Category Archives: Stephen Peckham

Improving GP recruitment and retention needs a long-term strategy

The state of general practice remains a key talking point in UK healthcare with continuing concerns about difficulty of recruitment, practices closing and a general feeling that general practice is in crisis. The central policy response to this situation is the General Practice Forward View published in April 2016 which was developed from the 2015 10 Point Plan produced jointly by NHS England, the Department of Health, Health Education England, BMA and the RCGP. As part of the development work for the Forward View NHS England and the Department of Health commissioned the Policy Research Unit in Commissioning and the Healthcare System (PRUComm) to undertake an evidence synthesis on GP recruitment, retention and re-employment – although given the paucity of literature on re-employment the review focused on recruitment and retention. The review was undertaken by Professor Stephen Peckham, Director of PRUComm, and Dr Catherine Marchand of the Centre for Health Services Studies at the University of Kent.

Overall, the published evidence in relation to GP recruitment and retention is limited and focused mainly on attracting GPs to underserved rural areas. However, the literature does provide some useful insights to factors that may support the development of specific strategies for the recruitment and retention of GPs. It was also evident that there are clear overlaps between strategies for supporting increased recruitment and retention.

Key factors that are relevant to the recruitment of GPs are primarily related to providing students with appropriate opportunities for contact with and positive exposure to general practice and general practitioners. Having good role models is particularly important and early exposure in pre-clinical training may be important in influencing future medical training choices. The training environment and location of training can also play important roles in improving recruitment to areas where there are shortages of trainees. Financial factors seem less important in influencing student’s choice for general practice – particularly in the current UK context.

More attention could be paid to the fit between skills and attributes with intellectual content and demands of the specialisation – in particular portraying general practice as a stimulating and interesting specialisation. It is also clear that factors such as lifestyle (flexibility, work-life balance, quality of life), social orientation and desire for a varied scope of practice are important factors contributing to decisions about choice of specialisation. Strategies that emphasise what are seen as the most important and rewarding aspects of the GPs job – facilities, autonomy of work, diversity of cases, education and employment opportunities for physician’s spouses in the practice location – all have a positive influence on recruitment.

Interestingly many of the factors relating to retention are similar to those related to recruitment. Positive factors as viewed by students and GPs about general practice as a profession – such as patient contact, variety, continuity of care – are intrinsic to what it means for them to be a GP. Recruitment factors highlighted positive role models, engagement with practices and socialisation into general practice while retention factors are similar in terms of supporting the ability of GPs to practice being a GP.

The evidence does suggest that tackling key aspects of job stress are important but supporting the key factors of how GPs view the essential nature of general practice in terms of patient contact may be more critical together with developing new opportunities for diversity of practice through sub-specialities and broader portfolio careers. As for the new ways of working, it is likely that the inclusion of nurses, pharmacists, and even social workers might help reduce the strain of the workload and burnout symptoms of GPs. GPs leave both for reasons of job dissatisfaction – possibly reflecting a frustration or a disappointment toward the changing roles in their practice – and also to retire before 60 years old, even if not discontent. Reasons may include lack of resilience to deal with stress but also a simple view that they have undertaken sufficient lifetime service. Generally the findings of this review are consistent with the wider literature on organisational behaviour and human resource management.

Based on our analysis of the evidence, the elements that are most likely to increase and influence recruitment in general practice include:

• exposure of medical students to successful GP role models
• early exposure to general practice
• supporting intrinsic motivational factors and career determinants

Despite continuing interest in using “golden handshakes” there is little evidence that financial targeted support will increase recruitment as recent experience in some areas of England have already demonstrated.

While we found no clear evidence of the effect of investment in retainer schemes and incentives to remain in practice on retention things that will possibly influence GPs to remain in practice include:

• supporting intrinsic factors of the job
• strategies to improve job satisfaction
• reducing job stressors such as work overload, lack of support and high demand

Download PRUComm report [pdf]>>

NHSE – IPSOS/MORI report>>

PRUComm Research Review August 2016

This is the fourth annual review of our research and provides a brief overview of our current research activities.

Download PRUComm research review [pdf]>>

Public Health and Obesity in England – the New Infrastructure Examined

By Anna Coleman and Stephen Peckham

Since April 2013, we have been investigating the changing public health system in England. These changes came about as a result of the Health and Social Care Act (2012) and have had profound implications for the organisation and delivery of public health. Prior to the reforms, the public health system was criticised as lacking synergy and suffering from inefficiencies due to overlapping responsibilities. Hence a key objective of government policy was to address the perceived fragmentation through a number of changes made to the structures and organisation of public health functions, chiefly by moving public health into Local Authorities (LAs) in order to:

  • increase the emphasis on public health and disease prevention;
  • create a more joined-up system with clearer leadership;
  • have a greater impact on the wider determinants of health at local level.

Examining the impact of such changes has been challenging, especially in the context of the broader changes to the health and social care system, to other government policies in areas such as education and welfare and the wider austerity environment.

Transferring public health activities into local government sought to build on the developing role of Local Authorities (LAs) in shaping local places to create healthier environments through spatial planning and local initiatives to improve health and wellbeing.  At the same time a new body, Public Health England (PHE), was created to bring national health service leadership and commissioning and further changes were implemented with the creation of NHS England (NHSE) – at ‘arm’s length’ from Government – and Clinical Commissioning Groups (CCGs) which commission healthcare services at a local level . These structural changes have had wide ranging implications for the way in which the public health function is approached, organised and delivered. Since 2013 the key responsibility for improving the health of local populations, including reducing health inequalities, rests with democratically accountable upper tier and unitary LAs – although the NHS retains some responsibilities for protecting and improving the population’s health and reducing health inequalities through all its clinical activity.

Throughout our research we utilised ‘systems thinking’ to help us to focus on inter-relationships and emphasise holistic thinking gathered from multiple perspectives. This enabled us to describe what we found to be “a chaotic, sprawling, dynamic set of practices which were often intensely political, and a set of activities that might more closely resemble a non-system”, which was still developing as our research was conducted.

Our most recent report, is based on the findings from the last 3 years and included an initial scoping review; a review of the Communities and local Government Select Committee investigation (2013) into the proposed changes; interviews with national stakeholders; case studies in 5 LA areas (including interviews, observations, collection of documentation) and two rounds of web-based surveys (of Directors of public health and elected councillors with roles in public health) in 2014 and 2015.

Our research showed that initially LA public health teams concentrated on developing the structures and processes required for effective operation (Gadsby et al 2014). We demonstrate that this concern with structures and organisation has continued (Peckham et al 2016). Financial insecurity created additional problems with LAs sometimes unsure of the details of their financial settlement from government until many contracts had been negotiated. Budget cuts across other departments within LAs also brought pressures to public health teams, as costs were transferred and shared across departments. Similarly contracts have received new scrutiny, and both existing and new contracts have had to be (re)negotiated within a new provider landscape.

The organisational position of the public health team and the director of public health were also found to be important in terms of ability to influence strategic decision-making and work with other departments. System co-ordination remained an area where roles and responsibilities of various actors were not always clear. In addition, actors within the system had to negotiate ways of working with others, in a situation where much was new and still changing. This was further complicated in two–tier council areas where responsibilities are spread between organisations creating additional complexities of inter-organisational working. However, our surveys (Jenkins et al 2015Jenkins et al 2016) showed public health teams in two-tier authorities appeared to have fewer capacity issues in terms of supporting the information needs of CCGs.

Our research provides an early overview of the development of the public health system in England (2013-15) and highlights some important issues that have both policy and practice implications including:

  • support for a stronger LA role in public health;
  • a system still in flux and some continuing confusion about organisational responsibilities in terms of commissioning;
  • financial constraint impacting on capacity of public health teams alongside broader financial constraint in local government;
  • competing policy objectives; an ongoing struggle between local agendas (e.g. tackling inequalities) and a central government push (e.g. towards integration);
  • some innovation and creativity in using public health resources, but also some concern expressed about inappropriate use of public health funding;
  • the development of collaborative work between some LA departments, but some poor linkages with CCGs;
  • distinct differences in development across our sites.

Overall, our findings suggest that the development of the new public health system in England is still in progress with both the internal organisation of public health in LAs, the NHS and PHE in a continuing state of flux. Despite much activity around the re-organisation of systems, structures and processes, which have had important consequences for roles, relationships and functions, we haven’t seen a corresponding shift in priorities and strategies. We identified a mismatch between the rhetoric at policy level, emphasising the importance of prevention and the reality, which has seen cuts in public health funding.  We found that the Health and Social Care Act (2012) and associated policies paid insufficient attention to the nature and quality of relationships across the various organisations and individuals that constitute the new public health system. As a result, some of the challenges identified during the passage of the Health and Social Care Bill have been averted, although many remain. Some of the opportunities identified have been realised, but many are highly dependent on a range of locally contextual factors.

Our findings also mirror those set out in another recent blog, where Brackley argues that more work is needed to recognise the value of public health professionals within local authorities, the long term benefits of the prevention agenda and that “interventions that cannot easily be measured – at least in the short-term – in pounds and pence” are important.

For more details and a wider discussion of our data and finding refer to our final report which has just been published.

Refs

James Brackley (2016) ‘Everything is public health’: opportunity or threat for local public health professionals? 24/5/16

Erica Gadsby, Stephen Peckham, Anna Coleman, Julia Segar, Neil Perkins, Linda Jenkins, and Donna Bramwell. (2014) PHOENIX: Public Health and Obesity in England – the New Infrastructure eXamined: First interim report: the scoping review. University of Kent, PRUComm.

L.M. Jenkins, D. Bramwell, A. Coleman, E.W. Gadsby, S. Peckham, N. Perkins, J. Segar (2015). Integration, influence and change in public health: findings from a survey of Directors of Public Health in England. Journal of Public Health Advance Access published October 20, 2015.

Stephen Peckham, Erica Gadsby, Anna Coleman, Linda Jenkins, Neil Perkins, Donna Bramwell, Jayne Ogilvie, Harry Rutter and Julia Segar (2016). PHOENIX: Public Health and Obesity in England – the New Infrastructure Examined: final Report. University of Kent, PRUComm.

Nick Riches, Anna Coleman, Erica Gadsby and Stephen Peckham (2014) The role of local authorities in health issues: a policy document analysis. Kent University, PRUComm.

Sympathising with commissioners

By Stephen Peckham

Commissioning is a complex and difficult process. It is fundamentally about relationships and with the organisation and structure of the NHS currently in flux the job of commissioners are constantly being faced with new challenges.

Right now, there is plenty that is new, changing and uncertain, both from the policy perspective and in practical terms. Most of those concerned are just finding their way. Many of the issues which pre-occupy commissioners are similar, regardless of whether PCTs, Clinical Commissioning Groups or any other group are in charge. They are often about getting right the information for decision-making and about feeling constrained by national and public priorities.

At PRUComm our job is to understand how commissioning processes work and how people are managing the complex challenges and relationships, so we can share the learning with colleagues. We’re not here to tell commissioners how they should be operating but by working with commissioners and policy makers we hope to support policy and practice.

We are pulling together some of the learning from previous research – in the UK and other countries – on commissioning. We will be examining areas such as  the impact of patient involvement and clinical leadership in the process. A focus of our energy will be the workings of the many different relationships – for example between NHS commissioners and local authorities as well as between local and national healthcare commissioners. Knowledge and analysis will be fed back to the Department of Health, which funds the unit, and across the NHS and among the local agencies with whom we work.

This is a relatively new field of research both here and internationally. It represents a great opportunity for us to bring learning from Britain to other similar health economies. We will have done our job well, if we can really help all the players in this vast process to get the best out of commissioning – for their organisations, but most of all for the key focus of commissioning – patients and the general public.

Those with responsibility in this field are trying to spend the money in the right way, but it is a dynamic, complicated and difficult process. Hopefully, we can offer them tools and some thinking that will make their tasks easier.

Stephen Peckham is Director of PRUComm