Ben Jackson

How can medical schools encourage students to choose general practice as a career

The NHS faces a continuing rise in volume and complexity of population health needs, with care moving increasingly from hospital to community. National reviews of medical training and workforce requirements report a critical need for an increase in the NHS GP workforce, and NHS England has now responded with a welcome promise of investment in primary care.1 This may provide funding for GPs, but where will these GPs come from? Medical schools and the Royal College of General Practitioners are working to promote general practice as a career, but the current uptake of GP training is disappointing, with only 17.4% of F2 doctors appointed to GP training in the UK in 2015.2 Health Education England’s GP training recruitment targets for 2016 are likely to be missed. Many questions must be asked. What explains the wide variations across medical schools in graduates’ choice of general practice as a career (range 7.3–30.0%)?2 Is there a cultural bias against primary care in medical schools? How important is the quantity and quality of undergraduate general practice exposure? Are we taking the wrong approach to selection processes in order to meet the needs of contemporary society? Undergraduate experience has a major influence on career choice. Evidence from the UK and abroad shows that undergraduate exposure to general practice has a positive influence on students considering general practice as a career.3 Yet, following a steady increase over the past 20 years, the percentage of teaching in general practice in UK medical schools has plateaued (mean 13%) since 2008 and the average amount of clinical contact in general practice settings has decreased overall.4 Capacity for undergraduate general practice placements is now a serious …

A Genome Scan and Linkage Disequilibrium Analysis among Chromosomal Races of the Australian Grasshopper Vandiemenella viatica

In the past decade the interest surrounding the role of recombination in speciation has been re-kindled by a new generation of chromosomal speciation models that invoke the recombination-suppression properties of some types of chromosomal rearrangement. A common prediction of recombination-suppression models is that gene exchange between diverging populations will be more restricted in regions of the genome that experience low recombination. We carried out a genome scan of three chromosomal races of the grasshopper Vandiemenella viatica (Orthoptera: Morabinae), occurring on Kangaroo Island, South Australia, using 1517 AFLP loci, with a view to elucidating the roles that selection and chromosomal variation have played in the formation of these taxa. An analysis of molecular variance demonstrated that chromosomal race accounted for a significant proportion of the genetic variance in the total dataset, which concurred with the findings of an earlier study. Sampling across one previously-identified hybrid zone, and the identification of outlier loci between parental races allowed us to establish that, in admixed populations, outlier loci which potentially pre-date the isolation of populations of races on Kangaroo Island exhibit higher levels of linkage disequilibrium with each other than putatively neutral loci. In turn this suggests that they might reside within genomic regions of low recombination, or be closely linked with each other.

Barriers and facilitators to integration of physician associates into the general practice workforce: a grounded theory approach

BACKGROUND Physician associates (PAs) are described as one solution to workforce capacity in primary care in the UK. Despite new investment in the role, how effective this will be in addressing unmet primary care needs is unclear. AIM To investigate the barriers and facilitators to the integration of PAs into the general practice workforce. DESIGN AND SETTING A modified grounded theory study in a region unfamiliar with the PA role. METHOD No a priori themes were assumed. Themes generated from stakeholder interviews informed a literature review and theoretical framework, and were then tested in focus groups with GPs, advanced nurse practitioners (ANPs), and patients. Recorded data were transcribed verbatim, and organised using NVivo version 10.2.2, with iterative analysis of emergent themes. A reflexive diary and independent verification of coding and analysis were included. RESULTS There were 51 participants (30 GPs, 11 ANPs, and 10 patients) in eight focus groups. GPs, ANPs, and patients recognised that support for general practice was needed to improve access. GPs expressed concerns regarding PAs around managing medical complexity and supervision burden, non-prescriber status, and medicolegal implications in routine practice. Patients were less concerned about specific competencies as long as there was effective supervision, and were accepting of a PA role. ANPs highlighted their own negative experiences entering advanced clinical practice, and the need for support to counteract stereotypical and prejudicial attitudes CONCLUSION: This study highlights the complex factors that may impede the introduction of PAs into UK primary care. A conceptual model is proposed to help regulators and educationalists support this integration, which has relevance to other proposed new roles in primary care.

General practice and the Sustainability and Transformation imperatives

Sustainability and Transformation Plans (STPs) have now been submitted for all 44 areas across England, swiftly followed by corresponding plans from clinical commissioning groups (CCGs) for how they intend to strengthen and transform health services across their communities. CCGs were required to outline how the investment described in the General Practice Forward View ( GPFV ) will be utilised to support general practice, to reverse some of the damage done by years of underinvestment, and create a position from which primary care can begin to strengthen.1 Stronger general practice is an imperative for the sustainability of STPs if the NHS is to function in a form recognisable from its founding principles. When people feel unwell, they look to the trusted places within their NHS. It is GP surgeries that have the expertise to provide comprehensive, generalist first-contact care, but when they are unable to meet demand people predictably seek help in accident and emergency (AE a place ill designed for their problems. On presenting to A&E, the likelihood of someone having a preventable admission is directly …

Self-authorship theory and medical education: AMEE Guide No. 98

Abstract Responding to the healthcare needs of the twenty-first century is a challenge for medical education, requiring a holistic curriculum that stimulates intellectual growth and facilitates personal development of all learners. Self-authorship theory has a focus on the essential development of cognitive maturity, an integrated identity and mature relationships. The educational application of self-authorship situates learning in the experiences of learners and challenges learners’ current worldview enabling them to take responsibility for their own decisions and actions. Implications for curriculum development and implementation are discussed, including the need to provide a challenging, yet supportive, learning environment. The use of self-authorship theory to inform educational research is also discussed.

Mining for Deep End GPs: a group forged with steel in Yorkshire and Humber

Working at the heart of their communities, Yorkshire and Humber GPs witness the effects of poverty on their patients’ health every day. Working with practice teams, and increasingly the voluntary sector, GPs try to ameliorate the social determinants of health for the vulnerable and socially excluded. Unemployment remains high in this area because the textile, mining, and steel industries, which employed many of the region’s 5 million or so residents in the past, have gradually died off. Substantial numbers of the oldest and youngest in the region are living in poverty: 23% of children and 20% of older people compared with the national averages of 4.9% and 7.4%, respectively.1 Deprivation is concentrated in the major urban centres of Bradford, Leeds, Hull, and Sheffield, alongside pockets of destitution in the former mill towns of West Yorkshire and some rural areas: some of the poorest communities in Europe can be found in our region. Marmot has confirmed the impact of deprivation on health and life expectancy through the social gradient theory.2 Sadly there are numerous examples to illustrate this from our region. For example, if you hop on the number 83 bus in the leafy south west of Sheffield and travel northwards, the life expectancy of women quickly drops by 10 years.3 In Hull there are life expectancy gaps of 12 years for men and 11 years for women between the richest and poorest.4 Rates of premature mortality from coronary heart disease are more than double in deprived areas of Sheffield compared with affluent counterparts.5 The contrast in life expectancy and health in relation to poverty can only be described as unjust and immoral. In 2009 Glasgow University’s Professor Graham Watt used the metaphor of a swimming pool to represent both the social gradient and increased workload …

Apprentice leaders in training: ‘talking the walk’

In 2012, a working group of South Yorkshire general practice (GP) educators and First 5 GPs was convened. They wished to consider how to build upon the well-received post-Clinical Skills Assessment leadership groups [1] to deliver training that better nurtured leadership and change management skills for all trainees in Health Education Yorkshire and the Humber (HEYH). This process involved deriving a new ‘skill set’ of trainable leadership skills from the Medical Leadership Competency Framework, subsequently refined further by the GP school curriculum team in HEYH.[2] During this work a shift occurred in the thinking within the group, when the assumption that the majority of such training would take place within small groups at release programmes was challenged by a recognition that the experience during practice placements was the vital component. [3] The notion of GP training as an apprenticeship in leadership was born. This was supported in subsequent discussion at trainers’ workshops and with programme directors but tempered with a clear message that trainers’ awareness and confidence would need addressing to incorporate this into training. We describe the contribution of GP trainers to this debate from a series of continuing professional development (CPD) sessions in HEYH focusing on how to train for this new leadership skill set. Key messages

New teams in general practice

The NHS is seriously under-doctored, with general practice being one of the worst-affected specialties. GPs are a highly trusted and valued profession by patients. In addition, the ‘gatekeeping’ function and continuity of care they provide is critical to the efficiency of the services as a whole, keeps hospital admissions down, and produces better healthcare outcomes for communities and populations. Major efforts are being made to recruit new GPs and retain existing GPs, but there are serious implications for the future of primary care, and general practice in particular, as GPs struggle to cope with increased workloads. Increasing the number of GPs in the workforce is critical, and this work continues as a priority. However, a parallel stream of work has developed to consider ways in which tasks ‘traditionally’ undertaken by a GP might be diverted to new healthcare professionals within primary care teams, freeing up GPs to concentrate on the care and management of their more complex patients.

Introducing quality improvement teaching into general practice undergraduate placements

ABSTRACT Quality Improvement skills are deemed essential for future clinical practice of doctors by professional regulatory bodies. This paper presents the challenges of a curriculum development initiative to ensure that all medical students have involvement with a quality improvement project during a general practice placement in their fourth year. The curriculum development is described within a ‘Plan-Do-Study-Act’ framework. The learning is presented as a reflective discussion with conclusions and recommendations on how potential current barriers to implementing authentic participation in quality improvement projects for undergraduate medical students might be met. The key barriers include lack of opportunities within the curriculum structure to allow sufficient time for authentic quality improvement projects and a lack of confidence amongst placement tutors to support medical students with quality improvement projects.

Embedding a sustainable skills-based safeguarding children course across multiple postgraduate general practice training programmes

Issues around safeguarding children are a priority for all healthcare staff and adequate training is a prerequisite to ensure appropriate action can be taken. The Laming report recommends that all general practitioners (GPs) have ‘the necessary skills and training to carry out their duties’.[1] This duty, as defined by United Kingdom (UK) government guidance goes further than ‘child protection’ and involves safeguarding children’s health and development to enable them to have the best outcomes possible, as well as protecting them from maltreatment. [2] The General Medical Council recognises GPs are in a unique position in this regard as they often have a duty of care for both the adult who poses a risk to a child and for the child who is at risk.[3] Woodman et al build on this, suggesting that the role of the GP in these instances is broader than simply recognising potential harm and making referrals, and includes lesser grades of action throughout the continuity of their relationships with children and their families.[4] In the UK, GP trainees are taught communication skills to foster a patient-centred approach to medicine and a shared understanding of presenting problems and the best approach to management.[5] In situations where an adult is implicated as a potential risk to a child, this collaborative approach is challenged. Illustrating this, Lazenbatt and Freeman found two of the greatest barriers to GPs taking action when presented with potential safeguarding issues were fear of hostility from the family and the risk of damage to relationships with the potential of subsequent complaints against them.[6] In 2015 the Royal College of General Practitioners (RCGP) mandated that trainees demonstrate level 3 competence in safeguarding children in order to obtain a Certificate of Completion of Training (CCT). This can consist of on-line training along with additional reflection on relevant experience. We describe a skills based model of safeguarding training, developed collaboratively between GP educators and safeguarding professionals utilising blended learning approaches. It focuses on active development of skills to address the barriers described. It continues to be offered to around 100 GP trainees in four South Yorkshire programmes eight years after introduction.