What are the impacts of setting up new medical schools? A narrative review.

BACKGROUND: The growth of the UK's population together with an aging society with increasingly complex health and social care needs has placed a greater demand on statutory care services. In view of this emerging landscape, the UK Government has sought to increase its medically trained workforce in order to better respond to the demands placed on the health service. Five universities were announced as homes to new medical schools offering undergraduate places to boost the numbers of doctors training in England. The aim of this narrative review was to explore how new medical schools could improve the health outcomes of the local population and evaluate the potential contribution it may make to the local economy, workforce and to research and innovation. METHODS: A narrative review was undertaken using a systematic approach for the search literature strategy. The articles were evaluated by undertaking a critical assessment evaluating the fitness of a paper for review according to results, methods used to test the hypothesis, conclusions and impact and limitations. Thematic analysis was employed to organise and summarise the findings across a heterogeneous body of literature included in the review. The analysis was developed in an inductive manner and there were not any predefined themes to guide data extraction and analysis. RESULTS: Thirty-six articles were selected for inclusion for this narrative review. The review identified six key themes: influence of prior rural exposure, medical school environment and rural enrichment programmes, workforce, health outcomes of local populations, social accountability, economic contribution of medical schools to communities and impact on rural research. CONCLUSIONS: The studies included found a wealth of information on a wide-range of topics on the expansion of undergraduate education and its implications on the future medical workforce. It was shown that medical schools can have a positive effect on the health, social, economic and research activity of a region, but this literature tended to be heterogeneous in focus without consideration of the inter-connections between the wider societal and economic impacts arising from long-term sustainable change being brought to a region.

Health system resilience and health workforce capacities: Comparing health system responses during the COVID-19 pandemic in six European countries.

BACKGROUND: The health workforce is a key component of any health system and the present crisis offers a unique opportunity to better understand its specific contribution to health system resilience. The literature acknowledges the importance of the health workforce, but there is little systematic knowledge about how the health workforce matters across different countries. AIMS: We aim to analyse the adaptive, absorptive and transformative capacities of the health workforce during the first wave of the COVID-19 pandemic in Europe (January-May/June 2020), and to assess how health systems prerequisites influence these capacities. MATERIALS AND METHODS: We selected countries according to different types of health systems and pandemic burdens. The analysis is based on short, descriptive country case studies, using written secondary and primary sources and expert information. RESULTS AND DISCUSSION: Our analysis shows that in our countries, the health workforce drew on a wide range of capacities during the first wave of the pandemic. However, health systems prerequisites seemed to have little influence on the health workforce's specific combinations of capacities. CONCLUSION: This calls for a reconceptualisation of the institutional perquisites of health system resilience to fully grasp the health workforce contribution. Here, strengthening governance emerges as key to effective health system responses to the COVID-19 crisis, as it integrates health professions as frontline workers and collective actors.

Priorities for family physician and general practitioner recruitment and retention in Singapore: a PRIORITIZE study.

BACKGROUND: A shortage of primary care physicians has been reported in many countries. Primary care systems are diverse and the challenges leading to a decline in workforce are at times context-specific and require tailored solutions. Inviting frontline clinicians to share their insights can help identify optimal strategies for a particular setting. To determine priorities for family physicians' and general practitioners' recruitment and retention in Singapore, we invited primary care physicians to rank pertinent strategies using PRIORITIZE, a transparent, systematic priority-setting approach. METHODS: The study advisory board, consisting of representatives of Singapore's key primary care stakeholders, determined the criteria for prioritising of general practitioners (GPs) and family physicians (FPs) recruitment and retention strategies in Singapore. A comprehensive list of GPs and FPs recruitment and retention strategies was extracted from a recent systematic review of the relevant literature. A questionnaire listing the strategies and the scoring criteria was administered online to doctors practicing in public and private sector in Singapore. Respondents' scores were combined to create a ranked list of locally most relevant strategies for improving GPs and FPs recruitment and retention. RESULTS: We recruited a diverse sample of 50 GPs and FPs practicing in a variety of primary care settings, many with a range of additional professional responsibilities. Around 60 and 66% of respondents thought that there was a problem with recruitment and retention of GPs and FPs in Singapore, respectively. Strategies focusing on promoting primary care by emphasizing the advantages and enhancing the status of the profession as well as training-related strategies, such as sub-specialisation and high-quality rotations were considered priorities for improving recruitment. For retention of GPs and FPs, improving working conditions by increasing GPs' and FPs' salary and recognition, as well as varying or reducing time commitment, were seen as the most important strategies. The ranking between physicians working in public and private sector was mostly similar, with nine out of the top ten recruitment and retention strategies being the same. CONCLUSION: Primary care physicians' ranking of recruitment and retention strategies for GPs and FPs in Singapore provide important insight into the challenges and the solutions as seen by the members of the profession themselves. This information can guide future policy and decision making in this area.

Incorporating the interaction between health and work into the undergraduate medical curriculum - a qualitative evaluation of a teaching pilot in English medical schools.

Introduction: There is a growing recognition of the impact of work on health both positive and negative. It is important that all health care professionals are equipped to understand the effects of work and worklessness on health and help patients remain in work or manage a healthy return to work where appropriate. Despite explicit reference to health and work in the General Medical Council's Outcomes for Graduates, currently, this is not a theme that is integrated across the undergraduate medical curricula.Aim: This study evaluates medical tutors' and undergraduates' perspectives of a selection of health and work topics in a teaching pilot to consider the suitability and appropriateness for delivery, integration into the curriculum, tailoring of the resources, and appropriateness and expected attainment of learning objectives.Methods: Qualitative, semi-structured interviews and focus groups were carried out with five medical tutors and 36 undergraduates. Interviews and focus groups were recorded, transcribed and thematically analysed.Results: Medical tutors and undergraduates identified suitability of appropriate subject specialities and years of teaching, whether learning objectives were important and if these had been achieved, and recommendations for future delivery.Discussion: Medical tutors were committed to delivering the health and work topics with the flexibility of tailoring the resources to existing subject specialities and with respect to the year of study. Learning objectives were perceived appropriate by tutors, despite ambivalence about their importance from some undergraduates. Resources were identified as having relevance to public health undergraduate teaching and during general practice placements.

A pay for performance scheme in primary care: Meta-synthesis of qualitative studies on the provider experiences of the quality and outcomes framework in the UK.

BACKGROUND: The Quality and Outcomes Framework (QOF) is an incentive scheme for general practice, which was introduced across the UK in 2004. The Quality and Outcomes Framework is one of the biggest pay for performance (P4P) scheme in the world, worth £691 million in 2016/17. We now know that P4P is good at driving some kinds of improvement but not others. In some areas, it also generated moral controversy, which in turn created conflicts of interest for providers. We aimed to undertake a meta-synthesis of 18 qualitative studies of the QOF to identify themes on the impact of the QOF on individual practitioners and other staff. METHODS: We searched 5 electronic databases, Medline, Embase, Healthstar, CINAHL and Web of Science, for qualitative studies of the QOF from the providers' perspective in primary care, published in UK between 2004 and 2018. Data was analysed using the Schwartz Value Theory as a theoretical framework to analyse the published papers through the conceptual lens of Professionalism. A line of argument synthesis was undertaken to express the synthesis. RESULTS: We included 18 qualitative studies that where on the providers' perspective. Four themes were identified; 1) Loss of autonomy, control and ownership; 2) Incentivised conformity; 3) Continuity of care, holism and the caring role of practitioners' in primary care; and 4) Structural and organisational changes. Our synthesis found, the Values that were enhanced by the QOF were power, achievement, conformity, security, and tradition. The findings indicated that P4P schemes should aim to support Values such as benevolence, self-direction, stimulation, hedonism and universalism, which professionals ranked highly and have shown to have positive implications for Professionalism and efficiency of health systems. CONCLUSIONS: Understanding how practitioners experience the complexities of P4P is crucial to designing and delivering schemes to enhance and not compromise the values of professionals. Future P4P schemes should aim to permit professionals with competing high priority values to be part of P4P or other quality improvement initiatives and for them to take on an 'influencer role' rather than being 'responsive agents'. Through understanding the underlying Values and not just explicit concerns of professionals, may ensure higher levels of acceptance and enduring success for P4P schemes.

Bridging the discursive gap between lay and medical discourse in care coordination.

For older people with multiple chronic co-morbidities, strategies to coordinate care depend heavily on information exchange. We analyse the information-sharing difficulties arising from differences between patients' oral narratives and medical sense-making; and whether a modified form of 'narrative medicine' might mitigate them. We systematically compared 66 general practice patients' own narratives of their health problems and care with the contents of their clinical records. Data were collected in England during 2012-13. Patients' narratives differed from the accounts in their medical record, especially the summary, regarding mobility, falls, mental health, physical frailty and its consequences for accessing care. Parts of patients' viewpoints were never formally encoded, parts were lost when clinicians de-coded it, parts supplemented, and sometimes the whole narrative was re-framed. These discrepancies appeared to restrict the patient record's utility even for GPs for the purposes of risk stratification, case management, knowing what other care-givers were doing, and coordinating care. The findings suggest combining the encoding/decoding theory of communication with inter-subjectivity and intentionality theories as sequential, complementary elements of an explanation of how patients communicate with clinicians. A revised form of narrative medicine might mitigate the discursive gap and its consequences for care coordination.

Leadership for health commissioning in the new NHS.

PURPOSE: The purpose of this paper is to explore the early experiences of those involved with the development of Clinical Commissioning Groups (CCGs), examining how the aspiration towards a "clinically-led" system is being realised. The authors investigate emerging leadership approaches within CCGs in light of the criterion for authorisation that calls for "great leaders". DESIGN/METHODOLOGY/APPROACH: Qualitative research was carried out in eight case studies (CCGs) across England over a nine-month period (September 2011 to May 2012) when CCGs were in their early development. The authors conducted a mix of interviews (with GPs and managers), observations (at CCG meetings) and examined associated documentation. Data were thematically analysed. FINDINGS: The authors found evidence of two identified approaches to leadership - positive deviancy and responsible guardianship - being undertaken by GPs and managers in the developing CCGs. Historical experiences and past ways of working appeared to be influencing current developments and a commonly emerging theme was a desire for the CCG to "do things differently" to the previous commissioning bodies. The authors discuss how the current reorganisation threatens the guardianship approach to leadership and question if the new systems being implemented to monitor CCGs' performance may make it difficult for CCGs to retain creativity and innovation, and thus the ability to foster the positive deviant approach to leadership. ORIGINALITY/VALUE: This is a large scale piece of qualitative research carried out as CCGs were beginning to develop. It provides insight into how leadership is developing in CCGs highlighting the complexity involved in these roles.

The use of financial incentives to help improve health outcomes: is the quality and outcomes framework fit for purpose? A systematic review.

BACKGROUND: The quality and outcomes framework (QOF) is one of the world's largest pay-for-performance schemes, rewarding general practitioners for the quality of care they provide. This review examines the evidence on the efficacy of the scheme for improving health outcomes, its impact on non-incentivized activities and the robustness of the clinical targets adopted in the scheme. METHODS: The review was conducted using six electronic databases, six sources of grey literature and bibliography searches from relevant publications. Studies were identified using a comprehensive search strategy based on MeSH terms and keyword searches. A total of 21,543 references were identified of which 32 met the eligibility criteria with 11 studies selected for the review. RESULTS: Findings provide strong evidence that the QOF initially improved health outcomes for a limited number of conditions but subsequently fell to the pre-existing trend. There was limited impact on non-incentivized activities with adverse effects for some sub-population groups. CONCLUSION: The QOF has limited impact on improving health outcomes due to its focus on process-based indicators and the indicators' ceiling thresholds. Further research is required to strengthen the quality of evidence available on the QOF's impact on population health to ensure that the incentive scheme is both clinically and cost-effective.

Water fluoridation: a critical review of the physiological effects of ingested fluoride as a public health intervention.

Fluorine is the world's 13th most abundant element and constitutes 0.08% of the Earth crust. It has the highest electronegativity of all elements. Fluoride is widely distributed in the environment, occurring in the air, soils, rocks, and water. Although fluoride is used industrially in a fluorine compound, the manufacture of ceramics, pesticides, aerosol propellants, refrigerants, glassware, and Teflon cookware, it is a generally unwanted byproduct of aluminium, fertilizer, and iron ore manufacture. The medicinal use of fluorides for the prevention of dental caries began in January 1945 when community water supplies in Grand Rapids, United States, were fluoridated to a level of 1 ppm as a dental caries prevention measure. However, water fluoridation remains a controversial public health measure. This paper reviews the human health effects of fluoride. The authors conclude that available evidence suggests that fluoride has a potential to cause major adverse human health problems, while having only a modest dental caries prevention effect. As part of efforts to reduce hazardous fluoride ingestion, the practice of artificial water fluoridation should be reconsidered globally, while industrial safety measures need to be tightened in order to reduce unethical discharge of fluoride compounds into the environment. Public health approaches for global dental caries reduction that do not involve systemic ingestion of fluoride are urgently needed.

Does a free maternity policy in Kenya work? Impact and cost-benefit consideration based on demographic health survey data.

This paper evaluates the overall effect of the Kenyan free maternity policy (FMP) on the main outcomes (early neonatal and neonatal deaths) and intermediate outcomes (delivery through Caesarean Section (CS), skilled birth attendance (SBA), birth in a public hospital and low birth weight (LBW)) using the 2014 Demographic Health Survey. We applied the difference-in-difference (DID) approach to compare births (to the same mothers) happening before and after the start of the policy (June 2013) and a limited cost-benefit analysis (CBA) to assess the net social benefit of the FMP. The probabilities of birth resulting in early neonatal and neonatal mortality are significantly reduced by 17-21% and 19-20%, respectively, after the FMP introduction. The probability of birth happening through CS reduced by 1.7% after implementing the FMP, while that of LBW birth is increased by 3.7% though not statistically significant. SBA and birth in a public facility did not moderate the policy's effects on early neonatal mortality, neonatal mortality, and delivery through CS. They were not significant determinants of the policy effects on the outcomes. There is a significant causal impact of the FMP in reducing the probability of early neonatal and neonatal mortality, but not the delivery through CS. The FMP cost-to-benefit ratio was 21.22, and there were on average 4015 fewer neonatal deaths in 2013/2014 due to the FMP. The net benefits are higher than the costs; thus, there is a need to expand and sustainably fund the FMP to avert more neonatal deaths potentially.

Examining the quality of care across the continuum of maternal care (antenatal, perinatal and postnatal care) under the expanded free maternity policy (Linda Mama Policy) in Kenya: a mixed-methods study.

BACKGROUND: Kenya still faces the challenge of mothers and neonates dying from preventable pregnancy-related complications. The free maternity policy (FMP), implemented in 2013 and expanded in 2017 (Linda Mama Policy (LMP)), sought to address this challenge. This study examines the quality of care (QoC) across the continuum of maternal care under the LMP in Kenya. METHODS: We conducted a convergent parallel mixed-methods study across multiple levels of the Kenyan health system, involving key informant interviews with national stakeholders (n=15), in-depth interviews with county officials and healthcare workers (HCWs) (n=21), exit interview survey with mothers (n=553) who utilised the LMP delivery services, and focus group discussions (n=9) with mothers who returned for postnatal visits (at 6, 10 and 14 weeks). Quantitative data were analysed descriptively, while qualitative data were analysed thematically. All the data were triangulated at the analysis and discussion stage using a framework approach guided by the QoC for maternal and newborns. RESULTS: The results showed that the expanded FMP enhanced maternal care access: geographical, financial and service utilisation. However, the facilities and HCWs bore the brunt of the increased workload and burnout. There was a longer waiting time for the initial visit by the pregnant women because of the enhanced antenatal care package of the LMP. The availability and standards of equipment, supplies and infrastructure still posed challenges. Nurses were multitasking and motivated despite the human resources challenge. Mothers were happy to have received care information; however, there were challenges regarding respect and dignity they received (inadequate food, over-crowding, bed-sharing and lack of privacy), and they experienced physical, verbal and emotional abuse and a lack of attention/care. CONCLUSIONS: Addressing the negative aspects of QoC while strengthening the positives is necessary to achieve the Universal Health Coverage goals through better quality service for every woman.

The effect of general practice team composition and climate on staff and patient experiences: a systematic review.

BACKGROUND: Recent policy initiatives seeking to address the workforce crisis in general practice have promoted greater multidisciplinarity. Evidence is lacking on how changes in staffing and the relational climate in practice teams affect the experiences of staff and patients. AIM: To synthesise evidence on how the composition of the practice workforce and team climate affect staff job satisfaction and burnout, and the processes and quality of care for patients. DESIGN & SETTING: A systematic literature review of international evidence. METHOD: Four different searches were carried out using MEDLINE, Embase, Cochrane Library, CINAHL, PsycINFO, and Web of Science. Evidence from English language articles from 2012-2022 was identified, with no restriction on study design. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and data were synthesised thematically. RESULTS: In total, 11 studies in primary healthcare settings were included, 10 from US integrated healthcare systems, one from Canada. Findings indicated that when teams are understaffed and work environments are stressful, patient care and staff wellbeing suffer. However, a good relational climate can buffer against burnout and protect patient care quality in situations of high workload. Good team dynamics and stable team membership are important for patient care coordination and job satisfaction. Female physicians are at greater risk of burnout. CONCLUSION: Evidence regarding team composition and team climate in relation to staff and patient outcomes in general practice remains limited. Challenges exist when drawing conclusions across different team compositions and definitions of team climate. Further research is needed to explore the conditions that generate a 'good' climate.

Is It Time to Explore the Health Policy Process Within Governance and Health Systems Frameworks? Comment on "Modelling the Health Policy Process: One Size Fits All or Horses for Courses?"

There is clearly a need to improve the use of more robust policy theory on health policy analysis. Powell and Mannion in an editorial on the relationship between health policy analysis and the wider field of public policy theory note, as others have done before, the limited application of policy theory in health policy analysis. However, they also highlight that within the health policy analysis arena new models have emerged which have wider use within policy analysis such as the health policy triangle. While Powell and Mannion suggest that health policy analysis can take one of two paths I argue that we should be developing more integrated frameworks of health policy processes, governance and systems which would involve the use of robust public policy theories and models.

Exploring the Adaptations of the Free Maternity Policy Implementation by Health Workers and County Officials in Kenya.

BACKGROUND: In 2017, Kenya launched the free maternity policy (FMP) that aimed to provide all pregnant women access to maternal services in private, faith-based, and levels 3-6 public institutions. We explored the adaptive strategies health care workers (HCWs) and county officials used to bridge the implementation challenges and achieve the FMP objectives. METHODS: We conducted an exploratory qualitative study using Lipsky's theoretical framework in 3 facilities (levels 3, 4, and 5) in Kiambu County, Kenya. The study involved in-depth interviews (n=21) with county officials, facility in-charges and HCWs, and key informants from national and development partner agencies. Data were audio-recorded, transcribed, and analyzed using a framework thematic approach. RESULTS: The results show that HCWs and county officials applied several strategies that were critical in shaping the policymaking, working practice, and professionalism and ethical aspects of the FMP. Strategies of policymaking: hospitals employed additional staff, and the county developed bylaws to strengthen the flow of funds. Strategies of working practice: hospitals and HCWs enhanced patient referrals, and facilities enhanced communication. Strategies of professionalism and ethics: nurses registered and provided service to mothers, and facilities included employees in planning and budgeting. Maladaptations included facilities having leeway to provide FMP services to populations who were excluded from the policy but had to bear the costs. Some discharged mothers immediately after birth, even before offering the fully costed policy benefits, to avoid incurring additional costs. CONCLUSIONS: The role of policy implementers and the built-in flexibility and agility in implementing the FMP could enhance service delivery, manage the administrative pressures of implementation, and provide mothers with personalized, responsive service. However, despite their benefits, some resulting unintended consequences may need interventions.

Research engagement and research capacity building: a priority for healthcare organisations in the UK.

PURPOSE: To research involvement of healthcare staff in the UK and identify practical organisational and policy solutions to improve and boost capacity of the existing workforce to conduct research. DESIGN/METHODOLOGY/APPROACH: A mixed-method study presenting three work packages here: secondary analysis of levels of staff research activity, funding, academic outputs and workforce among healthcare organisations in the United Kingdom; 39 Research and Development lead and funder interviews; an online survey of 11 healthcare organisations across the UK, with 1,016 responses from healthcare staff included for analysis; and 51 interviews of healthcare staff in different roles from six UK healthcare organisations. FINDINGS: Interest in research involvement is strong and widespread but hampered by a lack of systematic organisational support despite national policies and strategies to increase staff engagement in research. While useful, these external strategies have limited universal success due to lack of organisational support. Healthcare organisations should embed research within organisational and human resources policies and increase the visibility of research through strategic organisational goals and governance processes. A systems-based approach is needed. RESEARCH LIMITATIONS/IMPLICATIONS: The research gathered data from a limited number of NHS trusts but these were purposively sampled to provide a range of different acute/community health service organisations in different areas. But data was therefore more detailed and nuanced due to a more in-depth approach. PRACTICAL IMPLICATIONS: The findings are relevant for developing policies and practice within healthcare organisations to support research engagement. The findings also set out key policy and strategic recommendations that will support greater research engagement. SOCIAL IMPLICATIONS: Increased research activity and engagement in healthcare providers improves healthcare outcomes for patients. ORIGINALITY/VALUE: This is a large scale (UK-wide) study involving a broad range of healthcare staff, with good engagement of nurses, midwives and Allied Healthcare Professionals who have not been previously achieved. This allowed valuable analysis of under-researched groups and comparisons by professional groups. The findings highlight the need for tailored action to embed research reporting, skills, professional development and infrastructure into organisational policies, strategies and systems, along with broader system-wide development.

The effect of becoming a Fistula Advocate on the recovery of women with Obstetric Fistula in Sierra Leone: A qualitative study.

Engaging women affected by Obstetric Fistula as advocates has been proposed as an effective strategy to raise awareness of the condition. Limited literature exists on the experience of those who become advocates. A model of community education, in Sierra Leone, trained women affected by Obstetric Fistula to become volunteer Fistula Advocates. This study explored Advocates' perception of their role and its influence on their recovery and reintegration. This was a qualitative study, undertaken in Sierra Leone, collecting data from 7 Fistula Advocates and 3 Key Informants (with roles in either clinical or outreach care for women with Obstetric Fistula or training and supervision of Advocates), using semi-structured interviews. Data was subject to a thematic analysis and related to a conceptual framework for mental health recovery. Intrinsic factors motivating Advocates to undertake this role were influenced by psycho-social support received and the possibility for financial independence. Advocates used personal stories in their work to define a new identity, change perceptions and reduce stigma. Benefits associated with the interactions and relationships created through providing and receiving peer support were voiced. Surgical treatment was described as an important factor influencing recovery. The Advocates said economic empowerment helped recovery and reintegration, and the voluntary nature of the Advocate role limited the impact of this. Overall Advocates perceived their role positively, reporting psychological, social, and economic benefits. The complexities of recovery from Obstetric Fistula were highlighted and connections drawn between the treatment of physical symptoms, the socio-cultural context and mental health recovery. They described the role positively influencing existing relationships and initiating supportive, empowering social interactions between women affected by Obstetric Fistula and with Non-Governmental Organisation staff and community members. The study offers insights into the potential for community-based approaches to facilitate access to treatment for sensitive and stigmatising health problems and support recovery.

A qualitative study of HIV testing and referral practices of private hospital doctors treating patients with TB in Chennai, India.

OBJECTIVE: In India, 50%-80% of patients with tuberculosis (TB) seek private care. This study set out to explore HIV testing and referral practices of private hospital doctors treating patients with TB. METHODS: Interviews were conducted with private hospital doctors (n = 15). Interviews covered HIV testing, linking HIV-positive patients with TB to HIV care, and coordination of care for co-infected patients. RESULTS: Doctors did not routinely refer patients with TB to government HIV testing facilities as per national policy guidance. If deemed appropriate, then testing was conducted privately. Testing was more common when a facility guideline mandated testing or a public-private initiative for TB management was in place. Otherwise, testing was based on doctors' judgement. Patients accustomed to private care who could not afford treatment were reportedly reluctant to shift to public facilities. A lack of communication between public and private doctors was found to undermine co-management. CONCLUSIONS: In this sample, private provider practices were influenced by both the social and the health systems contexts in which they operated. An understanding of patient perceptions of HIV, private doctors concerns for retaining patients, and the contrasting philosophies of private medicine versus public health objectives was found to be critical to explain HIV testing and referral behaviours. The government has proposed to scale up HIV testing and treatment among patients with TB, yet operationalising this will require engagement with the realities of a large, diverse private sector. It will also require considering what role government policies can have on shaping private practice and how to potentially integrate public and private care.

Now we need a framework for action.

Over the past decade, there has been growing policy interest in the role of primary care within the Canadian health system, with the recognition that it has not been fully integrated and that its full potential has not been developed. The framework of Kates et al. starts to address some key organizational issues, by placing the patient, family and community at the centre of the healthcare system and by combining the Institute for Healthcare Improvement's Triple Aim approach with the Institute of Medicine's six improvement aims. What this framework does not do is provide a model of how to organize or deliver primary care or demonstrate how policy makers and those responsible for designing the healthcare system should structure organizational models, payment systems or accountability structures. Kates et al. have provided a useful first step. We now require a commitment to act.

General practitioners' views on retaining Singapore's primary care doctors: a cross-sectional survey and qualitative analysis.

BACKGROUND: To support its ageing population and the increasing need for chronic care in the community, Singapore needs to boost the number of doctors in its primary care workforce. To better understand how to improve doctor retention and build a more robust primary care system, we conducted a cross-sectional survey with doctors in general practice and family medicine to explore their career satisfaction, their career plans, factors related to their plans to leave, and their view on retaining GPs in primary care. METHODS: An anonymous online survey was distributed to general practitioners working in the public and private sectors. The survey contained questions on career satisfaction, career plans in the next 5 years, and factors important for retaining doctors in primary care. In addition, there were open-ended questions for respondents to elaborate on retention initiatives and other factors that may improve engagement among primary care doctors. Quantitative data was analyzed with descriptive statistics, principal component analysis, χ2 tests, t-tests, and Pearson's correlations; qualitative data was analyzed thematically. RESULTS: The survey was attempted by 355 general practitioners and completed in full by 303. The respondents were most satisfied with rapport with patients and their current professional role; they were least satisfied with the amount of paperwork and the status of general practice in society. In terms of their career plans in the next 5 years, 49/341 (14.4%) of the respondents plan to leave general practice permanently, 43/341 (12.6%) plan to take a career break, and 175/341 (51.3%) plan to reduce their clinical hours. Higher remuneration, recognizing general practice and family medicine as a medical specialty, and reducing the litigious pressures on medical practice were rated as the most important factors for retaining primary care. Free-text responses also revealed a growing dissatisfaction with the Third-Party Administrators that manage insurance arrangements. CONCLUSION: While the proportion of doctors who intend to leave is smaller than that reported in overseas studies, our findings highlight an urgent need for targeted interventions to engage and retain primary care doctors. Increasing recognition and support for general practitioners and their professional practice may contribute to strengthening community care for the ageing population.