background or your past history. They see that you’re a locum. That’s why the paper we wrote about that work was titled “You’re just a locum”, because that was mainly how many of the locums describe their experience.
We have also previously undertaken a big review of the literature about outcomes, because there are lots of preconceptions about locums and their clinical practice. The review highlights two really useful things. One was, there’s not very much research. So a lot of the preconceptions about locums are just that – preconceptions. The other was, the way locums practice is as much, if not more, a product of how organisations choose to use them as it is of the locums themselves. So it highlighted some of the issues about locum engagement and the extent to which locums are properly inducted and supported in the workplace – the sorts of work they’re given and the opportunities they’re given for professional development.
You have previously mentioned going qualitative research and case studies – for this study will you be doing any interviews with GPs?
We’re doing a small number of case study organisations, a few NHS trusts and a few CCGs where really the CCG is the kind of focus of the case study, and what we’re trying to do is identify a number of GP practices within that CCG.
CCGs don’t engage very much, I think, in locum organisation, and we’re starting to understand better the way in which GP practices, primary care networks (PCNs) and CCGs differently interact with locums. Some PCNs actually get quite engaged in organising locum cover but it’s mostly something GP practices do.
We’re also doing some more quantitative work, which uses existing datasets to try and understand what differences exist in locum practice. So in primary care, there’s a brilliant data set, the Clinical Practice Research Database (CPRD), which covers a very large chunk of primary care practices, and consultations in that data set are tagged by staff type.
So we can, for example, look at GP locums alongside other types of GPs, and try and understand whether there are differences in the patient population that comes to see them, and differences in things like referral and prescribing behaviour. No one’s ever done that piece of work before. So we’re really quite excited about that.
Have ‘bank’ models of locums come up in your research much yet?
We don’t know yet. So we are going to be and I think, I think also, primary care and NHS trusts are just really different worlds in this. So we’re trying to cover both of them.
We’re developing the questionnaire, it is going to be different because the questions just have to be different. We were originally thinking about trying to survey CCGs, but we’ve moved towards surveying practices, because we think that’s where the knowledge really is.
We will be asking some questions about innovations at a practice or a PCN level, and the extent to which they use locum agencies or, or external providers, if you like, or the extent to which they rely very much on formal or informal banking arrangements. So the informal banking arrangements can be that they’ve got past practice members of staff who have since retired, but who come back and do some shifts. It can be that they’ve got, you know, if you’d like known quantity locums, who’ve worked with them for years, and to perhaps have a career break or have family responsibilities, but who like the opportunity to do some makeup? We’re trying to kind of understand.
Are there any particular outcomes that might affect GPs that you want to talk about?
It’s very hard to say at this stage. What we know so far, from the studies we’ve done, is not that particular to primary care and general practice. We really want the research to be helpful, and to help change practice. And so what we hope is that we’ll be able to provide feedback to some of the national organisations but also to NHS trusts, and to CCGs and PCNs that helps them to do things like look at what innovations have been used elsewhere and understand how they’ve been used, and what some of their advantages and disadvantages might be.
We want to put to bed some of the sort of myths and preconceptions, and advance knowledge and understanding. For example, are locum behaviours different from permanent doctors and why? So you know, just before talking to you I was reading a piece about the locum workforce which asserts that when you have locums coming into a practice, things like test ordering behaviours change, and they order more tests, and they make more referrals. I don’t know that we’ve actually got any evidence of that.
And of course, if there are differences, there’ll be driven by some kind of organisational constructs. So there are things that you can then do to try and address that.
What kind of partnerships or kind of research relationships are key to this work?
One of the aspects we haven’t yet talked about is, what do patients think about being treated by a locum? Are patients aware that the person they’re seeing is a locum in primary care? Does it matter to them? And if so, for what reason? We’re going to be doing some focus groups for groups of patients to try and understand their experience of having consultations with locums and to what extent they’re aware and what issues are salient to them.
When will you be looking for GP locums to interview?
Mostly over the next six to 12 months. We’ve done about 20 something interviews so far and our plan is to carry on doing that right through most of this calendar year.
I would add that in our last piece of work, it seemed really hard to recruit GP locums to be interviewed. We’d like to interview GP locums and we’d urge your members to please get in touch with us. If people are interested in talking to us, we would love to hear from them and we’ve got the capacity to do quite a few interviews.
Taking part involves participating in an interview over the phone, Zoom or MS Teams at a time convenient for the GP. Interviews typically take 30 minutes to an hour. With the GP’s permission, interviews will be recorded. During the interview, a researcher will ask the GP to reflect on your experiences of working as a locum.To take part, please contact Jane Ferguson (firstname.lastname@example.org) or Gemma Stringer (email@example.com).