Tag Archives: NHS

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>>

Alliance contracting, prime contracting and outcome based contracting: What can the NHS learn from elsewhere? A literature review

This report is part of the research of the Policy Research Unit in Commissioning and the Health Care System (PRUComm) on new models of contracting in the NHS, commissioned by the Department of Health.

Over the past few years the need to find new ways to integrate services has become an important policy priority in the English NHS. The formation of new organisational configurations in local health economies announced in the Five Year Forward View entails separate organisations working closely together to improve the integration of local services and allow the better use of resources. One way to achieve collaboration across organisational boundaries is through the adoption of new models of contracting, such as alliance contracting, prime provider contracting and outcome based contracting. Despite their relative novelty in the English NHS, these models have a history of use in other sectors such as construction and defence, as well as in the commissioning of public services in the UK and overseas.

This report summarises the findings of a literature review of the available evidence concerning the characteristics of these new contractual models and their implementation in other sectors. The available evidence is considered in order to draw out the lessons which may be learnt to aid the implementation of these models in the English NHS.

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Interrogating institutional change: Actors’ attitudes to competition and cooperation in commissioning health services in England

Since the beginning of the 1990s the public healthcare system in England has been subject to reforms. This has resulted in a structurally hybrid system of public service with elements of the market. Utilizing a theory of new institutionalism, this article explores National Health Service (NHS) managers’ views on competition and cooperation as mechanisms for commissioning health services. We interrogate the extent of institutional change in the NHS by examining managers’ understanding of the formal rules, normative positions and frameworks for action under the regime of the Health and Social Care Act 2012. Interviews with managers showed an overall preference for cooperative approaches, but also evidence of marketization in the normative outlook and actions. This suggests that hybridity in the NHS has already spread from structure and rules to other institutional pillars. The study showed that managers were adept at navigating the complex policy environment despite its inherent contradictions.

Link to the paper>>

Engaging GPs in commissioning: Realist evaluation of the early experiences of Clinical Commissioning Groups in the English NHS

Objectives To explore the ‘added value’ that general practitioners (GPs) bring to commissioning in the English NHS. We describe the experience of Clinical Commissioning Groups (CCGs) in the context of previous clinically led commissioning policy initiatives.

Methods Realist evaluation. We identified the programme theories underlying the claims made about GP ‘added value’ in commissioning from interviews with key informants. We tested these theories against observational data from four case study sites to explore whether and how these claims were borne out in practice.

Results The complexity of CCG structures means CCGs are quite different from one another with different distributions of responsibilities between the various committees. This makes it difficult to compare CCGs with one another. Greater GP involvement was important but it was not clear where and how GPs could add most value. We identified some of the mechanisms and conditions which enable CCGs to maximize the ‘added value’ that GPs bring to commissioning.

Conclusion To maximize the value of clinical input, CCGs need to invest time and effort in preparing those involved, ensuring that they systematically gather evidence about service gaps and problems from their members, and engaging members in debate about the future shape of services.

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Commissioning through Competition and Cooperation

Following several versions of the NHS quasi market since 1990, a wide ranging set of reforms was introduced into the NHS under the recent Coalition government by the Health and Social Care Act 2012 (HSCA 2012). The idea behind these is the same as that behind previous versions of the NHS quasi market: that competition between a wider range of providers will produce the desired results of improved quality and greater efficiency. The HSCA 2012 made a direct correlation between competitive behaviour in the NHS and competition law. The Procurement, Choice and Competition Regulations No.2 2013 relate to sections 75-77 and 304 (9) and (10) of the HSCA 2012, and indicate that competitive procurement by commissioners is to be preferred, although not in all circumstances. Monitor (the former NHS Foundation Trust regulator) took on the role of economic regulator for the whole of the NHS. Along with the national competition authorities (being, since April 2014 the Competition and Markets Authority, and prior to that, The Office of Fair Trading and the Competition Commission), has powers to enforce competition law to prevent anti-competitive behaviour.

At the same time, it is still necessary for providers of care to cooperate with each other in order to deliver high quality care. There are many aspects of care quality where cooperation is needed, such as continuity of care as patients move between organisations, and sharing of knowledge between clinicians. Monitor is also responsible for promoting co-operation. It is the role of NHS commissioners (including Clinical Commissioning Groups ‘CCGs’), however, to ensure that the appropriate levels of competition and cooperation exist in their local health economies.

During the course of this study, an important policy document, The Five Year Forward View (5YFV) was published by NHS England in October 2014. This did not mention competition between organisations and instead focussed on how organisations in the NHS need to cooperate with each other, and in fact at times merge to form larger organisations. And it should be noted that there have been no relevant legislative changes, so the HSCA 2012 remains in force. While studies have noted that incentives for competition and cooperation exist in healthcare, few have researched the interaction between the two. There was a need to investigate the way in which local health systems were managed to ensure that cooperative behaviour was appropriately coexisting with competition.

This project aimed to investigate how commissioners in local health systems managed the interplay of competition and cooperation in their local health economies, looking at acute and community health services (CH).

Download final report [pdf]>>
Download appendix [pdf]>>

Understanding primary care co-commissioning: Uptake, scope of activity and process of change

The Health and Social Care Act 2012 gave the responsibility for commissioning primary care services to NHS England (NHSE). Part of the rationale for this was to move towards a more standardised model of primary care commissioning. However, it has become clear since 2010 that local flexibility and understanding is also required in order to properly match primary care provision to the needs of an aging population. Primary care co-commissioning was first mooted in the Call to Action in 2014, where “joint commissioning” was identified as one of national level supports to improve general practice. In May 2014, it was officially announced that CCGs would get ‘new powers’ under a new commissioning initiative. There are 3 levels of responsibility; (1) ‘greater involvement’ (where CCGs would have ‘influence’ but not take the lead in shaping primary care locally), (2) joint commissioning (where CCGs would set up a joint committee with NHSE AT), and (3) delegated authority (where CCGs would take over budgets from NHSE Area Teams and take the lead in primary care commissioning). Initially there was no clear expectation that CCGs would move from Level 1 and 2 to taking on full responsibility (Level 3) over time. However, one year on, CCGs operating at Level 1 and 2 were encouraged to consider applying for full delegation. This report aims to explore the uptake of primary care co-commissioning nationally, develop an understanding of the rationale underlying the policy and the expected outcomes, and understand the scope of co-commissioning activity and the process of change.

Download interim report [pdf]>>
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Exploring the GP ‘added value’ in commissioning

One of the main focusses of the Health and Social Care Act 2012 (implemented from 2013) was on the development of Clinical Commissioning Groups (CCGs) to replace Primary Care Trusts (PCTs) in commissioning healthcare for their local populations. This report presents the findings from a second phase of our ongoing study following the development of CCGs in England since 2011.

In the first phase of this study (January 2011 to September 2012), we followed the development of CCGs from birth to authorisation i.e. from their involvement in the ‘pathfinder’ programme and officially becoming sub-committees of their local PCT Cluster until their authorisation in April 2013. One of the issues highlighted by our participants in the first phase of the study was the perception of GP ‘added value’. The aim of the second phase of our study was therefore to follow up those claims made in the first phase around issues of GP ‘added value’. We explored further the potential added value that clinicians, specifically GPs, bring to the commissioning process in interviews, and followed this up with observations of commissioners at work.

Our research used ‘Realist Evaluation’ (Pawson & Tilley, 1997). This approach involves: seeking out participants ‘programme theories’ as to how a particular policy or programme will bring about the desired outcomes; exploring the extent to which these programme theories ‘work’ in the real world; and examining in detail the mechanisms and contexts which underpin them. The
approach is often said to be exploring ‘what works, for whom, in what circumstances’? We applied this approach to GPs roles in CCGs, using interviews to find out what CCG leaders believe are the key aspects of their contribution to commissioning. We then observed a wide range of meetings in order to explore the extent to which the claims they made were borne out in practice, and to try to elucidate the important conditions which supported their roles.

Download full report [pdf]>>
Download summary [pdf]>>

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