Dr Andy Hamilton - LEET Report 2018
‘A Look into the Future of Primary Care’
Undertaking the ST3 Gloucestershire Leadership Scholar role gave me an introduction to the world of medical leadership, the workings of the NHS, and programmes like the GP 5 Year Forward View. I gained a lot from being involved in the setting up a of the Gloucestershire Newly Qualified GP Scheme in 2017, and this helped to demystify the local CCG, and the people and organisations associated with it.
I decided to take these experiences forward into the LEET year and to discover a bit more about myself as a leader and about the future direction of primary care as a topic. Having developed an interest in the make-up of the GP workforce in ST3, I wanted to learn more about the direction of travel for workforce nationally, including new models of care and different skill mix, and how that will be applied locally in Gloucestershire, and even more locally at my practice.
I requested to stay at my ST3 practice (Churchdown) because they are already embracing a wider skill mix, are interested in education of professionals in primary care, and were about to go through a huge moment of change moving to a new purpose built surgery during the LEET year. I felt that there was something that I could learn from this experience for the future.
Gloucestershire CEPN & Gloucestershire CCG
This year there was an expectation that the LEETs would be allied to the CEPN (Community Education Provider Network) in their area. CEPNs are designed to evaluate and improve training and education for allied professionals coming into primary care, and to increase training placements for both established groups like nurses, and the new primary care workforce such as Clinical Pharmacists, Physios, Mental Health Workers and Physician Associates. As the CEPN is hosted by the CCG in Gloucestershire, many of the projects also overlap with CCG workforce initiatives, which provided excellent opportunities to be involved in some exciting and innovative projects. My leadership mentor for the year was Dr Lizzie Eley, who is the clinical chair of the CEPN, and with Lizzie’s support, I was integrated into all the work of the CEPN. I was also able to attend both regional CEPN reference groups, and a national training hub meeting to further understand the workforce issues and solutions nationally. Much of the work I was involved in during the year was actually GP focused CCG projects, but using the educational expertise of the CEPN.
Gloucestershire Newly Qualified GP Scheme
I have been involved in the on-going evaluation and development of the Gloucestershire CCG NQGP scheme, which started in 2017 to support new GPs with the transition from training to independent practice in the county. The scheme matches NQGPs with recruiting practices who agree to provide mentoring for the new GP. The participants can make use of a bursary to help with development of specialist interests or indemnity fees for OOH up to a value of £6000, and we consulted with current participants on the design of further personal development and peer networking opportunities as part of the scheme going forward. Four NQGPs started on the scheme in September 2017, and I presented a poster on this work at the RCGP conference in October 2017.
Gloucester City Health Inequalities Fellowship
Most of my non-clinical time has been taken up with developing the separate but allied ‘Gloucester Health Inequalities Fellowship’ which was born out of the CCG looking to provide enhanced support with recruitment for inner city practices in Gloucester. This has been a big project involving analysing similar schemes in the UK, gauging support from practices, engaging with a range of stakeholders such as the County Council Public Health team, academics, trainees, and providers in the city working with disadvantaged groups. Working closely with the CCG, a co-funding model was developed with the practices, with additional input from the CEPN and Health Education England. The recruitment process included visits to the Severn Deanery careers fair, and national advertisement in the BMJ. In addition, a GP Tutor has been recruited to oversee the fellowship, provide mentoring, and arrange teaching/peer networking sessions.
The aims and structure of the fellowship are below.
- Inspire and support new or experienced GPs to undertake a salaried post in an inner city setting, and develop skills to address local health inequalities for practice patients.
- To augment clinical learning with opportunities to develop your academic knowledge base, and gain qualifications in public health via the UWE Postgraduate Certificate in Public Health.
- To disseminate learning within the county and support the future of primary care in Gloucestershire.
- To release senior clinician time for innovation, service redesign, and practice resilience.
1) Clinical sessions – four per week working in core General Practice as a salaried GP, building experience in the provision of general medical services in inner city Gloucester. Employed directly by one of the fellowship practices.
2) Health Inequalities session – one paid session a week focusing on local health inequalities, to include an initial two to three month induction/shadowing period with providers who work with disadvantaged populations. This will be followed by project development and mentoring tailored to the learning needs of the fellow, and health needs of the population.
3) Academic – One day a week undertaking the Postgraduate Certificate in Public Health at the University of the West of England (UWE), to develop expertise in the wider determinants of inequality in health and healthcare. Fully funded course fees and travel.
It has been a very interesting process, and I have learned a lot about politics, power and persuasion in the NHS during the year. There was 14 expressions of interest for the posts and 8 applications, with 4 fellows starting in January 2019. The scheme has created a lot of interest, and I will be presenting a poster on it at the RCGP conference in October 2018. I look forward to seeing it develop.
Having spent ST3 at Churchdown, the transition to ST4 was a natural progression. Taking on the LEET role my clinical time was reduced and I had to get used to working more flexibly, and trying to complete work on the day. I continued to take part in the on-call rota, and the LEET year allows you to build clinical confidence and competence whilst still in a supportive environment.
The practice, and particularly my educational supervisor Dr Sharon Drewett were very supportive with the leadership aspect of the year, making sure that I can attend meetings when required, and allowing me to take a leading role in the Productive General Practice Quick Start programme through October and November. Through that programme I worked on practice communications allied to a change from Vision to EMIS, and also related to on going work with reception navigation and appropriate appointments.
I have been part of the practices move to a new building, and witnessed first hand the challenges that this change brought, which was an important part of my reason for staying at Churchdown. Allied to this I took part in the 6 day NHSE GP Improvement Leaders Programme in London, and through that commenced a project looking at workplace wellbeing and practice culture related to the move of practice. Picking up previous staff wellbeing work, I designed a survey to collect qualitative data about the things that staff wanted to preserve about their ways of working in the old surgery, and how we might improve staff wellbeing in the new surgery. Five months after the move, I helped organise an away day for the practice to follow up on that project, and to work up ideas which could contribute to staff wellbeing and practice cohesion.
Teaching & Recruitment
The LEET year gave me lots of opportunity for teaching, sometimes taking me out of my comfort zone, but good experience. I undertook a workshop with my ST3 peers on the topic of ‘post CCT plans’ in December 2017, and volunteered for two one-day teaching sessions on chronic disease in General Practice for F2 doctors alongside the TPDs from the Somerset patch. I facilitated a small group at the VTS joint trainer/trainee meeting, and assisted in a RCGP Severn Faculty CSA preparation evening. I have continued to take part in both the teaching of 3rd year medical students, and hosting of 6th form work experience at Churchdown, in conjunction with the lead GP.
I took part in the South West GPVTS selection centre, and both medical school selection at Bristol University, and LEET interviews through the Deanery. I also took part in the interview panel for a new CEPN Educational Facilitator. It was an interesting experience to be on the other side of the table for the first time.
In addition to the core clinical and leadership work of the LEET year, I have also taken advantage of the flexibility of the role to explore the many leadership topics and development opportunities on offer.
- RCGP Conference - Liverpool
- RCGP Severn Faculty AGM – presentation as a bursary recipient following the RCGP conference.
- RCGP Severn Faculty board meeting (observer)
- RCGP – Looking forward to an ‘at scale’ future workshop - Bristol
- FMLM Conference education pre-day – Liverpool
- Gloucestershire CCG AGM
- NE Gloucester Cluster meeting – Extended hours pilot discussion.
- LMC meeting – Gloucestershire
- WEAHSN Conference – Bristol
- WEAHSN Primary Care Collaborative – Cohort 1 + 2 share and learn event – Swindon
- WEAHSN CEPN reference group meeting – representatives from CEPNs in the region – Bristol
- National Training Hubs ‘ST4’ teleconference – linking with other ‘fellows’ working in CEPNs around the country.
- National Training Hub meeting - London
- LEET meetings – South West meetings 6 weekly. Topics – self-awareness/personality types, LEAN methodology.
- Severn Deanery Coaching – I accessed leadership coaching with Dr Elaine Anderson (retired GP) through the professional support unit at the deanery.
- Gloucestershire VTS TPD meetings
The LEET year has been a challenging but hugely rewarding experience. Clinically, I have had the opportunity to consolidate the learning of ST1-3, practicing largely autonomously, but with the support of regular tutorials and advice. Within the surgery I have worked closely with the managing partner, taking an active role in service improvement and staff wellbeing. I have taken part in the move to new premises, and learned from the challenges faced by the practice during that process.
In my non-clinical work, I have had the opportunity to work alongside enthusiastic people, and discovered a huge amount about the workings of the NHS both on a local and national level. I have been supported to work on interesting and important projects inside Gloucestershire CEPN and CCG, which have taught me a lot about the future of primary care, medical politics, and the importance of networks. The experiences gained will stand me in good stead for whichever path my career takes in the years to come.
On a personal level, I have learned a lot about my strengths and weaknesses, the personality traits that shape my style of leadership, and roles which I should or should not pursue in the future. It has been an immersive year, which has given me unique experiences at an early stage in my career.
Michelle Penn – LEET Report 2017
Increasing Medical Student Primary Care Placements
General Practice is in the midst of a recruitment crisis. Lack of investment in primary care, increasing workload and uncertainty over the future of general practice is contributing to large numbers of GPs retiring early, leaving the profession or choosing to work overseas. The subsequent pressure on General Practice is undoubtedly affecting the attractiveness of the profession to medical students and junior doctors.
There is good evidence that having increased exposure to primary care as an undergraduate results in a higher proportion of students entering a career in general practice. This has been evidenced by a number of medical schools in the UK who have increased the time spent in primary care placements within their medical curriculum.
September 2017 sees the start of the phased introduction of a new University of Bristol MB ChB undergraduate curriculum with an almost 3-fold increase in the amount of time spent in general practice. It is hoped that these changes will help address the current recruitment crisis. However, this creates a need for a large increase in the number of student placements currently offered by practices.
During my GPST4 Leadership and Excellence Extension of Training year I have been working alongside staff at the Centre of Academic Primary Care at the University of Bristol to consider how the number of general practice placements for medical students can be increased, to meet the needs of their new curriculum.
The recent report written by Valerie Wass entitled ‘By choice - not by chance’ outlines recommendations for how medical students can be supported towards future careers in general practice. It specifically refers to GP trainees being involved with medical student teaching, with one of the recommendations as follows:
“Positive and enthusiastic General Practitioner role models should be identified and made visible across all medical schools. This includes enhancing and supporting the role of General Practitioner Specialist Trainees (GPSTs) as educators and assessors and interaction in primary care between medical students and near peers in training”
In view of this, I chose to undertake a survey to investigate the views of GPST3 trainees across Severn on medical student teaching. I focused on ST3s as they are the most likely level of GP trainee to be involved in medical student teaching. I attended each training patch (Bath, Bristol, Swindon, Gloucester and Somerset) during an ST3 teaching session in order to explain my project, promote the GPST4 LEET role, and ensure a good response rate to the survey.
In total I received 115 responses (100% response rate of those surveyed)out of a total of approximately 175 ST3s. The survey included questions about whether the GPST3 was already teaching medical students, whether they would like to teach, what the barriers and motivators are to teaching, whether they had received training on how to teach, and what type of sessions they would be happy to teach.
ST3 survey analysis
The survey concluded that 48.2% of ST3s already teach medical students. Of those that do not teach, 84.7% (50 ST3s) would like to. Most had a good level of confidence to teach, despite only 44.3% stating that they had received formal training about how to teach. The biggest identified motivators for teaching were personal development and enjoyment. The biggest barriers to teaching were not having enough time, needing longer consultations, being unaware of the teaching opportunities at the University of Bristol, and feeling too stressed with other work. ST3s would generally be happy to deliver all types of sessions.
73.9% of GPST3s would like face to face training (on how to teach) delivered to them in their training patches. Most (56.3%) felt that if they had a medical student sitting in, 20 minute appointments would be appropriate. The number of sessions they would be prepared to teach within a year varied widely.
74.6% of respondents said that they would be more likely to apply to a job with medical student teaching opportunities. 18.4% were unsure. 7% stated they were would not be more likely to apply. 65.5% would be happy to teach other healthcare professionals.
GP trainees as medical student teachers
The results of this survey suggest that GPST3s are an underused resource of positive and enthusiastic near peer GP role models. Although at this current time placement needs are being met, as the need for more placement numbers increases during the roll-out of the new curriculum it will be important to have planned ahead for this. Therefore identifying this underused pool of teachers and determining how they can be better utilised and involved with delivery of teaching is of great importance.
I presented this at a local trainers group meeting to gain the views of GPST trainers. They were unanimously supportive of trainees being involved with medical student teaching, and felt it was of benefit to the GP trainees, the medical students and the training practices. I also presented this at a Severn Deanery APD meeting. There were discussions about the logistics of GPSTs teaching students in the context of the working week and it was agreed that teaching should be listed as a recognised activity for which independent education sessions can be used, up to a maximum of 8 sessions per year for teaching and planning. The guidance on the Severn Deanery website has been modified to reflect this. I ran a pilot workshop in Bath and trained 6 GPSTs who otherwise had not signed up to become medical student teachers.
I had discussions with staff at the Centre for Academic Primary Care, the Academy GP Leads and the Postgraduate GP Education teams about the possibility of delivering teaching workshops as part of the GPST compulsory teaching programme with an aim of capturing more of these potential teachers. It has been agreed that the teaching workshops will be delivered to GPST2s (and in some areas offered to GPST1s and local GPs) in each patch this coming academic year in place of the usual centralised teaching workshop in Bristol. This pilot will be helpful to assess whether the survey results are backed up by more trainees opting to teach if workshops are delivered as part of the GP training programmes.
Honorary Teaching Fellow Pilot
One of the key findings from the trainee survey was that 74.6% of GPSTs stated that they would be more likely to apply to a salaried job if it had teaching medical students (paid protected time) as part of the job plan. In view of this I have worked alongside Simon Thornton, GP Engagement Lead at University of Bristol, to develop an Honorary Teaching Fellow pilot.
Currently practices are allocated students year by year, and are not guaranteed which students they will receive and therefore what income they will get. We felt that it may be more attractive to practices if they are guaranteed a particular ‘package’ of students for at least 2 years, so that they can integrate the teaching into a partner or salaried GP’s work plan. In view of the survey findings, we also felt that creating specific teaching roles may help practices to recruit.
We devised a project plan, which sets out a ‘package’ of two 5th year students, one 4th year student and two 3rd year student groups. This would generate an income of £6,200 for the practice. We then calculated how much time would be spent by a GP teaching this package of students and therefore loss of clinical time to the practice. This equated to 94 hours and consequently an estimate of £6020 based on a £9000/session salary. This shows that developing this type of role should be cost neutral, if not cost beneficial to the practice; the exact figures would depend on a number of variables such as how much the practice pay their salaried GPs and what their current spend on locum GPs is. In his role with the University, Simon was able to incentivise the posts by offering honorary teaching fellow status and a £500 bursary (for a conference) for the successful applicants.
I had conversations with colleagues including my supervisor (a GP partner), my practice manager and also a salaried GP in Swindon with a similar teaching role, to get feedback on the idea. They all felt it was a feasible business plan. The next step was recruiting practices to the pilot scheme. The University was keen to focus on Bath and Swindon in view of their current poor placement numbers, and Bristol given its proximity to the University. I circulated an advert about the scheme to Bath via the local CEPN, and to Swindon via a network of GP trainers, the Swindon GP Education Trust, and the CCG newsletter. We received expressions of interest from 7 practices, and after further discussions 2 practices have gone on to become part of the pilot scheme; one in Swindon and one in Bristol. We helped the practices to devise an advert, and assisted by sending the advert to the postgraduate team administrators to circulate to GPST3s and recently qualified GPs, and a CCG contact in Swindon circulated the advert to GPs in the locality.
The pilot was a partial success. We recruited to the new post in Bristol, but unfortunately were unsuccessful recruiting to the post in Swindon. This perhaps supports the survey result that salaried jobs with a teaching role are attractive, however other factors such as location and other aspects of the job role also impact on the attractiveness of the post and the ability to recruit. Moving forward, this could be used as a model to aid recruitment and create extra medical student placements.
Because I have been working directly with staff at the Centre for Academic Primary Care at the University of Bristol they will be able to take forward plans following the work I have begun should they feel it will be beneficial. I have created a network of links with TPDs, APDs and academy GP leads who are aware of the work. I have accepted a salaried job with a medical student teaching role at a core teaching practice in Yate, so will be have ongoing contact with the University team.
Conclusions and recommendations
It is clear from the survey that GPST3s are an underused resource of positive and enthusiastic near peer GP role models. We must embrace this enthusiasm, and enable them to become involved with teaching in order to develop the next generation of educators and support the planned increase in medical student placement numbers in primary care.
My recommendations are for the University of Bristol to deliver teaching workshops as part of the GPST structured timetable, which has support from ST3s, the postgraduate GP education teams and the academy GP leads. The honorary teaching fellow job role may be a model that can be more widely rolled out in future years if successful.
Working on this project has been interesting, complex and difficult. Due to the strain on primary care there are many practices that do not feel they have capacity to engage with medical students, or new innovative schemes. I have found that this has been a major barrier. I have learnt a lot about how to pursue a project. I decided to focus on education, as this is something I am passionate about. Having recently been a ST3 teacher myself I feel that many more people (ST3s, students and local practices) would gain benefit from increased ST3 involvement with teaching.
It took time to find the right person to get support from, but once I did this, momentum did build. As someone outside of the University team it was difficult to have influence over the decisions made about whether the project could move forward. On reflection I think that identifying the major stakeholders earlier on in the development of the project to ensure their views were in line with my vision would have been beneficial and sped up the process.
At the beginning of my LEET year, I aimed to engage with a project around themes being pursued by the local Community Education Provider Networks. Something that interests me is the development of portfolio GP jobs as I believe that having a general practice career with an extended role can be beneficial to personal resilience and therefore longevity of career, and also the local workforce. This view was echoed by most First 5 GPs in a survey completed by one of the HESW LEETs in 2016.
I took on the task of researching what mixed job roles/fellowships were already available nationally. I then discussed these roles with the teams that had created them to find out how they had been set up, and their successes and failures.
I identified 7 localities across the UK that had developed GP fellowship schemes. There was a wide range of different specialist roles, from having a focus on leadership, co-morbidity, urgent care, palliative care and medical education as some examples. They varied widely in terms of structures of posts and funding.
I identified the following key learning points from my discussions:
- When developing fellowships it is important to be clear what the aims are and tailor the programme to this (e.g. to help new models of care/develop leaders/improve recruitment).
- The salary needs to be competitive.
- Fellowships must be developed early in order to be successful. Other fellowships have failed to recruit because they were advertised too late. The ideal model is to advertise in March with a closing date just after the March CSA results.
- Post CCT fellowships should be advertised to all qualified GPs, but it is helpful to target specific people who you would like to apply (e.g. GPST3s and first 5 groups).
- Depending on the aim of the fellowship it may be worth exploring funding sources. Wessex have secured some fully funded posts from NHS England as part of the vulnerable practice scheme. They have also developed CEPN fellows, the funding of which is from the Health Education Wessex Deanery underspend.
I shared this learning with the local CEPNs via the CEPN reference group. Some of the fellowships also shared their documents with me, including contracts, adverts and information packs; having these may save time if fellowships are being set up in our local areas. The Swindon CEPN have used this information to move forward with planning of the development of mixed GP job roles within the Great Western Hospital.
Training Hub Fellow Network
It was suggested at the beginning of our LEET year that it might be useful to develop a national GP fellow network; to include any GP trainees or first 5 GPs in similar roles to us as GPST4 LEETs. The premise behind this being that sharing projects and ideas may improve efficiency of us as LEETs, and avoid ‘reinventing the wheel’ of projects that have already been done elsewhere.
I started by collating contact details for people in similar roles, both of those I had come across in my work around GP fellowships, and by circulating an email to all heads of the GP schools. I then used email to gain views from those involved as to how they felt the network may best work. It was decided that we would try a Facebook group, as it is a modality people already log on to, and notifications would show whether any new content had been posted. Unfortunately this was not well used, and only a few people posted on the group.
After attending the National Training Hubs Group meeting it was suggested that a more useful network might be fellows/trainees involved directly with CEPNs. I therefore contacted the leads of each CEPN nationally to identify people in this position. Again, I used email to gain views on whether this forum would be useful. The general consensus was that it would be helpful in order to share projects/ideas. After discussion with Andrew Frankel (National Training Hubs Lead) we agreed that it would be helpful for the National Training Hubs Group to be open and inviting to fellows so they can hear what is going on nationally and engage with the group. There are a number of national work streams, which may align with projects that some of the fellows are doing, and in these cases it would be mutually beneficial for fellows to become contributors to the small working groups.
Moving forward I have contacted all the current fellows in the network asking them to give me contact details for all the successors of the posts who will be starting in the new academic year. We plan for them to be invited to the monthly National Training Hubs meeting, which they can attend by phone or in person, and have national documents shared with them. The National Training Hubs group will share with the fellow network a list of the work streams and projects that are planned for later this year that they may wish to be involved with. It would also be advantageous to plan face to face meetings, perhaps twice a year, where fellows can network in person and share their work and ideas.
Creating a national network has proved to be much more difficult than anticipated. Even once I had identified the people that should be involved with the network it was difficult to get them to engage with the network and contribute. I think the key to this is to identify the precise aims of the network; what is it trying to achieve? Also having specific things that the members are required/encouraged to do may be helpful. I think that having a face to face networking event is important, as once this has occurred it is more likely that people will have ongoing digital contact. Therefore, once I have gathered contact details for next years fellows, I will aim to help arrange a face to face networking event and handover leading the development of the network to one of my LEET successors.
Other LEET activities
- Attended a number of QI training days and used this knowledge to run a QI project within my practice looking at the appointments system.
- Attended the LEET teaching programme.
- Completed the Health Economics Leadership and Management course.
- Been a member of the Bath Education team and have regularly taught GPST1 and GPST2 small groups. I also attended the TPD meetings and the annual planning day.
- Taught medical students at my practice.
- Learnt interview skills by interviewing for the Wiltshire CEPN Project Manager and also the next cohort of LEETs and scholars.
- Assessor at the HESW GP recruitment centre.
- Sought careers coaching which has helped me develop my leadership skills and increase my work efficiency. This has taught me to value creative time, and recognise the steps I have made in my self-development.
- Examiner for the University of Bristol medical student OSCEs.
- Gained a bursary to the RCGP conference and will be presenting 2 posters.
- Improved presentation skills having presented at a variety of forums including local, regional and national meetings.
- Engaged with the local CEPN network, in particular sitting on the Wiltshire CEPN group and the CEPN reference group.
- Attended a resilience day course.
- I feel much more confident when meeting new people within leadership roles, and am not afraid to voice my own opinions and ideas.
- Tight timelines can make things difficult, and in the context of change within the NHS 1 year is not a long time.
- It is difficult to know what projects will be successful and which won’t. This explains why this year I have ended up being involved with a number of smaller projects rather than one large project.
- This year has given me the opportunity to learn about my personality type and understand what I enjoy the most and excel at, which seems to be structured roles involving teaching. It has been good to experience self directed roles, but these do not play to the strengths of my personality, and it has been important for me to recognise this when considering what jobs I may take on in the future.
- I have gained an understanding of the political climate within the NHS and the move towards new models of care.
- I have learnt how to put leadership skills into practice; such as the need to identify key stakeholders and those who are engaged and enthusiastic about your project, the need to be flexible, and the need to be patient!
My LEET year has been an extremely informative time, and I have gained huge amounts of experience and personal development within the realms of leadership. I have come across a number of barriers, but have recognised the importance of being flexible and working around these. I feel that the opportunities that the LEET year has offered me will stand me in great stead to pursue my interests in medical education, and has given me a great base of understanding about the wider issues within the NHS as I enter my career as a qualified GP.
Severn and Peninsula
Leadership and Excellence Extension to Training (LEET)
I have been looking at the factors that influence the decision First5 GP’s make regarding their current and ideal careers. With the findings I have been developing possible career structures and training opportunities to hep new GP’s create an enjoyable and sustainable career. I live in Falmouth, Cornwall and look forward to a year of work as a locum before going to work in South Africa for a year with my husband.
I’m a Cornwall trainee who is passionate about General Practice and quality improvement. I have been working on developing training hubs across a newly merged practice in St Austell.
I'm a GPST4 working in Plymouth as a prescriber at the Harbour Drug and Alcohol service and North Road West Medical Centre. My main project focuses on the optimisation of hidden harm identification and assessment in GP.
I’ve spent my ST4 year immersed in referral pathways and commissioning with a view to improving the primary-secondary care interface for skin disease. I have lead a diverse team of hospital consultants, managers, administrators and commissioners to develop, from scratch, a fully-commissioned teledermatology service for Cornish GP’s. It has been a huge learning curve but very rewarding. In September I’m heading out to Myanmar with my paediatrician wife to help improve referral pathways for sick children with Unicef.
I have been developing the concept of training hubs in a group of training practices in South Devon. I have a keen interest in education, inter-professional learning, narrative medicine, and resilience, and I’ve also been working with the University of Exeter Medical School to develop 'Self-Care' workshops for the students. When not at work I enjoy acting and walking on Dartmoor with my husband and two young children.
Over the last 12 months I have helped develop the North Devon Pathology Optimisation Team in collaboration with Dr Tom Lewis (Consultant Microbiologist North Devon District Hospital), Dr Darunee Whiting (GP North Devon), Linda Ellerker (Biomedical Scientist, North Devon Lab) and Amy Holleran (Biomedical Scientist, North Devon Lab).
My work has focused on how we can manage anaemia more efficiently within primary care, and more specifically menorrhagia (heavy menstrual bleeding).
My name is Jess Parkin and I'm the Somerset LEET, living here in Taunton and working in Summervale Surgery, Ilminster. My project this year has been a qualitative evaluation of the experiences of newly qualified GPs, specifically looking into the transition period from trainee to GP. The aim has been to discover what NQGPs experiences have been, what has been helpful, and if there are any needs or wants for further support, either in training or once qualified. The process has personally been quite transformative, in terms of my own preparedness for GP, and I hope to feed my findings back to trainees and TPDs with the overall aim of improving the transition experience, and therefore retention of NQGPs.
My project focuses on the retention of GPs in the mid to late stage of their careers. I aim to organise an event to support GPs with new approaches to working in November 2016 as a culmination of interviews, a survey and focus groups. In other news, I am also planning a wedding and have completed a 2 year house renovation project!
I am Clare Delany, I current live in Totnes, Devon and work in Ashburton Surgery. I started my ST4 in 2014 performing an analysis of the discharge process from the community hospital in Newton Abbot. Then I went on maternity leave and since coming back I have changed the focus to ‘resilience’ both organizational (working with the LMC having developed a self assessment tool kit) and personal resilience within GPs. I am due to finish in March 2017.
I have been interested in GP recruitment for some time and decided to focus my energy on foundation trainees and other doctors. GP Careers Champions is a merged project with undergraduate and postgraduate arms, and provides the opportunity to discuss the career or have taster experience with enthusiastic individuals ("Champions") to showcase GP in a positive light and boost recruitment.
I am the LEET trainee in Bath and due to my interest in education I chose to focus my main project on promoting general practice to undergraduates at Bristol University (where I am also an academic mentor). I have also regularly taught the GPSTs in Bath, participated in career fairs and interviews, assisted with a successful tendering exercise for a local provider and lead a quality improvement project at my surgery. The year has provided ample opportunity for me to explore my non-clinical interests and has been an invaluable start to my career.
First 5's in Cornwall - what are their intentions and what influences their career choices?
For my project this year I chose to look at retention of the GP workforce. After a lot of reading and meetings I narrowed this down to focus on the First 5 cohort (those in their first 5 years post completion of training) in Cornwall. The reasons for this being that there were only a few studies out there that concentrated on this group, they’re the leaders of the future, so it would be interesting to hear about their plans; plus I started my training with a lot of them and I’m about to join that cohort so I wanted to see what their experience of a career in General Practice had been so far and whether I could have an effect on that and apply it to my own future.
- To examine the career intentions of GPs (in their first five years post qualification) in Cornwall.
- To find out what influences their career choices.
- To develop recommendations on workforce planning for Regional GP Organisations and local GP surgeries wishing to recruit and retain staff.
I used Survey Monkey to create an online survey which was then followed up by face to face interviews with volunteers. The survey was sent out by the deanery, the LMC and the local RCGP First5 group.
64.5% of survey responders were moderately to extremely likely to reduce working hours in the near future with 50% of total respondents already working just 4-6 sessions per week. 90% of interviewees want to work part time. Workload and poor work-life balance were main influences in reducing hours.
95% of survey respondents are moderately to extremely likely to undertake portfolio work in the near future and 100% of interviewees described wanting a portfolio career. These findings were evenly split between men and women.
42.5% stated partnership as their ideal role while 30% prefer salaried. Strong influences on choosing a place of work included being a training practice, getting on with colleagues and good work-life balance.
This study was done with the intention of finding out about the First5s in Cornwall so it is difficult to be able to generalise these results across other areas of the UK, however, its results do fit in with a recent Kings Fund study.
I got a response rate of 35% but I suspect this is higher in reality as the mode of distribution unlikely got the survey to all First5s in Cornwall.
As a follow up to this, I conducted a survey of existing GP trainees to see what they were intending to do after qualifying – how many sessions they were planned on working per week and whether there was interest in post CCT fellowship jobs.
The survey revealed that 97.8% are interested in doing portfolio work after qualification and 95.7% would be interested in a specific job that combined general practice with developing a special interest, the most popular being Acute medicine, Dermatology and Community Paediatrics. It was split evenly between whether they wanted to do this job as an extension in training or post CCT. Of those surveyed 62.2% plan to work 4-6 sessions compared with 28.9% intending to do 7-9. This time women were more likely to want to do 4-6 sessions per week.
I have since run a teaching session for the ST3s about looking to the future and doing some small group work on designing the ideal career, determining what the barriers are to this and focussing on how to overcome them and plan how to fit portfolio work into their future. There wasn’t anyone that wanted to just be a sessional GP.
1. Evaluation of existing Post CCT Fellowship posts and whether they could be created in Cornwall.
2. Changes to GP training to ease the transition from trainee to GP by encouraging trainees to think about and plan their career, including possible portfolio roles, as a kind of ‘practical resilience.’ This could help to increase their job satisfaction, resilience and hopefully their longevity in the world of General Practice.
3. An evaluation of current pilots of innovative ways of managing workload would be helpful to decide which could be implemented into local practices.
4. Further research on the rest of the GP workforce to add to planning for the future. There is currently a wider study across the South West to address this.
5. Extending the study across the UK to see if there are variations across different geographical locations.
The work I’ve done this year has encouraged me to think more about what I want my future to look like, and I compare with the typical survey respondent who wants to work 6 (maybe 7) sessions in General Practice with the rest of my working time being involved in education, as I think preparing the next generation of GPs for the uncertain future ahead will be vital to creating a workforce that is sustainable and enjoys their working life. I also want to get involved with the coming changes in Primary Care and be part of the group that will determine what that looks like. The LEET year has changed me from being a bit clueless about what I wanted to do, to developing new interests in research and training.
Training Hub Development
The ‘10 point plan’ looks at building the workforce and delivering a ‘skilled, trained and motivated workforce’ by focusing on recruitment, retention and return to practice.
Training Hubs are covered in point 3 of the 10 point plan and are described as being:
‘… Where groups of GP practices can offer inter-professional training to primary care staff, extending the skills base within general practice and developing a workforce which can meet the challenges of the new ways of working’
Building the workforce: the new deal for general practice.
Over the course of the last year I have been working on developing and implementing a ‘training hub’ across a newly merged GP practice in St Austell, Cornwall. The merger came about as a result of the failure of a local practice with 9,500 registered patients. The three remaining practices in the St Austell area were faced with the challenge of trying to manage this sudden influx of patients and quickly realised that this would be most effectively managed through a merger.
St Austell healthcare now has 32,000 patients and over a hundred employees operating across five separate sites.
Description of project
Stopping before starting
- Survey: Survey- monkey of all the GP partners in order to gauge their views on education and training. Views of the nursing and reception team also sought. I gained valuable information on individual educational needs, desired frequency of training and colleagues views on ‘training hub’s.
- Market Research: Visited and discussed with other practices including Beacon Medical and the Hurley group.
- Stakeholder analysis
- SWOT analysis
The next phase of my project was focused on developing, testing and implementing changes. I used PDSA cycles to try and help implement this – standing for Plan, Do, Study and Act.
I have conducted multiple PDSA cycles over the course of the last year.
- Designed the MDT protocol and helped implement and organise meetings across sites.
- Introduced a Minor Illness nurse teaching programme
- Implemented nurse supervision and joint clinics at the acute Hub.
- Designed a rolling monthly protected nurse teaching programme – inviting the community matrons and district nurses.
- Reception Training – Ongoing investment in teaching and training.
- GP teaching and training – Protected morning meetings with internal/external speakers.
- Multi-professional evening meetings with local consultant speakers involving community teams and inviting other local practices.
- Regular training and educational email updates to all staff.
3 Key Barriers:
- Too much change at once – full scale merger
- High initial Workload and patient demand with initial resistance to protected teaching time.
- Large team over multiple sites
3 Key Learning points
- Identify key stakeholders early
- If it doesn’t work keep trying
- Good relationships are key – Network
- NAPC funding as part of St Austell Healthcare’s successful bid to become a ‘Primary Care Home’ test site with dedicated funding for ongoing hub development.
- Ongoing investment in organisational culture of which training and education play a key role. The SWAHSN, Institute of healthcare Improvement and Investors in People teams are all involved with this.
- Salaried role as GP Educational Lead commencing September 2016.
This has been an exciting project that has enabled me to bring about real change over the course of the last year. Further development and investment will extend and evolve the training hub further – with more focus needed on integration with the community teams. It has been a challenging but rewarding project and I have been able to further develop myself as a General Practitioner and gain valuable leadership skills.
I have witnessed first- hand the difficulties encountered with practice mergers; and have gained a better understanding and awareness of practice management and finances through my weekly attendance at the Executive partners meeting. I continue to be passionate about General Practice and firmly believe that training hubs will enable us to deliver a workforce with the right capacity and skills to meet future patient demand.
Supporting vulnerable families: Treating adults with chemical dependency, and optimising identification, assessment and management of hidden harm.
Part 1: Gaining Knowledge, Skills, Experience and Accreditation in Substance Misuse Treatment.
Background/drivers for change: Reducing health inequalities was recently identified as a priority nationally1+2 and in Plymouth. Plymouth has high levels of health inequality, deprivation, and drug and alcohol use3. General practice appears inherently well placed to take a key role in addressing health inequalities and ensuring substance misusing patients have access to appropriate treatment. However, GPs working in deprived areas can find their work especially demanding and research shows it is often hard to recruit GPs into the areas with the greatest health needs2. In Plymouth to date only 18 of 45 local surgeries are involved in the provision of substance misuse treatment, moreover, there is a need to plan for succession of the 30 active GPs with the next generation of GPs who have sufficient skills4.
Aims: To gain sufficient competencies to work confidently as a GP with patients who have substance misuse problems. To recognise potential quality improvement work that can be done between general practice and specialist addiction services locally.
Method/Process: I was fortunate to have a clinical mentor in Dr Charlie Lowe and with his support I completed various courses culminating in the attainment of the full RCGP Certificate in the Management of Drug Misuse. I’ve been working as a prescriber in the Plymouth Specialist Addiction Service (plus similar work at North Road West Surgery) since November 2014.
Results/Impact: I now have the accreditation and confidence to continue working in the local specialist addictions services as a GPwSI in substance misuse treatment, and/or to apply this skill set to substance misuse treatment work within General Practice. I gained sufficient insight into the situation locally and nationally to be able to conduct the following two quality improvement projects (see overleaf). Moreover I have been able to share my experience and the new knowledge base I have acquired and help other clinicians (hospital registrars and GP registrars) gain a greater understanding of chemical dependency and its treatment.
Discussion: My ST4 year has been an eye-opener, a steep learning curve, and a rich learning experience: stimulating, challenging and (most of the time) highly enjoyable. Furthermore, many of the skills that I have developed in the drugs and alcohol service over the ST4 year are very transferable to work in general practice. I have noticed in particular increased aptitude in the areas of: risk management; handing over responsibility to the patient; consultations with people with personality disorders or dual diagnoses; dealing with ambivalence and use of motivational interviewing techniques.
Part 2: Optimising the identification, assessment and management of hidden harm in General Practice.
Background: The prevalence of hidden harm is enormous: the majority of people in drug treatment are either parents or live with children5. Drug use is one of the most significant risk factors for child maltreatment yet professionals often fail to identify these vulnerable children and fail to act early1. Services looking after drug users are being empowered to recognise their responsibility to ensure the health and wellbeing needs of the children are also being met. 5,6,7
Method/Process and Results:
Discussion: There were 197 patients with drug or alcohol problems, 33 of these patients had children in the home. There were 39 children associated (i.e. living with) our 33 index cases, of which only 23 were registered at our surgery. This highlights that in the context of hidden harm, we need to be very astute and proactive: we actually have a duty of care to consider the welfare of at least 16 children who are not registered with our practice. I noted an absence of any consistent (or readcoded) way of recording family status or details of dependent children in the notes at our practice. Moreover detailed review of case notes identified that important information pertaining to hidden harm risk (eg presence of CAFs) that was known to Harbour Specialist Service was not always shared with GP, plus and review of the children’s notes also highlighted a few cases where the children’ basic health needs (immunisation status, attendance at health appointments) were not being met.
Recommendations: Discussion with Harbour managers and agreement to highlight to keyworkers the need for increased information sharing. Liaison with the CCG and Plymouth Safeguarding Board with the aim of rolling out the project to GP surgeries in NEW Devon CCG.
Part 3: Reducing the chemical dependency health inequalities gap and stigma: empowering non-specialists to take an interest in treatment of people with substance misuse problems.
Background: Plymouth has a very large health inequalities gap3, moreover, in the context of patients with chemical dependency there is no doubt that the inverse care law prevails2. Whilst specialist services tend to attract healthcare workers with a commitment to help patients with chemical dependency, healthcare workers elsewhere commonly find such patients challenging. I am now in a unique place to offer insight and motivation to people who currently might be daunted by these clinical scenarios like I was prior to ST4.
Aim: Improving the support patient with chemical dependency receive in hospital
Background: Working at Harbour I became increasingly aware of recurrent problems occurring during patient admissions to the local hospital or at discharge.
Results: Decisions regarding the prescription of opiate substitution therapy in hospital tend to be made by (or after discussion with) the medical registrars (or persons more senior). The consultant organising the General Internal Medicine regional study day was keen to have me along and asked me to provide a teaching session on “Management of patients with opiate dependency on the acute take”. The session was attended by about thirty medical registrars from across the deanery. I had good feedback on the sessions; people’s confidence in this area increased hugely; and I was asked if I could come back to provide further sessions. Other feedback highlighted the absence of any trust policy on the intranet for a number of the hospitals (including our local hospital trust).
Ongoing/Forthcoming work: I have a meeting scheduled on June 21st with the Pharmacy Clinical Lead at Derriford and Harbour Managers to produce a shared policy on the management of opiate dependency. I have also been asked to run further teaching sessions at Derriford Hospital.
1.Department of Education. The Munro review of child protection: final report. A child centred system. CM8062. London. Crown. 2011.
2.Hutt, P. And Gilmour, S. Tackling inequalities in General Practice. An inquiry into the quality of General Practice in England. The Kings Fund. 2010
3.Public Health England Plymouth Unitary Authority Health profile 2014.
4.Dr Charlie Lowe, Plymouth Specialist Addiction Service, Service Lead. July 2015.
5.Hidden Harm – Responding to the needs of children of problem drug users. The Report of the Advisory Council on the Misuse of Drugs. Home Office 2003
6.Tiwari, T. (Ed). Safeguarding children and young people: The RCGP/NSPCC Safeguarding Children Toolkit for General Practice. Royal College of General Practitioners and National Society for Prevention of Cruelty to Children. 2014.
7.Plymouth City Council Inspection of Services for children in need of help and protection, children looked after and care leavers and review of effectiveness of the local safeguarding children board. Ofsted. January 2015.
Dr Andy Potter, North Road West Medical Centre, Plymouth. Dr Charlie Lowe, Clinical Lead at Plymouth Specialist Addiction Service. Sarah Martin, Nurse Prescriber at Plymouth Specialist Addiction Service. Hazel Robert, Manager at Plymouth Specialist Addiction Service. The Plymouth LES GPs with Special Interest in Substance Misuse Treatment, for their input and feedback regarding admission of patients with opiate dependency to hospital.
Bringing Teledermatology to Cornwall: The leadership journey of the ‘lone nut’
Defining the Needs
- Challenge of dermatology as a specialty – limited undergraduate training and many practices with a low dermatological skill base.
- 15% of all GP visits involves a skin problem and dermatology constitutes 6% of all referral activity in Cornwall.
- National shortage of consultant dermatologists (currently 2 vacant posts in Cornwall) placing huge pressure on outpatient appointments. GP’s feeling very unsupported in the interim.
- The solution: a new model of care?
To develop a new elective dermatology pathway that harnesses technology to improve the primary - secondary care interface and deliver better care.
- A workforce initiative that supports general practice: Improve access to specialist input for GP’s by using consultant time as a ‘finite resource’ more efficiently and effectively
- Break down the traditional divide between primary care and hospitals and reduce delay in commencing basic work up and therapy
- Improve overall competence and confidence of GP’s to manage common dermatologcial problems in the community.
- Improve access for patients who are infirm or geographically isolated providing care closer to home
After a 9 month initial pilot period (which I started during my ST3 year) I used the data to forecast benefits and cost savings and presented a Project Initiation Document to Kernow CCG. This was accepted in March 2016 and written into the contract between the CCG and the provider (RCHT). This transformed a pilot that was running on goodwill into a funded and sustainable county wide service.
- Ongoing monitoring of key performance data including conversion rate (amount of referrals definitely managed without subsequent f2f contact) and qualitative GP and consultant satisfaction.
- I chaired regular meetings with stakeholders presenting data and agreeing on changes through a ‘bottom up’ approach applying the ‘RAID’ change methodology.
- Through educational events, locality leads and newsletters.
- I conducted 11 practice visits to our ‘early adopters’ to engage GP’s and learn from their experience of using the service. Appointing GP champions in each practice.
- We have now processed over 260 referrals, which are coming in from 34 practices in Cornwall (59%) with a mean referral rate of 20 per month.
- Developing an intuitive yet properly governed process for in-consultation capture of clinical images, recognising that >50% of GP’s in the initial pilot wanted to use their own personal smartphone to do this. I spent some time on developing a dedicated smartphone app but did not succeed with this.
- Poor quality images and missing attachments are an on-going issue. I have been refining the process and improving material on the website including a dedicated youtube channel for GP’s and practice secretaries.
- Managing a virtual team, promoting a shared vision between a myriad of different ‘health tribes’ including the dermatology consultants, hospital managers, referral management service and CCG right down to individual GP’s and their practice secretaries. I achieved this through regular email updates to the whole group alongside targeted, small, timely meetings.
- Unprecedented financial pressure on the commissioners. I had to design the service with a ‘lean methodology’ harnessing freely available software wherever possible – I exploited the functionality of the existing e-referral system and NHS mail to keep costs down. The service has saved the CCG £10,184 in the last two financial quarters (source: RMS, June 2016) in reduced outpatient attendance.
I have appointed a GP ST2 trainee who also has an interest in dermatology and telemedicine to continue my role as a ‘GP lead’ on this project. We are currently working jointly with a view to her taking over the project in August.
Bringing a new service to Cornwall has been a journey of transformational change. This is both in terms of the project itself and, on a personal level, learning how to communicate an idea that you believe can work so you can bring others along with you to make it happen.
Developing Inter-professional Education & Training in Primary Care
GP Leadership Project in Newton Abbot, South Devon.
Newton Abbot is a locality within the South Devon & Torbay CCG with 7 GP training practices, a community hospital and a community nursing team serving a population of around 50,000. In early 2015 a group of Newton Abbot GP trainers agreed to work together around GP training. In the context of the national drive to boost the GP and primary care workforce through the development of inter-professional training hubs (point ‘3’ of the New Deal for Primary Care or ‘GP Ten Point Plan’), this project had two aims: to facilitate locality plans for joint GP training; and to identify and pilot opportunities for broader cross-practice training activities and inter-professional learning.
- Facilitate joint GP trainee learning opportunities
- Share innovation in practice-based education and training
- Increase understanding of current learning needs for GP and community nursing teams
- Promote wider inter-disciplinary learning opportunities
- Drive a coordinated approach to education and training across organisational and professional boundaries
Outcome (1) – Joint GP Training
Achievements: The Newton Abbot training group set up a single IT induction. An online calendar and documents folder was created to plan activities and share materials. Trainers encouraged short post-CCT trainee swaps to increase exposure to different practices and teams. Each practice offered a joint 2 hour tutorial, on topics including Frailty, CCG Referral Management, Teams & Personality Types, and ‘Vague Presentations in General Practice’. Trainees organised sessions with an extended scope physiotherapist and a local Dermatology GPwSI. Future tutorials in Safeguarding (with Health Visitors & School Nurses) and ‘Literature & Medicine’ are planned.
Barriers to the implementation: Take up and perceived usability of the online calendar varied. The challenges of high workload and time pressures hampered regular planning and review. Some trainees felt it was not equitable for fellow registrars in their VTS patch and consciously opted out of the joint tutorials with the view that all medical training should be ‘properly funded’. For trainers, there was uncertainty over external administrative and financial support to support future joint working and a tension between the wish to create a self-generating enterprise vs the meetings and communication required to maintain momentum and engagement.
Impacts: Trainees and trainers gave positive feedback. Most agreed they had achieved their objectives of enhancing the trainee and trainer experience whilst retaining the 1-1 apprenticeship model, and some saw the potential to include other members of the practice team. Benefits for trainees included access to different trainers’ expertise and styles, small group discussion to aid learning, and the experience of different practice structures. Trainers welcomed reduced tutorial workload, awareness of different training styles and sharing expertise.
‘I've learnt a lot from the sessions and they have been a great addition to VTS’ (GP ST3)
‘Smaller group tutorials allow for more peer-peer learning and reflection’ (GP Trainer)
‘Looking forward to locum experience whilst still protected as a trainee’ (GP ST3)
‘It would be helpful to invite other professionals where relevant. We could learn from one another. An example of this would be for chronic disease problems that are nurse led’ (GP ST3)
Outcomes - (2) – Multi-professional Education Pilot
The GP training venture inspired a related initiative testing joint training for other practice staff, and practice and community nursing teams. An early trainer meeting explored links between GP education and wider primary care workforce development. Innovative CPD, education and training bridging practice teams and community nursing had the potential to boost the appeal of working and training in the locality for all staff groups and enhance relationships. The challenge was how to deliver meaningful locality-led ideas, within the resources available.
A series of visits and interviews with GPs, practice staff, community nursing team and the hospital, and an online learning needs survey, created a snapshot of current knowledge and skills gaps and also a map of the primary care CPD activity across the locality. The CPD map highlighted innovation and identified gaps, variation and duplication in education & training activity for GPs, nurses, HCAs and administrative staff. The survey demonstrated shared learning needs between clinical and non-clinical staff groups in subjects such as dementia. Many staff had ideas for improvement and some came forward as ‘Champions’ interested in contributing to enhanced staff education and development.
As a result, the locality commissioning group agreed to a pilot cross-practice & community nursing educational event in one of 5 annual protected learning afternoons already funded by the practices. The first Newton Abbot Joint Learning Event took place on 16th June 2016 across two of the GP practices. The project lead worked with practice managers and project ‘champions’ (including GPs, lead practice nurses, an in-practice pharmacist, and patient participation group) to design the multi-professional training afternoon, using existing training contacts and some pharmaceutical sponsorship to minimise costs. Reception, HCA, and nursing teams benefited from Customer Service training, a Dementia Friends session and case-scenario session on Confidentiality. Clinical workshops in Palliative care, Elderly Care and Dementia Carers, Contraception, and Resilience in Teams were attended by a variety of managers, GPs, community and practice nurses, and HCAs.
Barriers to success included resistance to investing any practice resource in joint training. Emphasising the cost benefits of reduced duplication, shared expertise and pooled resources helped maintain momentum. The joint event as a complement to the joint GP training demonstrated what can be achieved within current resources and how education and training can be a great way to test and evaluate working together before formal integration or mergers occur.
Impact, Future Potential & Sustainability
A key impact of the project has been increased cooperation between the 6 practices and a greater interest in and willingness to work together in future in delivering education and training:
‘The group has helped create a culture of collaboration around learning and education between practices’ (GP Trainer)
- Trainers and practice managers are more open to other health care professionals such as nursing participating in future joint training. A ‘framework’ document for the GP training ideas will streamline the process for next year whilst allowing adaptation and development. The project impacts have been submitted for inclusion in the 6 practices joint 12m plan.
- Clinical leads and practice managers are looking to coordinate wider staff training opportunities through an annual central calendar. This may be piloted as part of the Devon CPEN (Community Education Provider Network) online CPD/training website.
- Practice partners are scoping potential to host rotational training placements for GPs across practices and the local community hospital. A regional ‘Integrated Workforce’ small task group are exploring cross-organisational training placements for HCAs, nurses and other workers with some interest in Newton Abbot as a pilot site.
A Journey From ‘Inside-Out’ to ‘Outside-In’ Thinking
North Devon Pathology Optimisation Team
I have been working on a methodology for promoting collaborative working that has been set up in North Devon to deliver more effective pathology. With a purpose of 'enabling patients to be able to make informed decisions about their care' we have shown substantial improvements in the quality of their outcomes.
Our hypothesis that focuses on attention to input through:
- "Clean In " (Tests are necessary, maximally appropriate, and sufficient)
- "Clean Through" (Tests are processed without error, with known variation, and on time)
- "Clean Out" (Results are understood by patient and doctor, are helpful, and reflect what is normal for patient)
Has led to delivering this purpose.
An example of where we have adopted this framework and shown improved outputs is in females with menorrhagia. Approximately 4000 full blood counts a year are performed in North Devon for menorrhagia. Of these women 80% of them will be managed sub-optimally at presentation.
Through adopting a “Clean In, Clean Through, Clean Out” approach, it has resulted in better care for patients, less harm, more capacity, and reduced costs.
By looking from a patient perspective (i.e. an outside in approach) and focusing on our purpose, we see our work as part of a larger system and have a strategy for solving problems that matter to patients. Any other approach, such as focusing on targets (i.e. thinking from inside out), risks solving the wrong problems.
Attitudes and experiences of newly qualified GPs (NQGPs) in the first year of work; a qualitative evaluation of the transition from ST3 to NQGP
To explore how NQGPs found the transition from registrar to fully-fledged GP with the aim to discover if there were any needs or wants for further support, either in training or once qualified.
A piloted survey was circulated to all NQGPs who completed training from Severn Deanery in August 2015. The responses were gathered between February and April 2016, providing information on current role, geography, challenging and rewarding aspects of the first 3-6 months practising, and ‘pearls of wisdom’ which would be helpful to ST3s about to qualify. Two geographically distant focus groups were run in April and May with two semi-structured interviews with NQGPs who couldn’t attend the Severn area focus group.
A number of recurring themes evolved with regards to the most challenging and the most rewarding aspects of the job in the first year of qualifying. NQGPs also shared a number of really useful pearls of wisdom with regards to pre-qualification, choosing a job and doing the job which will be passed onto incoming ST3s to help guide them to make the most of their final year of training.
Recommendations arising from these results were made and shared with a number of groups including the local CCG, TPDs and the APDs in the Severn region. I have submitted an abstract to the RCGP conference with the hope of having a poster there.
Retention of GPs in the mid to late stage of their careers
General practice is facing unprecedented levels of pressure and a dramatic increase in workload. According to a BMA survey of 15, 560 GPs, a third of GPs are considering retirement within the next 5 years1. These are dedicated GPs with years of experience and a wealth of knowledge that the profession can ill afford to lose prematurely. The Eighth National GP Worklife Survey concludes that overall job satisfaction for GPs has shown a clear decline between 2012 and 2015, and is currently at its lowest level since 20012. Worryingly, the proportion of GPs intending to quit medical work has increased for both the over and the under 50s2.
The recently published General Practice Forward View recognises the increase in workload that GPs are expected to carry out in conjunction with increasing patient expectations, complexity of patients and a devolving of work from secondary to primary care3. It discusses proposed changes and allocation of funding to ease the pressure on general practice. This is a welcome step in the right direction, but does little to address problems in the immediate to mid-term. We risk losing many of our colleagues before these changes can take effect.
As my LEET year project I wanted to concentrate on the mid to late career GPs in Bristol to examine their current situation, plans to retire and ascertain if there were any interventions that could help to retain them in practice.
Bristol GPs are among those that are experiencing intense pressure. I have interviewed 15 and surveyed 81 GPs in the Bristol area to determine the current feeling in the profession locally. The results echo the findings of national studies. Namely stress, exhaustion and workload are encouraging many to think about leaving the profession or retiring early.
The most commonly cited challenges in general practice included length of working day, time pressure and the passing of work from secondary to primary care. “All the tasks in general practice are made more challenging because of the lack of time to address them adequately”
There was considerable appetite for help towards these issues with 68% of respondents stating that they would attend, or would consider attending an event aimed at supporting GPs. Many topics were positively received, especially an inspirational speaker, resilience training, new ways of working and information about becoming a GP with a specialist interest. One respondent wrote about their experience working in an alternative GP environment “After stepping out of my comfort zone, I have found that my clinical skills and knowledge are really valued. It has been scary but rewarding but has re energised me and I think has had a positive impact on my clinical work”.
Although many survey respondents cited that system changes are needed (as per the GP Forward View), these will not make significant waves for years to come. I argue that GPs need support now. Using my survey data I have developed an event catered specifically for mid to late career GPs that could help to address low morale and enable time-poor GPs to explore career opportunities and network. "A day catered towards GPs who are passionate about general practice, but feel exhausted and stressed by the ever increasing workload. This day aims to showcase ideas to enrich your career, change direction or revitalise your outlook ".
The Severn RCGP Faculty have been incredibly supportive and interested in my project and recently deemed that the support of GPs in their mid-careers is a priority area for 2016/17. They have agreed to provide financial and organisational support for me to bring this event to life in November 2016 as a part of the RCGP local calendar of events. I am also in contact with central RCGP in London who are potentially interested in developing a similar event in the future.
My plan for the next two months of my LEET year is to organise the event in November and present the format to groups of GPs for peer review. I hope to start advertising the content in early September 2016.
This has been a fascinating and challenging year for me, but there have been plenty of lessons learned along the way. One of which was the importance of talking to everyone about your idea. Some will be negative, but many will help spark off new avenues and put you in contact with the right people to enable progression of your project.
- British Medical Association National survey of GPs. The future of General Practice 2015. A report by ICM on behalf of the BMA. Accessed here https://www.bma.org.uk/collective-voice/committees/general-practitioners-committee/gpc-surveys/future-of-general-practice
- Eighth National GP Worklife Survey 2015
- General Practice Forward View. April 2016
My first project started in 2014 looking into how the voluntary sector and health professionals interact, this led to an analysis of the, often very prolonged, discharge planning of the local community hospital in Newton Abbot. General conclusions could be divided into
- Patient factors - hugely complex patients, difficulty in deciding upon capacity for placement, long wait for suitable placements.
- Team factors - Emotional decision making, lacking coordination, limited staff capacity to plan discharge and care for patients, patient perception unrealistic.
- System factors - process for documentation longwinded, loss of POC on admission, shortage of carers in community
Direct outcome as a result of this analysis was establishing the integral role of a discharge coordinator and CCG were able to fund a voluntary sector worker in this role. Another direct benefit was the closer working of the two wards at the hospital, one a dedicated stroke rehabilitation unit with ward based PT, OTs preforming joint assessments and extending care into the home environment to aid early discharge (with perception of much more swift and efficient discharge system) vs a general admission ward with over 50 percent of patients ‘medically fit’ for discharge waiting for a package of care or placement.
For my second project as the press continues to inform us ‘GP practices are in crisis’ with every headline pouring more desolation onto the situation with ‘GP crisis looms as surgeries may shut’, ‘don’t’ worry about your local hospital – it’s your GP surgery that will shut first’and ‘GP shortage could close more than 500 surgeries and leave thousands without a doctor’. All highly alarming. But the reality is that the constant changing face of general practice, the limitations in funding, recruiting and retention ‘crisis’, pressures from regulatory bodies and the increasing complexity and demands of patients managed in general practice, to name but a few of the issues, means that some GPs practices are finding that the only solution is to hand back their contract and close their doors.
In association with the Devon LMC I have helped develop a self assessment tool - Resilience Assessment tool (RAT) - to offer support to GPs through this current climate of limited resources and help practices identify areas of vulnerability. The areas in question are premises, finance, demand, quality and safety, workforce, relationships, regulation, workforce and then metric analysis of the above.
There is no pressure to report their findings to anybody else but if a practice thinks it may be of benefit it may disclose findings to the LMC and/or CCG.
It is not a precise tool, but hopefully a broad indicator for practices to perform a closer inspection of the areas identified as vulnerable. The RAT uses threshold markers for many parameters to identify risk. As there is little work already in this area the thresholds are arbitrary but the hope is that this will be a development version with incoming data providing future standards and benchmarking.
It is hoped that practices who do identify themselves as having areas of weakness, whether previously known about or not, would be able to analyze and address these either internally or if they wished, share the data with the LMC. It is clear that this is not a tool to identify poor clinical performance and must not be seen as such. The GP forward view pays particular attention to the need to support practices that identify themselves as having significant vulnerabilities if general practice is to have future.
There are of course limitations to the RAT - the time taken to complete the assessment tool and having to declare ones’ vulnerabilities I fear may mean that practices may be un-keen to share these with a third party. It is possible that practices may already be aware of weaknesses and feel powerless to solve them and potentially unwilling to see these benchmarked against other practices.
Taking the next step beyond the assessment phase the plan is to develop a ‘toolkit’ on the back of the feedback received. The aim is that this would be multifaceted and offer practical steps on the areas of vulnerability. How this will look is still under development.
Continuing on with the LEET year I intend to perform a questionnaire sent to GPs to assess their own personal resilience specifically looking at personal workload and demand, relationships, future plans, stressors, stress management and support. Leading on from this I will perform focused questionnaires on willing individuals to act as case studies. I hope from this I will be able to make credible recommendations and start to implement change.
Meg Rowlands and Anna Harrison
Aims of the Scheme
The GP Careers Champions Scheme has been set up by two GP LEET trainees (Leadership and Excellence Extension of Training) Dr Anna Harrison and Dr Megan Rowlands who have an interest in leadership and education, alongside a passion for General Practice as a career. The aim of the project is to promote general practice by improving access to mentorship and taster experiences within the Severn deanery.
Description of the Scheme
The scheme consists of a database of one hundred and thirty volunteer GPs and GP trainees (“Champions”) from across Severn. Champions are willing to offer mentorship, informal career guidance or taster experiences to undergraduates or postgraduates who are interested in pursuing a career in General Practice. Students and junior doctors fill out a mentorship request form expressing their interests and what type of mentorship they would like. Once this is received they are matched to a GP local to them who has similar interests. An information pack is also provided to mentees, which contains useful information and links to support the process.
Once matched, it is up to each individual pair to arrange meetings directly at their convenience. This may be via email, face-to-face discussion, telephone, Skype or a taster day. All mentees are contacted after they have met with their Champion to gain feedback and check their needs have been met, whilst Champions are contacted to check they are happy to remain on the database and mentor again. Certificates are issued to both the Champion and Mentee after feedback has been received.
Prior to embarking on the pilot both undergraduate and postgraduate research was undertaken (See graphs on next page). The pilot has had twenty-four matches so far across the deanery consisting of sixteen postgraduate matches (all of which included taster days) and eight undergraduate matches.
Highlights of Research Findings:
Feedback from both Champions and Mentees has been extremely positive. Comments have included:
“(GP) very friendly, easy to talk to and a great role model. Talked about her experiences, she gave me great insights into GP training and the wide range of career opportunities. I feel we were very well matched because we both have interests in humanitarian aid, and we talked about how this could be possible with a background in GP.”Postgraduate Mentee
“My GP really went out of her way to help me get the most of out the day - Thank you!”Postgraduate Mentee
“It was so helpful talking to a GP and I learned a lot- much easier talking to someone who had actually been through the process than trying to find the information online!”Undergraduate Mentee
“It all worked very well. I hope it continues!” Champion
“I think it worked really well. It was easy to arrange a time for (the mentee) to come to the practice and we had a really interesting morning. She was very enthusiastic and I hope the session was of value to her.” Champion
A considerable amount of hard work, thought and care has gone into initiating the scheme and setting up the pilot. Feedback so far has been incredibly positive and most importantly it has the support of the GP School, Foundation School and the University of Bristol. Therefore, there is plenty of scope for this scheme to continue successfully and be developed further.
So far the scheme has been managed within the LEET roles, therefore funding is required to support the continuation of the project. The RCGP Severn faculty have been identified as being well placed to take on this role as they have an overarching interest in promoting general practice on a local and national scale. They also have a pre-existing infrastructure and network that will be crucial in maintaining and developing this project. The scheme was presented as a business plan on 15th June 2016 at the RCGP faculty AGM and is currently awaiting a decision regarding finances.
This is an exciting project that sells General Practice in an extremely positive light and has so far received excellent feedback. The scheme has the support of critical stakeholders, namely: the GP School, the Foundation School, the University of Bristol and we are currently awaiting a decision regarding whether on-going funding can be provided by the RCGP. There have also been discussions with and interest from the RCGP “Student Engagement Manager” regarding its potential on a larger scale. There is scope for it to be sustainable with minimal on going costs and also huge potential to develop it both locally and nationally.