Methods
To explore issues of implementation regarding the emergent policy and practice proposals, we conducted facilitated stakeholder group consultation meetings in two locations in England: one in London and one in Leeds.
Recruitment
Target stakeholder groups included representatives of CCGs, LMCs, NHS England Local Area Teams, AHSNs and PPI groups, as well as representatives from national medical and government organisations including the Department of Health and Social Care (DHSC), the BMA, the RCGP, HEE, NHS Employers and the GMC. Members of our project advisory board provided key stakeholders from within HEE, NHS England, the BMA and the RCGP, and these were supplemented by extensive web searches for names and contact details of CCG/LMC chairpersons and others in workforce planning roles within national organisations or who had published on the subject of GP workforce in recent years.
The project management group reviewed the list of potential participants to ensure that no key groups or individuals had been omitted. All participants were e-mailed a formal invitation containing web-page links to register attendance at a meeting in June 2017 in either London or Leeds. Non-respondents were followed up by e-mail at regular intervals, and a new invitation was sent to any new individuals suggested by those unable to attend. Of 121 individuals approached, 48 registered to attend one of the meetings, of whom 44 (36% of those approached) attended on the day (22 at each meeting) (see Appendix 36).
Formulating the discussion topics
Both meetings involved discussion of the same topics to facilitate comparisons and identify differences between regions on emergent ideas. We identified 11 policy/strategy topics for discussion.
The discussion topics were derived mainly from the key policies and strategies prioritised by the RAM workstream (see Chapter 5) where the RAM panel had reached overall agreement that these policies and strategies were ‘appropriate’ and some where there was also consensus on them being ‘feasible’.
Topics 1–10 encompass the 16 policies and strategies that had been rated by the RAM panel (with consensus) as ‘appropriate’ and ‘feasible’ ().
Mapping the 16 policies and strategies rated as ‘appropriate’ and ‘feasible’ by the RAM panel onto the draft stakeholder consultation discussion topics
A further six topics were then added for consideration within the stakeholder consultations. Topics 11–13 had been rated (in the form of statements) by the RAM panel as being ‘uncertain’ or with no consensus regarding appropriateness (‘external HR interventions and monitoring/support’) or as being ‘appropriate’ but ‘uncertain’ regarding feasibility (‘maximum number of consultations for GPs’ and ‘making consultations longer’). Topics 14 and 15 had been suggested as areas for potential inclusion in the RAM during the initial statement development work, but had not been taken forward for rating by the RAM panel. Topic 16 was added as an area of methodology for supporting implementation of policies and strategies, or for future research.
From the 16 topics in , we formed three broad categories (Box 2). Eleven discussion topics were formed from the 16 draft topic titles by combining the two topics concerning identifying the ‘at-risk’ (of workforce undersupply) status of general practices and a new focus on under-doctored areas (1 and 2); the two topics concerning portfolio working (7 and 8); the two topics concerning incentives and support packages for GPs (4 and 5); and also the three topics covering support and planned exits for GPs nearing retirement and the implications of losing previous pension incentives (9, 15 and 16).
Draft discussion topic titles for the stakeholder consultations
Final stakeholder consultation discussion topics
In addition, graphic facilitation was seen as an innovative and potentially useful means of capturing some of the process and key discussion points from the stakeholder events and so was undertaken at each meeting with the aim of capturing the key themes generated by the group discussions.
Data collection and analysis
We adopted a consistent structure for the two meetings (see Appendix 37). Following presentation of our research findings, stakeholders were asked to work in their allocated round-table groups, seated at tables of seven or eight people. During round-table discussions, each group covered between one and three policy and strategy areas in each 45-minute discussion session.
We anticipated that stakeholders would take a broad view of the feasibility of policy and strategy implementation, noting barriers and facilitators that might impede or enhance the utility of our research to the front-line NHS. Discussions were facilitated by two project team members at each of the table groups and were structured as follows:
What factors could have an impact – positively or negatively – on the implementation of the emergent recommendation?
Please comment on feasibility and acceptability of the emergent recommendation.
What are the structures or groups that would need to be involved in introducing change to this area?
What are the three key next steps to move this agenda forward?
Facilitators recorded stakeholders’ comments on sticky notes (and/or stakeholders did this themselves) and added them to flip charts during the discussion, which were referred back to during the closing summary session. In addition, stakeholders were provided with a poster summarising the findings of the systematic review, and facilitated whole-group discussion throughout the event and at the end of the day’s proceedings.
Post-event processing of collected information
Following discussion among the research team, Emily Fletcher summarised the key messages that had been collected on the sticky notes on flip charts by examining those comments that fell within the following broad categories: (1) positive and negative factors for implementation; (2) comments regarding feasibility and acceptability; (3) region-specific (i.e. ‘north’ or ‘south’) issues raised; and (4) key actions required, including those organisations that needed to be involved to make changes to the policy area. This summary was initially produced by Emily Fletcher and was cross-checked with members of the project team who had acted as table group facilitators (JLC, RA, CS, SD, SR, RC and AA).
Discussion
Members of key stakeholder organisations with involvement and expertise in NHS and primary care workforce planning worked in small round-table groups to consider 11 policy and strategy areas focused on retention of the existing GP workforce in three broad categories (‘protection’ of GPs and managing patient expectations; incentives and support mechanism for GPs; and portfolio and wider working arrangements). Discussions were structured to record key comments and views and beliefs relating to feasibility, acceptability, positive and negative factors that might affect implementation, and key actions to be taken forward by particular workforce partner groups or stakeholder organisations.
A number of policy and strategy areas generated clear actions, with potential responsibility for implementation and response being attributable to specific organisations.
In addressing issues regarding protection of GPs in their current roles and in seeking to manage patients’ expectations of primary care, emergent policies and strategies from this project highlighted the importance of routine practice operation and management. Discussions about setting a maximum number of GP consultations per working day and also on increasing the traditional length of consultations concluded that these were potentially both helpful policies that were also considered to be potentially feasible. However, the inherent contradiction of attempting to constrain individual workload in the face of recruitment challenges that are likely to represent countervailing forces was fully recognised.
Actions were identified for organisations at a range of levels: practice teams being responsible for analysing their workload and improving consultation planning. Nationally (NHS England, HEE, RCGP), proposing a maximum limit on consultation number and making a change to the traditional 10-minute consultation length could be introduced via the use of National Institute for Health and Care Excellence (NICE)-supported guidelines providing evidence-based summaries of relevant evidence, and GP training (i.e. the RCGP postgraduate training curricula and the summative clinical skills assessment of trainee GPs) might also be a vehicle to influence GPs’ consulting style. Discussion on the use of marketing strategies to manage patients’ expectations of GP services (national/regional-level policy) led stakeholders to conclude that a national, consistent strategy developed, and with implementation overseen, by NHS England (co-ordinated and with national branding) was needed in order for such interventions to be effective.
In discussing incentives and support mechanisms, emergent policies and strategies related to both overarching HR management systems and actual HR practices, potentially implementable at all three levels considered (national/regional, practice and GP level). Discussion of practices being able to self-register their ‘at-risk’ status regarding workforce undersupply highlighted considerable uncertainty among expert stakeholders over both the method of defining at-risk status and the practical implications of being identified as being ‘at risk’. Informal/local knowledge on ‘struggling’ practices was identified as being key, and, for this reason, CCGs (overseeing the process of definition and assessment of ‘at-risk’ status) and practice groups or federations were suggested as possible organisations that might lead action around providing support to ‘at-risk’ practices. Our predictive risk modelling work within ReGROUP provides a potential model to apply in practice.
Discussions on practices’ HR systems being managed via arrangements that were external to practice administration and organisation reflected the uncertainty expressed by participants in the RAM panel (see Chapter 5). Stakeholders concluded that GPs and practice managers are central to the success of practice HR processes but could be better supported with training (perhaps within the responsibility of HEE or NHS England) to oversee this element of general practice.
Discussions on both supporting the uptake of GP health and well-being interventions, and also on professional support for GPs in their first 5 years post GP qualification acknowledged the importance of policies/strategies to ensure and promote the success of these recently established initiatives (such as the NHS-supported GP Health Service152). National organisations with an interest in GP health and well-being [RCGP, Community Education Provider Networks (CEPNs), HEE], along with any group that might develop and implement a new scheme or initiative, should be encouraged to develop schemes and services that have limited bureaucracy and good ease of access and clarity of purpose. Professional groups, including the RCGP and the Royal College of Nursing, were called on to consider health and well-being support for all health professionals, in addition to GPs, who are working in general practice; stakeholders suggested that CEPNs/HEE should ensure that efforts to support newly qualified GPs are linked with current RCGP First5 activities, thus providing a co-ordinated approach across organisations. Practice teams also have responsibility for planning time during the working day in order that the practice team create ‘headspace’ for thinking, planning and reflection, and act as a focus for internal mutual support between colleagues.
Finally, discussions on supporting ‘planned exits’ for GPs nearing retirement (and the implications of losing previous pension incentives) were a key addition to the RAM workstream, which had not included this area within those presented to the RAM panel. NHS regional offices were identified as being in a position to support the identification of this target GP group and proactively offer support in making changes to the scope of practice of these individuals in a positive and supportive way. Review of the appraisal/revalidation process, particularly for these GPs, was seen as a key priority and was identified by stakeholders as an important area of concern, which warranted reducing the bureaucratic burden for GPs. Such approaches were seen as being within the remit of the GMC and appraisal infrastructure and were seen as possible successful targets for innovative thinking and service redesign.
In supporting GPs to develop portfolio working and in supporting their wider working arrangements, emergent policies and strategies related to both HR practices and operational functions/practice management, implementable at practice level. Discussions on portfolio careers, contracts for GPs to work across several practices and allocation of workload to other health-care professionals were all viewed as ways to formalise and support various styles of managing workload/work–life balance that are already widely in use. In almost all areas, national organisations were identified as having a part to play: the GMC to provide data on the scope of GPs’ portfolio roles and to reflect these roles within the appraisal/revalidation process; and the RCGP/HEE to increase flexibility within GPs’ training to promote and support the development of portfolio careers, clarify the career path for GPs working across practices, and define the required competencies, skills and training needed to be a ‘consultant GP’. The BMA and NHS England nationally, as well as regional CCGs and practice federations, were called on to clarify the often complex statutory and governance issues and employment arrangements for GPs with portfolio careers or who work across multiple practices. Successful employment of other health professionals in general practice would be supported by practice teams planning time for MDT discussions during the working day, by the DHSC/NHS England providing financial incentives (directly to practices) for employing a wider range of health professionals, and by other key groups (RCGP, GMC) identifying a regulatory body to manage indemnity arrangements associated with the work of all health professionals in the primary care team.
Strengths and limitations
A strength of this work was the successful recruitment and involvement of representatives from key stakeholder organisations, including some in very senior and influential roles within medicine and in health more widely, and within major professional, government, policy and related organisations. Importantly, we incorporated the participation of PPI representatives at both meetings. A core member of the project’s PPI group acted as a facilitator for the round-table discussions in London, and two members of the public in Leeds representing a local practice PPG and the University of Manchester PPI network actively participated as stakeholders. This directly supported the view of the project’s PPI group that patients and members of the public should take part in the conversations and could bring their experience as patients or from other fields of work or industry.
The meetings followed an identical structure and used focused discussions on answering specific questions, and yielded clear statements on both the perceived feasibility of the strategies and potential specific actions to be taken by particular organisations or groups.
Although the RAM workstream excluded the consideration of policies and strategies regarding MDT working, role substitution and skill mix, and also the implications of recent changes in pension policies, this stakeholder consultation workstream did seek views on these areas. These were felt to be important areas for consideration by stakeholder participants, owing to the ongoing implementation of new roles and the likely impact of changes to pension arrangements on the number of older GPs considering early retirement.
Limitations include the fact that our findings comprise a summary list of the views captured across both meetings; the finer detail of individual comments are not reported. Nor have we systematically attempted to draw out the potential complementarity or inevitable tensions between some of the proposed retention strategies (e.g. between having a daily maximum limit on the number of consultations and increasing the typical length of GP consultations). In addition, in order to make good use of stakeholders’ time at the meetings and to present sufficient background material on the findings of the whole of the ReGROUP project, we needed to restrict the number of discussion topics that were possible to cover in detail. Furthermore, each of the 11 potential strategies was discussed in detail by only one table group of stakeholders at each meeting. Nevertheless, an attempt to implement change in 11 policy and strategy areas at the same time would cause disruption; further consideration of prioritising these areas to avoid creating additional pressure on the existing GP workforce is needed.
Conclusions
Following identification of policies and strategies that are likely to support the retention of GPs in direct patient care through the work described in the preceding chapters, we organised two successful stakeholder engagement events, which proved dynamic, supporting wide-ranging but focused discussion. The consultation has identified potentially important areas for policy and strategy development and has crystallised which workforce partner groups and stakeholder organisations might be best placed to lead on innovation and change. However, most of these areas will require some form of evaluation and so this work is a first step towards testing potentially important areas and gaining preliminary evidence on feasibility and acceptability.
