Monthly Archives: June 2015

The GP ‘Brand’ and recruitment: Lessons from the business world

photo-1Louise Skioldebrand is a partner, appraiser and trainer based in Stowmarket, Suffolk.

After the first round of recruitment only 72% of UK GP training posts were filled, with some areas as low as 36%…. we can look at possible reasons for this; young doctors are having to commit so early to their career choice, younger doctors preferring urban areas, and medical student selection at 18 being so academically skewed that they don’t want to consider GP as a career.

The current crisis has led the West Suffolk GPST scheme trainers to focus on recruitment and have had the privilege of being involved in two workshops led by Richard Mosley and Simon Barrow. They are experts in ‘Employer Brand Management’ and have written books on the subject. The ‘Employer Brand’ is defined as ‘the package of functional, economic and psychological benefits provided by employment and identified with the employing company’. The main role of the brand is to provide a coherent framework for management to simplify and focus priorities, increase productivity and improve recruitment, retention and commitment.

So how can we apply this to general practice?

Let’s look at what we need to focus on:

Employer brands provide a focal point for: Aspiration (eg Royal Shakespeare Company – it’s a company any actor should have on their resume); Identity (World Wildlife Fund – I’m proud to tell people where I work); Engagement (Pret a Manger – I’m committed to going the extra mile); Advocacy (Google – I tell people it’s the coolest place to work); and Trust/Loyalty (Proctor and Gamble – it would take a lot to get me to leave).

The Employer Brand must make sense for current and potential GPs…it is about ensuring reality and not ‘spin’. So what can we do to improve our image and to engage and retain GPs? We must deal with the ‘Brand Busters’ such as increasing workload, falling incomes, possible future seven day working, negative media image and our own cynicism. We should develop an “Employee Value Proposition (EVP)” – this describes the defining qualities you most want to be associated with in the future….

Why should people join us, stay with us and commit to us?

We need to build our brand with a consistent and distinctive message.

We need to have a coherent plan with effective leadership, fix what is holding us back, and deliver the message coherently with everyone on side. Maureen Baker and Chaand Nagpaul are trying their hardest but how can we get long term planning in place whilst political parties use us as footballs?

We need to establish when and how contact can be made at key decision points for students and young doctors, in order to deliver our message and to breed mutual respect. Suggestions such as GP taster weeks for those foundation doctors not doing GP (or perhaps make them compulsory for all specialists?), and more formal development of GPwSI during GP training could broaden appeal.

In the business world, the leading decision factors in retention (as for attraction) are base pay and opportunities for career advancement. Lessons from our Brand workshop included exploring how GPs want to be seen and why general practice is a good career option for junior doctors; we highlighted the holistic approach to patients, the flexible and independent working opportunities, both as a practice and as an individual, for creating a varied working day, week and career.

We discussed stories we could tell about being a GP which might help transform attitudes, such as being there for patients and their families in their hour of need, and the fact that we can influence many working factors including: staff recruitment, the systems we use, and developing a portfolio career. We focused on our locality’s strengths geographically and we looked at the importance of the ‘role model’ we are giving to our families, friends, staff, medical students and junior doctors. We looked at how we could show ourselves as at the centre of respect and trust through our community, by going into schools and talking about our career, and by offering work experience for pupils and medical students.

We explored how to make the profession look “sexy” and highlight the value of primary care – if there was none, the cost to society would be huge. We have special skills which enable cost-effective investigation and management of patients. We need adverts like “my GP saved my life”, repeating the positives.

EVP for GPs

So, going back to Employer Brand Management principles, the EVP for GP could be:

Be a general physician giving holistic care to your patients from cradle to grave, with a varied working day and potential to influence both your working environment, and to develop your career with special interests, management and training opportunities.

‘No patient is the same, no day is the same’.

Let’s eradicate the brand busters and make a career in general practice the first choice for a Foundation doctor!

Acute primary care in an integrated NHS

BJGP JonesProfessor Roger Jones is editor of the British Journal of General Practice.

The tsunami of chronic disease management – the ageing population, rocketing rates of non-communicable diseases, and increasing complexity – have dominated much of the debate about the future of general practice and of the NHS. The crucial function of general practitioners in making accurate, timely diagnoses in patients presenting with acute symptoms is easily overlooked, yet is at the very core of primary care. The implications of this for mending the fractures in the system and for the design of integrated models of care came home to me in the course of three conferences over the last couple of weeks.

The first was a European meeting on screening for colorectal cancer, held in the Czech Republic, involving European Commission and Parliament policy-makers, as well as clinicians and epidemiologists. The focus was on increasing the momentum in member states of the EU to develop and extend screening programmes for colon cancer, which is an enormous health problem in Europe. However, the flip side of this debate is the fact that the huge majority of bowel cancers are diagnosed outside screening programs, either in patients presenting in general practice with suspicious symptoms or, in a substantial minority, in emergency hospital admissions for the complications of advanced disease.

The next was a conference summarising the achievements of the Discovery programme, a large, NIHR and charity funded research programme of research aimed at collecting evidence to support early cancer diagnosis in general practice (http://discovery-programme.org). One of many important messages for primary care was the need to be prepared to investigate patients with potential cancer symptoms much more promptly than we do at present, and the consequent requirement for better investigative services that can be readily accessed by general practitioners. Discovery investigators presented new data to show that many of the “typical” symptoms associated with cancer presentations are, in fact, much less common than more general,  often vague, complaints, such as fatigue and “feeling different”. They have also demonstrated that patients presented with vignettes of possible cancer scenarios are much more willing to undergo investigations at an earlier stage than previously recognised.

The third meeting was the Annual Conference of the South London Faculty of the RCGP which took as this year’s theme “Early diagnosis in general practice”. I presented some recently-published data, including the important recent BMJ Open paper from Peter Rose and a number of European colleagues which shows that GPs in England, Wales and Northern Ireland are much less likely to request investigations for potentially worrying symptoms then their general practice colleagues in most of the eight other European countries taking part in the study. Given the relatively poor cancer outcomes in the UK (and, for some reason, in Denmark), this is an important finding, adding weight to the need for speed and accuracy in investigations for suspected cancer.

Taken together, these studies and observations are powerful ammunition for the commissioning of better access to investigations, and for careful review of two-week wait criteria. They do, I think, mean more than this, and have major implications for the kind of integration between primary and secondary care that should develop within the NHS in the near to medium term future. In his Five Year Forward View, Simon Stevens, the NHS Chief Executive, describes two possible models of integration – the so-called Multi-speciality Community Provider (MCP) model and the Primary and Acute Care Systems (PACS) model. The first of these is a more horizontal integrative approach to community-based services, including of course general practice, whilst in the PACS model there is scope for a single provider organisation to deliver both primary and secondary care services, with no pre-defined requirement for this to be general practice-led or hospital-led.

The RCGP has, understandably, focused on developing the MCP model, which is probably more likely to keep general practice in the “driving seat”, and meets the five College criteria for an acceptable approach to integration. However, it seems to me that much might be gained by looking more positively at the PACS model, within which investigative pathways for patients with potentially serious conditions – and this of course doesn’t just apply to cancer, but to a host of potentially serious clinical problems – could be developed jointly between generalists and specialists. This approach could, I believe, lead to the creation of much less delay and misunderstanding by removing many of the barriers to speedy diagnosis and swift intervention that presently exist at the primary: secondary care interface. It would be simplistic to suggest that the MCP model is better suited to chronic disease management and the PACS to acute presentations and treatment, but that may not be far from the truth.

It is also possible to see other potential advantages of the PACS system, in locations where it would provide the most clinical benefit. A single employing organisation could provide economies of scale that the small-business model of general practice simply cannot achieve. Making use of joint infrastructures, including finance, HR, and procurement is likely to have significant cost benefits. Beyond this, the possibility that primary care specialists might be employed under similar contractual arrangements to hospital specialists, with benefits for continuing professional development,  career structure and work force planning, and with potential positive spin-offs for recruitment and retention, should not be underestimated or discounted.

When Simon Stevens spoke on the BBC’s, Andrew Marr show recently, he was candid in saying that general practice has suffered from 10 years of under-investment. The RCGP has done a terrific job in making this argument and articulating a strong case for substantially increased investment in the infrastructure and in the general practice workforce. Whilst the burden of an elderly, co-morbid and increasingly dependent population is undoubtedly making general practice creak at the seams, it will be important in the future – in the very near future, given the shortage of doctors wishing to become general practitioners – to look at how other professions can support the central role of GPs in delivering primary medical care. It will also be crucial for general practice to forge alliances with other parts of the health service and, when this is in the best interests of patient care, to collaborate, as well as lead, in new systems of integrated care likely to provide the best clinical outcomes.

Altmetrics: now available for BJGP articles

Altmetrics_promo_homepage_newerThe world of scholarly publishing is changing rapidly, partly in response to digital publication, and also with more focus on the dissemination and implementation of published research. Traditional bibliometrics, such as the impact factor, have been used to measure aggregated citation rates as a proxy measure of journal quality. There is now more interest in looking at article-level and author-level metrics.

Peer-review publication is one component of an ‘ecosystem’ of dissemination, which includes, for example, citations, news and media coverage, discussion on social media and websites, and inclusion in practice guidelines. These new metrics – ‘altmetrics’ – defined as anything that is not a citation, can be captured in a number of ways.

The BJGP has launched the Altmetric donut, a colourful, arresting image which depicts the various media which have paid attention to a given article, with a numerical score reflecting the number of ‘mentions’. The Altmetric buttons, appearing within the ‘Info’ tab of each article, are not substitutes for traditional bibliometrics, but we think will become a useful addition to understanding how research results ‘get out’ and are incorporated into practice.

Seismic changes in GP teaching – where will the new GPs come from?

photo-2Alex Harding is a GP and academic based in Exeter.

UK General Practitioners are the largest part of the medical workforce, deliver the most care and deliver this care highly effectively. Most people who have ventured abroad and talked about health are surprised at the envious comments from patients and practitioners alike about the UK health system under the NHS.

However the UK GP workforce has not kept pace with the increases in healthcare need, increases in similar workforces abroad or increases in other health professionals in the UK.

In order to address this and an impending GP workforce crisis the English Department of Health has mandated HEE to ensure that by next year 50% of graduates will opt for GP training. At present however, 19% of final year students want to be GPs and many GP training schemes are struggling to recruit enough graduates. In some parts of the country there are now 40% vacancy rates.

There is some good research that shows that exposure to general practice as a medical student has a strong positive effect on future career choice and so appropriate general practice experience as a medical student is an important part of workforce planning.

With this in mind, we surveyed the UK medical schools regarding undergraduate and postgraduate teaching provision and how this was supported in financial and academic terms. We used standard methods to develop a questionnaire and then piloted and modified it.

We were pleased to get a 94% response rate, with 29 out of the 31 medical schools in existence at the time taking part.

The results came as a surprise. We found that the percentage of the curriculum taught in general practice was 13% and that this has remained static since 2002. We also found that when we measured teaching provision in another way (the total number of GP teaching sessions delivered over the entirety of the course) it had actually fallen – from 122 total sessions in 2007 to 102 sessions. This represents a 2 week loss of GP teaching overall.

We were interested to find out why this might be and looked at how teaching was supported. Here we found an apparent disparity between the teaching delivered and payment for teaching received. In addition, many respondents commented that the process of reimbursement for GP teaching seemed unnecessarily complex.

We then looked at teaching support from departments of general practice. We found that departments offering both educational and research capability had dropped by 50%.

Perhaps the most surprising finding however, has been the rapid expansion of postgraduate teaching. Prior to the year 2000 there were no foundation doctors, fewer postgraduate trainees and these trainees spent only 12 months in practice. Calculated in months of experience the total increase is over 80,000 months in little more than a decade. This compares with a total reduction of 15,000 months of undergraduate provision over the same time (2 week reduction for the 30,000 medical students currently being taught).

A number of things are apparent. Firstly, seismic changes have been occurring in general practice teaching – especially in the postgraduate sphere and in the fate of integrated departments of general practice. In contrast, undergraduate teaching seems to have risen slowly – having taken almost 50 years to reach its current level of 13%, but may now be falling.

It is tempting to propose some explanations. Dramatic increases in patient demand and government regulation may play a part in squeezing out medical students who are unable to make meaningful contributions to service delivery – unlike postgraduate trainees.

The rate of reimbursement for undergraduate teaching may also be relevant and is currently being reviewed. This may provide an opportunity to address the disparity between teaching provision and pay. A simpler mechanism of payment may also be beneficial where monies are paid direct to GPs rather than being routed through various other organisations. An important additional factor is reimbursement for space.   Lack of space was identified in our survey as the main factor preventing expansion of teaching. Finally, educational support from departments may also be helpful. These are not easy issues to resolve and central planning and guidance may be necessary. GPs and the NHS are part of the fabric of our society and a debate needs to happen regarding the role of general practice in undergraduate education. After the words concerning the value of general practice and education must come actions.

“I am sorry”: Burnout, bad day or normal general practice?

London11Dr S Vashisht qualified in Cardiff, trained in London and is a GP in Nottingham.

It will be our 30 year re-union soon and I will be travelling to Cardiff to reminisce with my classmates of 1985. That Class of 1985 is now full of fifty-something-year-old doctors. Thirty years is a long time in medicine.

I can remember that as a newly trained GP, my non-medical friends would tell me their tales of experience with the health service and with their GPs.  “I have phoned my GP for an appointment and I have been given an appointment in two weeks’ time. Two weeks’ time! I am ill now, and I could be dead in two weeks” one friend told me. I tried in vain to explain about the system of appointments. My friend didn’t understand that most flu-like illnesses are self-limiting. She felt unwell and wanted to feel better as soon as possible. Surely her GP should be able to prescribe something that would make her feel better?

Thirty years later I have a similar conversation with many patients. They do not want to take time off work, because of the strict monitoring of ‘sick time’ off in most work places. They have been unwell for three, five or seven days already. I examine them and tell them that it may take up to 3 weeks to get better from their flu like viral illness.  “There’s a new virus going around,” I explain.

Some are reassured, others are not convinced and yet others think they have wasted their time in coming to see me. “That doctor is no good, a complete waste of time. All doctors do is just tell you to take paracetamol.” The message about self limiting viral illness has not got across to the general public. Which forms of education, communication and skills could improve this scenario?

I have increasingly noted that my consultation starts with the patient telling me “Doctor I have been trying to get an appointment for 4 weeks and there are no free appointments” or “I phone at 8am and I can’t get through. When I get through there are no appointments left, so they just tell me to phone the next day”.  I often work as a locum, and this conversation with patients takes place in the inner-city practices, in the middle class areas, in those practices with stable long term staff, those practices that frequently use locums and in practices with a high turnover of staff.  “I am sorry about that. What can I do for you today?” I ask sympathetically.  “Well I have a few things I want to talk about.” My heart sinks a little… I have about 7.5 minutes of the consultation time left.  “Can you tell me the problems and we can can deal with the most important one today? I am sorry.” The consultation continues… I was already running a little late and by the end of this consultation I am running more than 15 minutes late.  I call the next patient in. “I am sorry to keep you waiting,” The patient is very understanding. “What can I do for you today?”  “Well doctor, I don’t know where to begin.” I realise this is not going to be a seven or ten minute consultation.

The next patient is called in and tells me: “Doctor I have been to outpatients and had a scan, but have not got an appointment for the results”.  I tell the patient “I am sorry about that. I will ask the secretary to chase up the clinic appointment.”

It seems that the next patient has not arrived. So I feel a sense of calm. I call the following  patient in and conduct a consultation and deal with two problems.

The patient who I thought had not arrived has now arrived. An elderly patient has come with her daughter. The patient has had a recent bereavement of her spouse and there are concerns about living alone, memory impairment, insomnia and low mood. I often wonder if we have researched how long it takes to do an MMSE. It takes me at least six or eight minutes to do.  I check that the address details are correct on the computer system. I note the patient’s daughter’s name and contact detail in the computer system. I think that consultation took  about 20 minutes. I am really running late and a little agitated. It’s at this point that I know I am going to continue to run late, and that I will be starting all subsequent consultations by saying “I am sorry to have kept you waiting”.

I realise that maybe I have had a little crisis today, or is it the beginning of professional burnout?