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.

Eliciting and prioritising determinants of improved care in multimorbidity: A modified online Delphi study.

Background: Multimorbidity is a major challenge to health and social care systems around the world. There is limited research exploring the wider contextual determinants that are important to improving care for this cohort. In this study, we aimed to elicit and prioritise determinants of improved care in people with multiple conditions. Methods: A three-round online Delphi study was conducted in England with health and social care professionals, data scientists, researchers, people living with multimorbidity and their carers. Results: Our findings suggest a care system which is still predominantly single condition focused. 'Person-centred and holistic care' and 'coordinated and joined up care', were highly rated determinants in relation to improved care for multimorbidity. We further identified a range of non-medical determinants that are important to providing holistic care for this cohort. Conclusions: Further progress towards a holistic and patient-centred model is needed to ensure that care more effectively addresses the complex range of medical and non-medical needs of people living with multimorbidity. This requires a move from a single condition focused biomedical model to a person-based biopsychosocial approach, which has yet to be achieved.

Consequences of the closure of general practices: a retrospective cross-sectional study.

BACKGROUND: Two general practices close every week in the UK. Given the pressure on UK general practices, such closures are likely to persist. Yet little is known about the consequences. Closure refers to when a practice ceases to exist, merges, or is taken over. AIM: To explore whether practice funding, list size, workforce composition, and quality change in surviving practices when surrounding general practices close. DESIGN AND SETTING: A cross-sectional study of English general practices was undertaken, using data from 2016-2020. METHOD: The exposure to closure for all practices existing on 31 March 2020 was estimated. This is the estimation proportion of a practice's patient list that had been through a closure in the preceding 3 years, between 1 April 2016 and 3 March 2019. The interaction between the exposure to closure estimate and the outcome variables (list size, funding, workforce, and quality) was analysed through multiple linear regression, while controlling for confounders (age profile, deprivation, ethnic group, and rurality). RESULTS: A total of 694 (8.41%) practices closed. A 10% increase in exposure to closure resulted in 1925.6 (95% confidence interval [CI] = 1675.8 to 2175.4) more patients in the practice with £2.37 (95% CI = £4.22 to £0.51) less funding per patient. While numbers of all staff types increased, there were 86.9 (95% CI = 50.5 to 123.3), 4.3%, more patients per GP. Increases for other staff types were proportionate to increases in patients. Patient satisfaction with services declined across all domains. No significant difference in Quality and Outcomes Framework (QOF) scores was identified. CONCLUSION: Higher exposure to closure led to larger practice sizes in remaining practices. Closure of practices changes workforce composition and reduces patient satisfaction with services.

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.

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.

Development and Validation of Population Clusters for Integrating Health and Social Care: Protocol for a Mixed Methods Study in Multiple Long-Term Conditions (Cluster-Artificial Intelligence for Multiple Long-Term Conditions).

BACKGROUND: Multiple long-term health conditions (multimorbidity) (MLTC-M) are increasingly prevalent and associated with high rates of morbidity, mortality, and health care expenditure. Strategies to address this have primarily focused on the biological aspects of disease, but MLTC-M also result from and are associated with additional psychosocial, economic, and environmental barriers. A shift toward more personalized, holistic, and integrated care could be effective. This could be made more efficient by identifying groups of populations based on their health and social needs. In turn, these will contribute to evidence-based solutions supporting delivery of interventions tailored to address the needs pertinent to each cluster. Evidence is needed on how to generate clusters based on health and social needs and quantify the impact of clusters on long-term health and costs. OBJECTIVE: We intend to develop and validate population clusters that consider determinants of health and social care needs for people with MLTC-M using data-driven machine learning (ML) methods compared to expert-driven approaches within primary care national databases, followed by evaluation of cluster trajectories and their association with health outcomes and costs. METHODS: The mixed methods program of work with parallel work streams include the following: (1) qualitative semistructured interview studies exploring patient, caregiver, and professional views on clinical and socioeconomic factors influencing experiences of living with or seeking care in MLTC-M; (2) modified Delphi with relevant stakeholders to generate variables on health and social (wider) determinants and to examine the feasibility of including these variables within existing primary care databases; and (3) cohort study with expert-driven segmentation, alongside data-driven algorithms. Outputs will be compared, clusters characterized, and trajectories over time examined to quantify associations with mortality, additional long-term conditions, worsening frailty, disease severity, and 10-year health and social care costs. RESULTS: The study will commence in October 2021 and is expected to be completed by October 2023. CONCLUSIONS: By studying MLTC-M clusters, we will assess how more personalized care can be developed, how accurate costs can be provided, and how to better understand the personal and medical profiles and environment of individuals within each cluster. Integrated care that considers "whole persons" and their environment is essential in addressing the complex, diverse, and individual needs of people living with MLTC-M. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/34405.

Associations between chronotype and employment status in a longitudinal study of an elderly population.

Individuals with an 'evening' chronotype tend to sleep and wake later than people described to be 'morning' type if given a free choice. Since early awakening times, due to school and occupation, may be more challenging for those with evening chronotype, they are expected to be at greater risk of adverse health, occupational and educational outcomes. Our objectives are to investigate associations between chronotype and occupational, educational and health outcomes in a longitudinal cohort. We use sleep, sociodemographic and health data from The University of Manchester Longitudinal Study of Cognition in Normal Healthy Old Age, 1982 through 2010. The relationship between employment and longitudinal midsleep trajectories were estimated using linear mixed models. Associations between employment status and Cornell Medical Index, Beck Depression Inventory scores, cortisol concentrations at different times of the day stratified by chronotype were estimated using regression. The relationship between chronotype, occupational success, education, and cognition were also examined using regression methods. In older adults, compared to non-employed participants, employed participants get up 0.45 hours earlier. Evening-type employed individuals had earlier midsleep time compared to their non-employed counterparts and had abnormal longitudinal trajectories with an increasing trend as they aged. Employed individuals with evening chronotype had a higher risk of depression than employed morning-types. Moreover, employed individuals with evening chronotype had a higher cortisol concentration at 14:00 h than non-employed individuals. In addition, memory score was lower in individuals with morning chronotype, however processing speed was higher in individuals with morning chronotype compared to evening. Morning-types had a higher age when they finished full time education. Relative to evening-types, those with morning chronotype were 6.5% more likely to be in a job classed as professional or intermediate. Our findings suggest that evening-types are at a disadvantage with regards to occupational, educational and health outcomes in older adults due to their vulnerability to circadian and sleep disruption.

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.

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.

Opportunities for, and implications of, skill mix changes in health care pathways: Pay, productivity and practice variations in a needs-based planning framework.

Health workforce planning is traditionally based on demographically-driven 'silo-based' models in which future requirements for particular health professions are determined by applying estimates of the future population to the existing population-based level of workforce supply. Estimates of future workforce requirements are focused on, and constrained by population size and requirements increase monotonically. Key failures of existing models include (1) lack of integration between planning the health care workforce, health care services and health care funding and (2) lack of integration between planning different health care inputs and the potential for substitution between inputs. Hence planning models fail to incorporate emerging developments in healthcare delivery and workforce change. We present an integrated needs-based framework for health workforce planning and apply the framework using data from nine European countries to explore the workforce and financial implications of re-configuring the delivery of care through changes in the allocation of treatment tasks between health care professions (skill mix). We show that cost consequences depend not only on pay differences. Instead, workforce planning in rapidly changing workforce environments must consider and incorporate between-provider group differences in productivity (the number of patients that are served per fixed period of time) and practice style (the number and mix of tasks used in providing care to the same type of patient).

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.

Stick or twist? Career decision-making during contractual uncertainty for NHS junior doctors.

OBJECTIVES: To examine the extent, and nature, of impact on junior doctors' career decisions, of a proposed new contract and the uncertainty surrounding it. DESIGN: Mixed methods. Online survey exploring: doctors' future training intentions; their preferred specialty training (ST) programmes; whether they intended to proceed immediately to ST; and other plans. Linked qualitative interviews to explore more fully how and why decisions were affected. SETTING: Doctors (F2s) in second year of Foundation School (FS) Programmes in England. PARTICIPANTS: Invitations sent by FSs. Open to all F2s November 2015-February 2016. All FSs represented. Survey completed by 816 F2s. Sample characteristics broadly similar to national F2 cohort. MAIN OUTCOME MEASURES: Proportions of doctors intending to proceed to ST posts in the UK, to defer or to exit UK medicine. Proportion of doctors indicating changes in training and career plans as a result of the contract and/or resulting uncertainty. Distribution of changes across training programmes. Explanations of these intentions from interviews and free text comments. RESULTS: Among the responding junior doctors, 20% indicated that issues related to the contract had prompted them to switch specialty and a further 20% had become uncertain about switching specialty. Switching specialty choice was more prevalent among those now choosing a community-based, rather than hospital-based specialty. 30% selecting general practice had switched choice because of the new contract. Interview data suggests that doctors felt they had become less valued or appreciated in the National Health Service and in society more broadly. CONCLUSIONS: Doctors reported that contract-related issues have affected their career plans. The most notable effect is a move away from acute to community-based specialities, with the former perceived as more negatively affected by the proposed changes. It is concerning that young doctors feel undervalued, and this requires further investigation.