Annabelle Stigwood, an independent researcher and CQC inspector, explains how her research might improve outcomes for patients and GPs, and how to get involved.
NASGP: Tell us a bit about the role of GP locums in the research that you’re doing into practices that have been placed into special measures.
Annabelle Stigwood: I am currently doing a masters degree at Anglia Ruskin University, whilst being employed by CQC as an inspector. I am now undertaking my major project, where I am exploring the experiences of GP providers who have been placed into Special Measures. My initial research has indicated that many GPs who were GP partners have left their practices following a rating of Special Measures by the CQC and that many of those former GP partners are now working as locums. I have heard of GPs who have reported harrowing personal and professional journeys, from dedicated GP partners or single-handed GPs in thriving, busy practices, meeting the demands of challenging populations, to leaving their practices in the most trying of circumstances.
These GPs have a really important and unique story to tell: whilst it is anticipated that many of the GPs who take part in my project will continue to be in partnership or running practices as single-handed GPs, the feedback from GP locums who may have left their practices as a result of CQC regulation has the opportunity to present a unique insight. There is no research of this nature, and these experiences need to be captured so that we understand how practice circumstances result in them being placed into special measures, what it is like to go through that process and what changes need to be made.
My project is independent academic research and so importantly, independent of the CQC. This means that it has been through robust ethical procedures to ensure participants are not identified. Due to my role with CQC, I must meet the university’s strict ethical requirements to ensure strict boundaries in my role as academic researcher and my CQC role, so GPs must take part freely. NASGP have kindly agreed to act as gatekeeper, to act as an intermediary between me and GP participants. Whilst I am confident that my knowledge of the special measures process will mean that I can facilitate a rich, valuable and well-informed conversation, this project is independent research, and the identity of participants will be protected.
The involvement of GP locums who are or were partners who have been in special measures will be invaluable.
What factors increase the likelihood that a practice will go into special measures?
My academic project will explore all the factors that may influence a practice being placed into special measures, those which are attributable to CQC’s own systems and processes, and wider factors within the primary healthcare system.
My initial research has indicated that deprivation, funding, support, ethnicity and isolation (i.e. working singlehanded) can all affect the performance of a practice, but until I start talking to GPs, I can’t understand the full picture and it may be that different themes emerge.
From my initial literature review and conversations, it’s clear that deprivation can have an impact on CQC ratings. Practices in areas of deprivation are more likely to be rated inadequate or requires improvement than those in more affluent areas. It is often more likely that those practices won’t receive the same level of funding. Furthermore, there are more single-handed practices in areas of deprivation and non-UK qualified GPs are more likely to work in more deprived areas, working with deprived patients who are in poorer health.
What this research aims to do is explore what other factors there are, how these factors are experienced by GP partners, and what support there is to overcome these factors.
What are some examples of the ways GP locums can support quality in practices?
In my inspector role, I have come across some truly excellent GP locums who have absolutely enriched the delivery of care. In part, this is attributable to the unique skills of that particular locum, but it is often very much about the leadership of the practice and how they make the locum feel important, valued and part of the practice, even if it’s just for a short period.
A good practice usually looks after their locums, making sure they have a good induction into the practice and know who to go to when they need an answer. A good locum pack is absolutely fundamental, but it goes beyond this: I have seen practices who take the time to understand their locum’s unique skills and interests, embedding them into the culture and ethos of the practice. When there are good systems for supporting locums, practices invite them to their educational meetings, and really value their input. For example, I have seen practices where locums hold external roles, and their unique knowledge and experience is used to inform the delivery of care.
Locums can often have a valuable insight into what works well and what doesn’t work quite so well from their experiences in different practices. A good practice will see that and will have effective mechanisms to act on that feedback. On the other end of the spectrum, when things don’t go quite so well, locums are seen as filling a gap. Their involvement in the practice is not fully integrated, and there are blurred lines of accountability. At its worst, there may be a blame culture and locums are not appropriately inducted or supported, which can adversely impact on patient care.
So, in essence it’s so important for the locum, practice and patients to make sure that locums have the support that they need whenever they work in a practice.
What risks do poor CQC ratings pose to GPs’ wellbeing?
We don’t completely know, and that’s what we really need to find out. There was a piece of research which considered the impact of GMC proceedings on the mental health of doctors undergoing those procedures, and the findings were quite startling. There is no research which has considered the impact of the imposition of CQC special measures on a GP’s wellbeing, so this research is of key importance.
This is the reason why I think that GP locums who were previously partners whose practice was placed into special measures may provide the richest feedback. Regrettably, I anticipate that they may have been through the most challenging of experiences. Through their narratives, I can explore the impact of CQC’s systems, and identify what factors were affecting the practice and what support they received from external organisations. Ultimately, though, I would like to explore the impact of this rating on their careers and personal lives. When we can present impact, this can compel change.
What outcomes might there be from your research, and how might they improve locums’ working lives?
Whilst this is independent research, this is supported by the CQC and the findings will be used to inform future ways of working. It will give GP locums a voice in shaping improvements, within the reassurance and safety of an ethically approved study.
The research will capture GPs’ journey to becoming locums from partnerships or single-handed GPs. It will provide a platform for locums to talk about their experiences of CQC regulation from a unique perspective as both locum and provider and give their exceptional insight into the challenges in the wider primary care system.
Who are you hoping to talk to, and when?
I would like to talk to sessional GPs (salaried or locum) who have experience of working in a partnership or single-handedly at GP practices that have been placed into special measures in the last five years.
I am currently undertaking the project, so I am keen to hear from participants as soon as possible. If participants could email firstname.lastname@example.org or use the contact form and let NASGP know that they are happy for me to contact them, I will make contact as soon as possible to arrange an interview via Teams. I anticipate the calls will take between an hour to an hour and a half.