Comparing the clinical practice and prescribing safety of locum and permanent doctors: observational study of primary care consultations in England.

BACKGROUND: Temporary doctors, known as locums, are a key component of the medical workforce in the NHS but evidence on differences in quality and safety between locum and permanent doctors is limited. We aimed to examine differences in the clinical practice, and prescribing safety for locum and permanent doctors working in primary care in England. METHODS: We accessed electronic health care records (EHRs) for 3.5 million patients from the CPRD GOLD database with linkage to Hospital Episode Statistics from 1st April 2010 to 31st March 2022. We used multi-level mixed effects logistic regression to compare consultations with locum and permanent GPs for several patient outcomes including general practice revisits; prescribing of antibiotics; strong opioids; hypnotics; A&E visits; emergency hospital admissions; admissions for ambulatory care sensitive conditions; test ordering; referrals; and prescribing safety indicators while controlling for patient and practice characteristics. RESULTS: Consultations with locum GPs were 22% more likely to involve a prescription for an antibiotic (OR = 1.22 (1.21 to 1.22)), 8% more likely to involve a prescription for a strong opioid (OR = 1.08 (1.06 to 1.09)), 4% more likely to be followed by an A&E visit on the same day (OR = 1.04 (1.01 to 1.08)) and 5% more likely to be followed by an A&E visit within 1 to 7 days (OR = 1.05 (1.02 to 1.08)). Consultations with a locum were 12% less likely to lead to a practice revisit within 7 days (OR = 0.88 (0.87 to 0.88)), 4% less likely to involve a prescription for a hypnotic (OR = 0.96 (0.94 to 0.98)), 15% less likely to involve a referral (OR = 0.85 (0.84 to 0.86)) and 19% less likely to involve a test (OR = 0.81 (0.80 to 0.82)). We found no evidence that emergency admissions, ACSC admissions and eight out of the eleven prescribing safety indicators were different if patients were seen by a locum or a permanent GP. CONCLUSIONS: Despite existing concerns, the clinical practice and performance of locum GPs did not appear to be systematically different from that of permanent GPs. The practice and performance of both locum and permanent GPs is likely shaped by the organisational setting and systems within which they work.

The use of locum doctors in the NHS - results of a national survey of NHS Trusts in England.

BACKGROUND: Locum working in healthcare organisations has benefits for individual doctors and organisations but there are concerns about the impact of locum working on continuity of care, patient safety, team function and cost. We conducted a national survey of NHS Trusts in England to explore locum work, and better understand why and where locum doctors were needed; how locum doctors were engaged, supported, perceived and managed; and any changes being made in the way locums are used. METHODS: An online survey was sent to 191 NHS Trusts and 98 were returned (51%) including 66 (67%) acute hospitals, 26 (27%) mental health and six (6%) community health providers. Data was analysed using frequency tables, t-tests and correlations. Free-text responses were analysed using thematic analysis. RESULTS: Most NHS Trusts use locums frequently and for varying lengths of time. Trusts prefer to use locums from internal locum banks but frequently rely on locum agencies. The benefits of using locums included maintaining workforce capacity and flexibility. Importantly, care provided by locums was generally viewed as the same or somewhat worse when compared to care provided by permanent doctors. The main disadvantages of using locum agencies included cost, lack of familiarity and impact on organisational development. Some respondents felt that locums could be unreliable and less likely to be invested in quality improvement. NHS Trusts were broadly unfamiliar with the national guidance from NHS England for supporting locums and there was a focus on processes like compliance checks and induction, with less focus on providing feedback and support for appraisal. CONCLUSIONS: Locum doctors provide a necessary service within NHS Trusts to maintain workforce capacity and provide patient care. There are potential issues related to the way that locums are perceived, utilised, and supported which might impact the quality of the care that they provide. Future research should consider the arrangements for locum working and the performance of locums and permanent doctors, investigating the organisation of locums in order to achieve safe and high-quality care for patients.

Climate Change and Public Health through the Lens of Rural, Eastern North Carolina.

BACKGROUND Recognizing that health outcomes are associated with climate threats is important and requires increased attention by health care providers and policymakers. The primary goal of this report is to provide information related to the public health threats of climate change, while identifying climate-sensitive populations primarily in rural, Eastern North Carolina.METHODS Publicly available data was used to evaluate regional (eg, Eastern, Piedmont, and Western) and county level socio-vulnerability characteristics of population groups in North Carolina, including: percent of persons living in poverty, percent of non-white persons, percent of persons under 18 years living in poverty, percent of elderly people living in poverty, percent of persons with a disability, and number of primary care physicians. One-way ANOVA was used to calculate and compare mean value estimates of population socio-vulnerability variables in Eastern North Carolina with Piedmont and Western regions.RESULTS Across all regional categories, the eastern part of the state had considerably higher averages than the state for percent of persons living in poverty (17.2%), percent of non-white persons (13.3%), percent of persons under 18 years old living in poverty (24.9%), percent of elderly people living in poverty (10.0%), and percent of persons with a disability (13.3%). Overwhelmingly, more counties in Eastern North Carolina had fewer primary care physicians (per 10,000 persons) than the state average (8.6 per 10,000 persons).CONCLUSION Eastern North Carolina has a disproportionally higher percent of population groups that are vulnerable to the threats of climate change. The need for health care providers to understand and communicate the challenges faced by rural, vulnerable population groups is of great public health importance. Communicating these health risks to policy makers is of equal importance.

Locum doctors in English general practices: evidence from a national survey.

BACKGROUND: Locum doctors give practices flexibility to deliver patient services but there are concerns about the impact of locum working on continuity of care, patient safety, team function, and cost. AIM: To explore locum working in English general practices, and understand why and where locum doctors were needed and how they were engaged, supported, perceived, and managed. DESIGN AND SETTING: An online survey was sent to 3745 practices. METHOD: Quantitative responses were analysed using frequency tables, t-tests, and correlations. Free-text responses were analysed using thematic analysis. RESULTS: In total, 605 (16.2%) responses were returned between June and December 2021. Practices made frequent use of locums, preferring regular locums familiar with processes and patients. Disadvantages of agency locums included cost, lack of patient familiarity, and impact on continuity of care. Care provided by locums was generally viewed as the same but sometimes worse compared with permanent GPs. Some practices reported that locums did not always perform the full range of duties, resulting in increased workload for other staff. Practices were largely unfamiliar with national guidance for organisations engaging locums, and, although processes such as verifying documentation were conducted, far fewer responders reported providing feedback, support for revalidation, or professional development. CONCLUSION: Locum working is an essential part of English general practice, but this research raises some concerns about the robustness of arrangements for locum working and the impact on quality and safety of care. Further research is needed about the clinical practice and performance of locums, and to explore how locum working can be organised in ways that assure safe and high-quality care.

Use of locum doctors in NHS trusts in England: analysis of routinely collected workforce data 2019-2021.

OBJECTIVES: Temporary doctors, known as locum doctors, play an important role in the delivery of care in the National Health Service (NHS); however, little is known about the extent of locum use in NHS trusts. This study aimed to quantify and describe locum use for all NHS trusts in England in 2019-2021. SETTING: Descriptive analyses of data on locum shifts from all NHS trusts in England in 2019-2021. Weekly data were available for the number of shifts filled by agency and bank staff and the number of shifts requested by each trust. Negative binomial models were used to investigate the association between the proportion of medical staffing provided by locums and NHS trust characteristics. RESULTS: In 2019, on average 4.4% of total medical staffing was provided by locums, but this varied substantially across trusts (25th-75th centile=2.2%-6.2%). Over time, on average two-thirds of locum shifts were filled by locum agencies and a third by trusts' staff banks. On average, 11.3% of shifts requested were left unfilled. In 2019-2021, the mean number of weekly shifts per trust increased by 19% (175.2-208.6) and the mean number of weekly unfilled shifts per trust increased by 54% (32.7 to 50.4). Trusts rated by the Care Quality Commission (CQC) as inadequate or requiring improvement (incidence rate ratio=1.495; 95% CI 1.191 to 1.877), and smaller trusts had a higher use of locums. Large variability was observed across regions for use of locums, proportion of shifts filled by locum agencies and unfilled shifts. CONCLUSIONS: There were large variations in the demand for and use of locum doctors in NHS trusts. Trusts with poor CQC ratings and smaller trusts appear to use locum doctors more intensively compared with other trust types. Unfilled shifts were at a 3-year high at the end of 2021 suggesting increased demand which may result from growing workforce shortages in NHS trusts.

Unlocking the potential of NHS primary care dental datasets.

Introduction Maximising the use of routinely collected health data for research is a key part of the UK Government's Industrial Strategy. Rich data are generated by NHS primary care dental services, but the extent of their use in research is unknown.Aims To profile the utility of the post-2006 NHS dental datasets for research, map how they have been used to date and develop recommendations to maximise their utility.Methods The content of and access to the four UK NHS dental datasets was collated using publicly available information and a free-text questionnaire, completed by the relevant data controllers. A scoping review was carried out to identify and map literature that has utilised NHS dental activity data.Results The contents of the UK NHS dental activity datasets are described, alongside how they may be accessed for research. Strengths and weaknesses of these datasets for research are highlighted. The scoping review identified 33 studies which had utilised NHS dental activity data since 2006. We classified 15 as public health practice, 11 as service evaluation and 7 as research.Conclusion In comparision to other NHS activity datasets, it appears that the UK dental datasets have been underutilised for research. We make 11 recommendations on how their utility for research may be increased.

Physicians under Pressure: Evidence from Antibiotics Prescribing in England.

BACKGROUND: Many physicians are experiencing increasing demands from both their patients and society. Evidence is scarce on the consequences of the pressure on physicians' decision making. We present a theoretical framework and predict that increasing pressure may make physicians disregard societal welfare when treating patients. SETTING: We test our prediction on general practitioners' antibiotic-prescribing choices. Because prescribing broad-spectrum antibiotics does not require microbiological testing, it can be performed more quickly than prescribing for narrow-spectrum antibiotics and is therefore often preferred by the patient. In contrast, from a societal perspective, inappropriate prescribing of broad-spectrum antibiotics should be minimized as it may contribute to antimicrobial resistance in the general population. METHODS: We combine longitudinal survey data and administrative data from 2010 to 2017 to create a balanced panel of up to 1072 English general practitioners (GPs). Using a series of linear models with GP fixed effects, we estimate the importance of different sources of pressure for GPs' prescribing. RESULTS: We find that the percentage of broad-spectrum antibiotics prescribed increases by 6.4% as pressure increases on English GPs. The link between pressure and prescribing holds for different sources of pressure. CONCLUSIONS: Our findings suggest that there may be societal costs of physicians working under pressure. Policy makers need to take these costs into account when evaluating existing policies as well as when introducing new policies affecting physicians' work pressure. An important avenue for further research is also to determine the underlying mechanisms related to the different sources of pressure.JEL-code: I11, J28, J45. HIGHLIGHTS: Many physicians are working under increasing pressure.We test the importance of pressure on physicians' prescribing of antibiotics.The prescribed rate of broad-spectrum antibiotics increases with pressure.Policy makers should be aware of the societal costs of pressured physicians.[Formula: see text].

Locum doctor use in English general practice: analysis of routinely collected workforce data 2017-2020.

BACKGROUND: Numbers of GP locums in the NHS have grown in recent years, yet evidence on the scale and scope of the locum workforce in general practice is sparse. AIM: To identify characteristics, geographical patterns, and drivers of GP locum use. DESIGN AND SETTING: Observational study of routine data from general practices in England. METHOD: Descriptive analyses of national GP workforce data between December 2017 and September 2020 were conducted to determine the volume and geographical distribution of locum use and examine the characteristics of locums compared with other GP types. Locum full-time equivalent (FTE) was modelled using negative binomial regression and estimated incidence rate ratios (IRRs) for associations between outcome and characteristics of practices and population. RESULTS: In December 2019, total locum FTE was 1217.9 compared with 33 996.6 for total GP FTE. Locums represented 3.3% of total GP FTE, which was fewer than other GP types. Median locum age was 42 years (interquartile range [IQR] 36 to 51) FTE and the majority were UK qualified (660 of 1034 [63.8%] total locum FTE), were male (642.6 of 1178.9 [54.5%] total locum FTE), and had long-term employment (834.1 of 1127.9 [74.0%]) total locum FTE. Rurality (IRR 1.250 [95% CI = 1.095 to 1.428]), inadequate Care Quality Commission ratings (IRR 2.108 [95% CI = 1.370 to 3.246), and single-handed practice (IRR 4.611 [95% CI = 4.101 to 5.184) were strong predictors of locum use. There was substantial variation in locum use between regions. CONCLUSION: GP locum use remained stable over time. Compared with other GPs, locums were younger male GPs, a substantial percentage of whom did not qualify in the UK, and those who served underperforming practices in rural areas. This is likely to reflect recruitment or high turnover challenges in these practices/areas and can provide a greater understanding of general practice workforce challenges in England.

Digital Interventions Supporting Self-care in People With Type 2 Diabetes Across Greater Manchester (Greater Manchester Diabetes My Way): Protocol for a Mixed Methods Evaluation.

BACKGROUND: Type 2 Diabetes (T2D) is common, with a prevalence of approximately 7% of the population in the United Kingdom. The quality of T2D care is inconsistent across the United Kingdom, and Greater Manchester (GM) does not currently achieve the National Institute for Health and Care Excellence treatment targets. Barriers to delivery of care include low attendance and poor engagement with local T2D interventions, which tend to consist of programs of education delivered in traditional, face-to-face clinical settings. Thus, a flexible approach to T2D management that is accessible to people from different backgrounds and communities is needed. Diabetes My Way (DMW) is a digital platform that offers a comprehensive self-management and educational program that should be accessible to a wide range of people through mobile apps and websites. Building on evidence generated by a Scotland-wide pilot study, DMW is being rolled out and tested across GM. OBJECTIVE: The overarching objectives are to assess whether DMW improves outcomes for patients with T2D in the GM area, to explore the acceptability of the DMW intervention to stakeholders, and to assess the cost-effectiveness of the intervention. METHODS: A mixed methods approach will be used. We will take a census approach to recruitment in that all eligible participants in GM will be invited to participate. The primary outcomes will be intervention-related changes compared with changes observed in a matched group of controls, and the secondary outcomes will be within-person intervention-related changes. The cost-effectiveness analysis will focus on obtaining reliable estimates of how each intervention affects risk factors such as HbA1c and costs across population groups. Qualitative data will be collected via semistructured interviews and focus groups and organized using template analysis. RESULTS: As of May 10, 2021, a total of 316 participants have been recruited for the quantitative study and have successfully enrolled. A total of 278 participants attempted to register but did not have appropriate permissions set by the general practitioners to gain access to their data. In total, 10 participants have been recruited for the qualitative study (7 practitioners and 3 patients). An extension to recruitment has been granted for the quantitative element of the research, and analysis should be complete by December 2022. Recruitment and analysis for the qualitative study should be complete by December 2021. CONCLUSIONS: The findings from this study can be used both to develop the DMW system and improve accessibility and usability in more deprived populations generally, thus improving equity in access to support for T2D self-management. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26237.

Competence levels in musculoskeletal medicine: comparison of osteopathic and allopathic medical graduates.

BACKGROUND: Consistent with osteopathic principles and practice, the nation's colleges of osteopathic medicine (COMs) have emphasized the significance of the musculoskeletal system to the practice of medicine. The authors hypothesized that graduating COM students would, therefore, demonstrate superior knowledge and competence in musculoskeletal medicine when compared with graduates of allopathic medical schools. METHODS: The authors asked graduating COM students to complete a standardized and previously validated 25-question basic competency examination on musculoskeletal medicine in short-answer format. Originally developed and validated in the late 1990s, the examination was distributed to allopathic medical residents at the beginning of their residencies. The authors compare their results with those reported by Freedman and Bernstein for allopathic residents. RESULTS: When the minimum passing level as determined by orthopedic program directors was applied to the results of these examinations, 70.4% of graduating COM students (n=54) and 82% of allopathic graduates (n=85) failed to demonstrate basic competency in musculoskeletal medicine. Similarly, the majority of both groups failed to attain the minimum passing level established by the directors of internal medicine programs (graduating COM students, 67%; allopathic graduates, 78%). CONCLUSION: In an examination of competence levels for musculoskeletal medicine, students about to graduate from a COM fared only marginally better than did their allopathic counterparts. To ensure that all graduating COM students have attained a level of basic competence in musculoskeletal medicine, the authors recommend further study as a prelude to evaluation of the didactic and clinical curriculum at all 22 COMs and their branch campuses.

Physician health programs: the Maryland experience.

BACKGROUND: This article briefly summarizes not only the history of physician health programs, including their singular success, but also their struggle to maintain the ethical integrity of the programs, their appropriate autonomy, and the privacy of physicians enrolled in them. METHOD: We review the history of the Maryland Physicians Health Program, how it initially developed and was funded, how the program became funded by the state, how this ultimately caused serious problems, and how these were eventually resolved. RESULTS: Maryland was able to achieve a 2-program solution that protected both the voluntary participants while meeting the needs of the state licensing board for participants mandated by the state licensing board. This result has been well received by both the physician community and the state licensing board. CONCLUSIONS: How the problems were solved and the ultimate agreement provide a model for others to use.