The hidden work of general practitioners: An ethnography.

High quality primary care is a foundational element of effective health services. Internationally, primary care physicians (general practitioners (GPs), family doctors) are experiencing significant workload pressures. How non-patient-facing work contributes to these pressures and what constitutes this work is poorly understood and often unrecognised and undervalued by patients, policy makers, and even clinicians engaged in it. This paper examines non-patient-facing work ethnographically, informed by practice theory, the Listening Guide, and empirical ethics. Ethnographic observations (104 h), in-depth interviews (n = 16; 8 with GPs and 8 with other primary care staff) and reflexive workshops were conducted in two general practices in England. Our analysis shows that 'hidden work' was integral to direct patient care, involving diverse clinical practices such as: interpreting test results; crafting referrals; and accepting interruptions from clinical colleagues. We suggest the term 'hidden care work' more accurately reflects the care-ful nature of this work, which was laden with ambiguity and clinical uncertainty. Completing hidden care work outside of expected working hours was normalised, creating feelings of inefficiency, and exacerbating workload pressure. Pushing tasks forward into an imagined future (when conditions might allow its completion) commonly led to overspill into GPs' own time. GPs experienced tension between their desire to provide safe, continuous, 'caring' care and the desire to work a manageable day, in a context of increasing demand and burgeoning complexity.

Trends in full-time working in general practice: repeated cross-sectional study.

BACKGROUND: There is little evidence and no agreement on what constitutes full-time working for general practitioners (GPs). This is essential for workforce planning, resource allocation and accurately describing GP activity. AIM: To clarify the definition of full-time working for general practitioners, how this has changed over time and whether these changes are explained by GP demographics. DESIGN AND SETTING: Repeated cross-sectional national surveys between 2010 and 2021. METHOD: Comparison of three measures of working time commitments (hours and sessions per week and hours per session) plus a measure of workload intensity across survey years. Multiple regression to adjust the changes over time for age, sex, ethnicity, contract type, area deprivation, and rurality. Unadjusted hours and sessions per week were compared to definitions of full-time working. RESULTS: Average hours and sessions per week reduced from 40.5 (95% CI: 38.5, 42.5) to 38.0 (36.3, 39.6) and 7.3 (7.2, 7.3) to 6.2 (6.2, 6.3) respectively between 2010 and 2021. In 2021, 54.6% of GPs worked at least 37.5 hours per week and 9.5% worked at least 9 sessions. Hours per session increased from 5.7 (5.7, 5.7) to 6.2 (6.2, 6.3) between 2010 and 2021. Partners worked more hours, sessions and hours per session. Adjustments increased the increase in hours per session from 0.54 to 0.61. CONCLUSION: At the current average duration of sessions, six sessions per week aligns with the NHS definition of full-time hours. However, hours per week is a more consistent way to define full-time work for GPs.

The patient experience of skill mix changes in primary care: an in-depth study of patient 'work' when accessing primary care.

BACKGROUND: This paper presents insights into patient experiences of changes in workforce composition due to increasing deployment in general practice of practitioners from a number of different professional disciplines (skill mix). We explore these experiences via the concept of 'patient illness work'; how a patient's capacity for action is linked to the work arising from healthcare. METHODS: We conducted four focus group interviews with Patient Participation Group members across participating English general practitioner practices. Thematic analysis and a theoretical lens of illness work were used to explore patients' attempts to understand and navigate new structures, roles and ways to access healthcare. RESULTS: Participants' lack of knowledge about incoming practitioners constrained their agency in accessing primary care. They reported both increased and burdensome illness work as they were given responsibility for navigating and understanding new systems of access while simultaneously understanding new practitioner roles. CONCLUSIONS: While skill mix changes were not resisted by patients, they were keen to improve their agency in capacity to access, by being better informed about newer practitioners to accept and trust them. Some patients require support to navigate change, especially where new systems demand specific capacities such as technological skills and adaptation to unfamiliar practitioners.

Predictors and population health outcomes of persistent high GP turnover in English general practices: a retrospective observational study.

OBJECTIVE: English primary care faces significant challenges, including 'persistent high turnover' of general practitioners (GPs) in some partnerships. It is unknown whether there are specific predictors of persistent high turnover and whether it is associated with poorer population health outcomes. DESIGN: A retrospective observational study. METHODS: We linked workforce data on individual GPs to practice-level data from Hospital Episode Statistics and the GP Patient Survey (2007-2019). We classified practices as experiencing persistent high turnover if more than 10% of GPs changed in at least 3 consecutive years. We used multivariable logistic or linear regression models for panel data with random effects to identify practice characteristics that predicted persistent high turnover and associations of practice outcomes (higher emergency hospital use and patient experience of continuity of care, access to care and overall patient satisfaction) with persistent high turnover. RESULTS: Each year, 6% of English practices experienced persistent high turnover, with a maximum of 9% (688/7619) in 2014. Larger practices, in more deprived areas and with a higher morbidity burden were more likely to experience persistent high turnover. Persistent high turnover was associated with 1.8 (95% CI 1.5 to 2.1) more emergency hospital attendances per 100 patients, 0.1 (95% CI 0.1 to 0.2) more admissions per 100 patients, 5.2% (95% CI -5.6% to -4.9%) fewer people seeing their preferred doctor, 10.6% (95% CI-11.4% to -9.8%) fewer people reporting obtaining an appointment on the same day and 1.3% (95% CI -1.6% to -1.1%) lower overall satisfaction with the practice. CONCLUSIONS: Persistent high turnover is independently linked to indicators of poorer service and health outcomes. Although causality needs to be further investigated, strategies and policies may be needed to both reduce high turnover and support practices facing challenges with high GP turnover when it occurs.

General practice managers' motivations for skill mix change in primary care: Results from a cross-sectional survey in England.

OBJECTIVES: The objectives are to determine the factors that motivated GP practice managers in England to employ non-medical roles, and to identify an ideal hypothetical GP practice workforce. METHODS: Cross-sectional survey of GP practice managers in England (n = 1205). The survey focused on six non-medical roles: advanced nurse practitioner, specialist nurse, health care assistant, physician associate, paramedic and pharmacist. RESULTS: The three most commonly selected motivating factors were: (i) to achieve a better match between what patients need and what the practitioner team can deliver; (ii) to increase overall appointment availability and (iii) to release GP time. Employment of pharmacists and physician associates was most commonly supported by additional funding. Practice managers preferred accessing new non-medical roles through a primary care network or similar, while there was a clear preference for direct employment of additional GPs, advanced nurse practitioners or practice nurses. The ideal practice workforce would comprise over 70% of GPs and nurses, containing, on average, fewer GPs than the current GP practice workforce. CONCLUSION: This study confirms that more diverse teams of practitioners are playing an increasing role in providing primary care in England. Managers prefer not to employ all new roles directly within the practice. A more detailed investigation of future workforce requirements is necessary to ensure that health policy supports the funding (whether practice or population based), recruitment, training, deployment and workloads associated with the mix of roles needed in an effective primary care workforce.

Investigating the links between diagnostic uncertainty, emotional exhaustion, and turnover intention in General Practitioners working in the United Kingdom.

Background: General Practitioners (GPs) report high levels of burnout, job dissatisfaction, and turnover intention. The complexity of presenting problems to general practice makes diagnostic uncertainty a common occurrence that has been linked to burnout. The interrelationship between diagnostic uncertainty with other factors such as burnout, job satisfaction and turnover intention have not been previously examined. Objectives: To examine associations between diagnostic uncertainty, emotional exhaustion (EE), depersonalization (DP), job satisfaction, and turnover intention in GPs. Methods: Seventy general practices in England were randomly selected through the Oxford-Royal College of General Practitioners Research and Surveillance Centre (RCGP-RSC). A total of 348 GPs within 67 these practices completed a 10-item online questionnaire which included questions on GP characteristics, work-life balance, job satisfaction, sickness presenteeism, diagnostic uncertainty, turnover intention as well as EE and DP. Associations between diagnostic uncertainty and each of EE, DP, job satisfaction, and turnover intention were evaluated in multivariate mixed-effect ordinal logistic regressions whilst adjusting for covariates, to account for the correlation in the three outcomes of interest. Results: Almost one-third of GPs (n = 101; 29%) reported experiencing >10% of diagnostic uncertainty in their day-to-day practice over the past year. GPs reporting greater diagnostic uncertainty had higher levels of EE [OR = 3.90; 95% CI = (2.54, 5.99)], job dissatisfaction [OR = 2.01; 95% CI = (1.30, 3.13)] and turnover intention [OR = 4.51; 95% CI = (2.86, 7.11)]. GPs with no sickness presenteeism had lower levels of EE [OR = 0.53; 95% CI = (0.35, 0.82)], job dissatisfaction [OR = 0.56; 95% CI = (0.35, 0.88)], and turnover intention [OR = 0.61; 95% CI = (0.41, 0.91)]. Conclusion: Diagnostic uncertainty may not only negatively impact on the wellbeing of GPs, but could also have adverse implications on workforce retention in primary care.

Skill-mix change and outcomes in primary care: Longitudinal analysis of general practices in England 2015-2019.

BACKGROUND: Increasing the employment of staff with new clinical roles in primary care has been proposed as a solution to the shortages of GPs and nurses. However, evidence of the impacts this has on practice outcomes is limited. We examine how outcomes changed following changes in skill-mix in general practices in England. METHODS: We obtained annual data on staff in 6,296 English general practices between 2015 and 2019 and grouped professionals into four categories: GPs, Nurses, Health Professionals, and Healthcare Associate Professionals. We linked 10 indicators of quality of care covering the dimensions of accessibility, clinical effectiveness, user experiences and health system costs. We used both fixed-effect and first-differences regressions to model changes in staff composition and outcomes, adjusting for practice and population factors. RESULTS: Employment increased over time for all four staff groups, with largest increases for Healthcare Professionals (from 0.04 FTE per practice in 2015 to 0.28 in 2019) and smallest for Nurses who experienced a 3.5 percent growth. Increases in numbers of GPs and Nurses were positively associated with changes in practice activity and outcomes. The introduction of new roles was negatively associated with patient satisfaction: a one FTE increase in Health Professionals was associated with decreases of 0.126 [-0.175, -0.078] and 0.116 [-0.161, -0.071] standard deviations in overall patient satisfaction and satisfaction with making an appointment. Pharmacists improved medicine prescribing outcomes. All staff categories were associated with higher health system costs. There was little evidence of direct complementarity or substitution between different staff groups. CONCLUSIONS: Introduction of new roles to support GPs does not have straightforward effects on quality or patient satisfaction. Problems can arise from the complex adaptation required to adjust practice organisation and from the novelty of these roles to patients. These findings suggest caution over the implementation of policies encouraging more employment of different professionals in primary care.

Processes supporting effective skill-mix implementation in general practice: A qualitative study.

OBJECTIVES: Health policy and funding initiatives have addressed increasing workloads in general practice through the deployment of clinicians from different disciplinary backgrounds. This study examines how general practices in England operate with increasingly diverse groups of practitioners. METHODS: Five general practices were selected for maximum variation of the duration and diversity of skill-mix in their workforce. Individual interviews were recorded with management and administrative staff and different types of practitioner. Patient surveys and focus groups gathered patients' perspectives of consulting with different practitioners. Researchers collaborated during coding and thematic analysis of transcripts of audio recordings. RESULTS: The introduction of a wide range of practitioners required significant changes in how practices dealt with patients requesting treatment, and these changes were not necessarily straightforward. The matching of patients with practitioners required effective categorization of health care patients' reported problem(s) and an understanding of practitioners' capabilities. We identified individual and organizational responses that could minimize the impact on patients, practitioners and practices of imperfections in the matching process. CONCLUSIONS: The processes underpinning the redistribution of tasks from GPs to non-GP practitioners are complex. As practitioner employment under the Primary Care Network contracts continues to increase, it is not clear how the necessarily fine-grained adjustments will be made for practitioners working across multiple practices.

Primary care workforce composition and population, professional, and system outcomes: a retrospective cross-sectional analysis.

BACKGROUND: The diversification of types of staff delivering primary care may affect professional, population, and system outcomes. AIM: To estimate associations between workforce composition and outcomes. DESIGN AND SETTING: Cross-sectional analysis of 6210 GP practices from a range of geographical settings across England in 2019. METHOD: A multivariable regression analysis was undertaken, relating numbers of staff in four groups - GPs, nurses, healthcare professionals, and health associate professionals - to patient access and satisfaction, quality of clinical care and prescribing, use of hospital services, GP working conditions (subsample of practices), and costs to the NHS. Data were obtained from the GP Patient Survey 2019, Quality and Outcomes Framework, prescribing data, the Hospital Episode Statistics database, the NHS Payments to General Practice 2019/2020, and the Tenth National GP Worklife Survey 2019. RESULTS: Having additional GPs was associated with higher levels of satisfaction for the GPs themselves and for patients, whereas additional staff of other types had opposite associations with these outcomes. Having additional nurses and health associate professionals was associated with lower costs per prescription but more prescribing activity than having additional staff from the other two groups. Having more GPs was associated with higher costs per prescription and lower use of narrow-spectrum antibiotics compared with the other staff groups. Except for health associate professionals, greater staff numbers were associated with more hospital activity. CONCLUSION: Professional, population, and system outcomes showed a variety of associations with primary care workforce composition. Having additional nurses was associated with lower quality in some aspects, and higher costs and activity. The association between additional healthcare professionals or health associate professionals and higher costs was less than that for additional GPs, but was also linked to lower patient and GP satisfaction.

Consultation patterns and frequent attenders in UK primary care from 2000 to 2019: a retrospective cohort analysis of consultation events across 845 general practices.

OBJECTIVE: To describe the distribution of consultations at the practice level and examine whether increases are uniform or driven by people who consult more frequently. DESIGN: Retrospective cohort study. SETTING: UK general practice data from the Clinical Practice Research Datalink (CPRD) GOLD database. PARTICIPANTS: 1 699 709 314 consultation events from 12 330 545 patients, in 845 general practices (1 April 2000 to 31 March 2019). METHODS: Consultation information was aggregated by financial year into: all consultations/all staff; all consultations/general practitioners (GPs); face-to-face consultations/all staff; face-to-face consultations/GPs. Patients with a number of consultations above the 90th centile, within each year, were classified as frequent attenders. Negative binomial regressions examined the association between available practice characteristics and consultation distribution. RESULTS: Among frequent attenders, all consultations by GPs increased from a median (25th and 75th centile) of 13 (10 and 16) to 21 (18 and 25) and all consultations by all staff increased from 27 (23-30) to 60 (51-69) over the study period. Approximately four out of ten consultations of any type concerned frequent attenders and the proportion of consultations attributed to them increased over time, particularly for face-to-face consultations with GPs, from a median of 38.0% (35.9%-40.3%) in 2000-2001 to 43.0% (40.6%-46.4%) in 2018-2019. Regression analyses indicated decreasing trends over time for face-to-face consultations and increasing trends for all consultation types, for both GPs and all staff. Frequent attenders consulted approximately five times more than the rest of the practice population, on average, with adjusted incidence rate ratios ranging between 4.992 (95% CI 4.917 to 5.068) for face-to-face consultations with all staff and 5.603 (95% CI 5.560 to 5.647) for all consultations with GPs. CONCLUSIONS: Frequent attenders progressively contributed to increased workload in general practices across the UK from 2000 to 2019. Important knowledge gaps remain in terms of the demographic, social and health characteristics of frequent attenders and how UK general practices can be prepared to meet the needs of these patients.

Rates of turnover among general practitioners: a retrospective study of all English general practices between 2007 and 2019.

OBJECTIVE: To quantify general practitioners' (GPs') turnover in England between 2007 and 2019, describe trends over time, regional differences and associations with social deprivation or other practice characteristics. DESIGN: A retrospective study of annual cross-sectional data. SETTING: All general practices in England (8085 in 2007, 6598 in 2019). METHODS: We calculated turnover rates, defined as the proportion of GPs leaving a practice. Rates and their median, 25th and 75th percentiles were calculated by year and region. The proportion of practices with persistent high turnover (>10%) over consecutive years were also calculated. A negative binomial regression model assessed the association between turnover and social deprivation or other practice characteristics. RESULTS: Turnover rates increased over time. The 75th percentile in 2009 was 11%, but increased to 14% in 2019. The highest turnover rate was observed in 2013-2014, corresponding to the 75th percentile of 18.2%. Over time, regions experienced increases in turnover rates, although it varied across English regions. The proportion of practices with high (10% to 40%) turnover within a year almost doubled from 14% in 2009 to 27% in 2019. A rise in the number of practices with persistent high turnover (>10%) for at least three consecutive years was also observed, from 2.7% (2.3%-3.1%) in 2007 to 6.3% (5.7%-6.9%) in 2017. The statistical analyses revealed that practice-area deprivation was moderately associated with turnover rate, with practices in the most deprived area having higher turnover rates compared with practices in the least deprived areas (incidence rate ratios 1.09; 95% CI 1.06 to 1.13). CONCLUSIONS: GP turnover has increased in the last decade nationally, with regional variability. Greater attention to GP turnover is needed, in the most deprived areas in particular, where GPs often need to deal with more complex health needs. There is a large cost associated with GP turnover and practices with very high persistent turnover need to be further researched, and the causes behind this identified, to allow support strategies and policies to be developed.

Determinants of primary care workforce variation in England.

BACKGROUND: The General Practice Forward View (GPFV) outlined how the government plans to attain a strengthened model of general practice. A key component of this proposal is an expansion of the workforce by employing a varied range of practitioners, in other words 'skill mix'. A significant proportion of this investment focuses on increasing the number of 'new' roles such as clinical pharmacists, physiotherapists, physician associates, and paramedics. AIM: The aim of this study is to examine what practice characteristics are associated with the current employment of these 'new' roles. METHOD: The study uses practice level workforce data (2015-2019), publicly available from NHS Digital. The authors model FTE of specific workforce groups (for example, advanced nurse) as a function of deprivation, practice rurality, patient demographics (total list size and percentage of patients aged >65 years) and FTEs from other staff groups. RESULTS: Although analysis is ongoing, initial estimation suggests that the employment of 'new' roles has occurred in larger practices (in terms of list size), in practices with a higher proportion of patients living in deprived areas and practices with a larger proportion of patients aged >65 years. FTE for advanced nurses is negatively associated with GP FTE. CONCLUSION: A negative correlation between advanced nurse FTE and GP FTE is potentially suggestive of substitution between roles, deliberate or otherwise. For example, practices may employ 'new' roles if they are unable to recruit GPs or they may recruit staff to free up GP time. Further work is needed to confirm these findings and to explore the reasons behind practice employment decisions.

Motivating factors behind skill mix change: results from a practice managers' survey in England.

BACKGROUND: The expansion of the primary care workforce by employing a varied range of practitioners ('skill mix') is a key component of the General Practice Forward View (GPFV). The extent of skill mix change and where that has occurred has been examined using publicly available practice level workforce data. However, such data does not provide information regarding specific motivating factors behind employment decisions for individual practices nor future workforce plans. AIM: To identify key motivating factors behind practice workforce decisions and their future workforce plans. METHOD: An online questionnaire was sent to practice managers in England. Data collection is ongoing; however, 1000 practices have responded to the survey so far. The questionnaire was composed of questions related to current workforce, motivating factors behind employment decisions, planned future workforce changes, financial assistance with employing staff (for example, HEE or CCG funding) and ideal workforce. RESULTS: Early results indicate that practices that have employed physician associates have done so to increase appointment availability (78% of practices) and release GP time (68%). Sixty-six per cent of practices who have employed pharmacists have received some form of financial assistance with 21% of practices still receiving assistance. When asked to construct an ideal workforce, 'new' roles accounted for 20% of that workforce on average, which is a significantly larger proportion than those roles currently account for. CONCLUSION: Although data collection and analysis are ongoing, the results of the survey provide novel insights into the underlying motivating factors behind employment decisions, specifically for new roles such as pharmacists, PAs and paramedics.

Regional variation in practitioner employment in general practices in England: a comparative analysis.

BACKGROUND: In recent years, UK health policy makers have responded to a GP shortage by introducing measures to support increased healthcare delivery by practitioners from a wider range of backgrounds. AIM: To ascertain the composition of the primary care workforce in England at a time when policy changes affecting deployment of different practitioner types are being introduced. DESIGN AND SETTING: This study was a comparative analysis of workforce data reported to NHS Digital by GP practices in England. METHOD: Statistics are reported using practice-level data from the NHS Digital June 2019 data extract. Because of the role played by Health Education England (HEE) in training and increasing the skills of a healthcare workforce that meets the needs of each region, the analysis compares average workforce composition across the 13 HEE regions in England RESULTS: The workforce participation in terms of full-time equivalent of each staff group across HEE regions demonstrates regional variation. Differences persist when expressed as mean full-time equivalent per thousand patients. Despite policy changes, most workers are employed in long-established primary care roles, with only a small proportion of newer types of practitioner, such as pharmacists, paramedics, physiotherapists, and physician associates. CONCLUSION: This study provides analysis of a more detailed and complete primary care workforce dataset than has previously been available in England. In describing the workforce composition at this time, the study provides a foundation for future comparative analyses of changing practitioner deployment before the introduction of primary care networks, and for evaluating outcomes and costs that may be associated with these changes.

Trends in GP incomes in England, 2008-2017: a retrospective analysis of repeated postal surveys.

BACKGROUND: There is widespread concern over the recruitment and retention of GPs in England. Income is a fundamental consideration affecting the attractiveness of working in general practice. AIM: To report on trends in average incomes earned by GPs in England, adjusted for inflation and contracted time commitment. DESIGN AND SETTING: Postal surveys of random samples of GPs working in England in 2008, 2010, 2012, 2015, and 2017. METHOD: Trends in average reported incomes of partner and salaried GPs were directly standardised for the reported number of sessions worked per week and adjusted for inflation. RESULTS: Data were obtained from between 1000 and 1300 responders each year, representing response rates between 25% and 44%. Almost all responders (96%) reported the income they earned from their job as a GP. Mean nominal annual income decreased by 1.1% from £99 437 in 2008 to £98 373 in 2017 for partner GPs and increased by 4.4% from £49 061 to £51 208 for salaried GPs. Mean sessions worked decreased from 7.7 to 7.0 per week for partner GPs and decreased from 5.6 to 5.3 per week for salaried GPs. Mean income adjusted for sessions worked and inflation decreased by 10.0% for partner GPs and by 7.0% for salaried GPs, between 2008 and 2017. CONCLUSION: The decrease in GP income adjusted for sessions worked and inflation over the last decade may have contributed to the current problems with recruitment and retention.

The influence of training experiences on career intentions of the future GP workforce: a qualitative study of new GPs in England.

BACKGROUND: The capacity of the UK GP workforce has not kept pace with increasing primary care workloads. Although many doctors successfully complete GP specialty training programmes, some do not progress to work in NHS general practice. AIM: This article explores the training experiences and perceptions of newly qualified GPs to understand how their education, training, and early experiences of work influence their career plans. DESIGN AND SETTING: A qualitative study of doctors in their final year of GP training (ST3) and within 5 years of completion of GP training (F5). METHOD: Participants across England were recruited through training programmes, First5 groups, and publicity using social media and networks. Open narrative interviews were conducted with individuals and focus groups. Audiorecorded interviews were transcribed, and a thematic analysis was supported by NVivo and situational analysis mapping techniques. RESULTS: Fifteen participants engaged in individual interviews and 10 focus groups were carried out with a total of 63 participants. Most doctors reported that training programmes had prepared them to deal confidently with most aspects of routine clinical GP work. However, they felt underprepared for the additional roles of running a practice and in their understanding of wider NHS organisational structures. Doctors wished to avoid unacceptably heavy workloads and voiced concerns about the longer-term sustainability of general practice. CONCLUSION: Strategies to attract and retain enough GPs to support delivery of comprehensive primary care should consider how doctors' early career experiences influence their career intentions. A coherent plan is needed to improve their preparation and increase confidence that they can achieve a professionally satisfying, effective, and sustainable career in NHS general practice.

How do workplaces, working practices and colleagues affect UK doctors' career decisions? A qualitative study of junior doctors' career decision making in the UK.

OBJECTIVES: This study draws on an in-depth investigation of factors that influenced the career decisions of junior doctors. SETTING: Junior doctors in the UK can choose to enter specialty training (ST) programmes within 2 years of becoming doctors. Their specialty choices contribute to shaping the balance of the future medical workforce, with views on general practice (GP) careers of particular interest because of current recruitment difficulties. This paper examines how experiences of medical work and perceptions about specialty training shape junior doctors' career decisions. PARTICIPANTS: Twenty doctors in the second year of a Foundation Training Programme in England were recruited. Purposive sampling was used to achieve a diverse sample from respondents to an online survey. RESULTS: Narrative interviewing techniques encouraged doctors to reflect on how experiences during medical school and in medical workplaces had influenced their preferences and perceptions of different specialties. They also spoke about personal aspirations, work priorities and their wider future.Junior doctors' decisions were informed by knowledge about the requirements of ST programmes and direct observation of the pressures under which ST doctors worked. When they encountered negative attitudes towards a specialty they had intended to choose, some became defensive while others kept silent. Achievement of an acceptable work-life balance was a central objective that could override other preferences.Events linked with specific specialties influenced doctors' attitudes towards them. For example, findings confirmed that while early, positive experiences of GP work could increase its attractiveness, negative experiences in GP settings had the opposite effect. CONCLUSIONS: Junior doctors' preferences and perceptions about medical work are influenced by multiple intrinsic and extrinsic factors and experiences. This paper highlights the importance of understanding how perceptions are formed and preferences are developed, as a basis for generating learning and working environments that nurture students and motivate their professional careers.

General practitioners' views of clinically led commissioning: cross-sectional survey in England.

OBJECTIVES: Involving general practitioners (GPs) in the commissioning/purchasing of services has been an important element in English health policy for many years. The Health and Social Care Act 2012 handed responsibility for commissioning of the majority of care for local populations to GP-led Clinical Commissioning Groups (CCGs). In this paper, we explore GP attitudes to involvement in commissioning and future intentions for engagement. DESIGN AND SETTING: Survey of a random sample of GPs across England in 2015. METHOD: The Eighth National GP Worklife Survey was distributed to GPs in spring 2015. Responses were received from 2611 respondents (response rate = 46%). We compared responses across different GP characteristics and conducted two sample tests of proportions to identify statistically significant differences in responses across groups. We also used multivariate logistic regression to identify the characteristics associated with wanting a formal CCG role in the future. RESULTS: While GPs generally agree that they can add value to aspects of commissioning, only a minority feel that this is an important part of their role. Many current leaders intend to quit in the next 5 years, and there is limited appetite among those not currently in a formal role to take up such a role in the future. CCGs were set up as 'membership organisations' but only a minority of respondents reported feeling that they had 'ownership' of their local CCG and these were often GPs with formal CCG roles. However, respondents generally agree that the CCG has a legitimate role in influencing the work that they do. CONCLUSION: CCGs need to engage in active succession planning to find the next generation of GP leaders. GPs believe that CCGs have a legitimate role in influencing their work, suggesting that there may be scope for CCGs to involve GPs more fully in roles short of formal leadership.

Unfashionable tales: narratives about what is (still) great in NHS general practice.

BACKGROUND: There is clear evidence that general practice has become a less popular career choice and among GPs there are high levels of dissatisfaction and demotivation. Little empirical evidence has emerged to indicate which factors contribute intrinsic value to the working lives of GPs and sustain their ongoing commitment. AIM: To understand which aspects of work continue to motivate and engage senior GPs by exploring their narrative accounts. DESIGN AND SETTING: This was part of a qualitative study in which senior GPs and hospital specialists contributed narratives in which they reflected on their working lives. METHOD: Individual, open interviews were conducted with eight GPs who had graduated in the early 1980s. Thematic analysis and situational analysis mapping were used to identify and connect related themes. RESULTS: During interviews in which doctors drew on a wide range of encounters and experiences, they revealed which aspects of work were associated with greater intrinsic rewards and contributed to their continuing motivation. Having chosen careers that suited their preferred settings and working practices, they recounted adjustments made in response to new challenges and confirmed experiencing greater enjoyment when performing roles affirming their sense of providing valued health care. CONCLUSION: This study's findings offer an alternative angle from which to consider the current unpopularity of general practice careers. The article proposes that long-term engagement of practitioners may be achieved through provision of adequate supportive resources to allow them to enact a sense of medical identity that matches with their acquired expectations of their role in the NHS.