Peter Spurgeon

Types of Work Stress and Implications for the Role of General Practitioners

This study investigated a wide range of job-related characteristics which had the potential of acting as stressors for General Practitioners (GPs). Three hundred and four GPs completed a detailed questionnaire which sought audit information including practice workload factors, coping approaches and attitudinal information including sources of stress and the value of management training. Ten independent factors were identified as underpinning GP stress and using multi-variate analysis, it was shown that each of these factors is predicted by a separate and distinct set of variables. This finding suggests that it is inappropriate to simply talk about GP stress since it is a multi-dimensional concept. This finding has important implications for identifying potentially successful mechanisms of coping and support.

Developing our leaders in the future.

The role of the chief executive in a transformed organisation is an extremely challenging one. The development of vision, building a commitment to it and communicating it constantly are key skills for a chief executive. However, the need to build and empower the stakeholders within and outside the organisation to support the changes required to deliver the vision requires leaders who can connect with a wide range of people and build alliances and partnerships to secure organisational success. A passion for understanding human intervention and behaviour is needed to encourage, cajole and drive teams and individuals to own and commit to change and a new direction. This requires leaders who have imagination and creativity--who seek connections and thread them together to create order out of incoherence. These skills are not taught in schools or textbooks, but are probably innate. They are what separate leaders from the rest. These skills need to be developed. A movement towards encouraging experimentation, career transfers and more individuality is needed if capable leaders of the future are to appear.

Leadership and vision in the NHS: how do we create the "vision thing"?

The development of NHS trusts has been a major part of the NHS reforms in the United Kingdom. The creation of trust boards has coincided with significant pressures from the combined forces for change and consolidation within publicly financed health care in the UK. The development of a long term strategic vision for trusts to ensure long-term survival is imperative. Considers evidence from international researchers and translates this into the context of NHS trusts. Discusses how they define and identify vision and ensure that vision building can be communicated and understood by key stakeholders within and outside the organization. Offers several practical suggestions on how their vision can be monitored and evaluated within the organization.

The importance of psycho-social variables in changing attitudes and behaviour

A PRIMARY objective of health education pro grammes is to increase the individuals acceptance of responsibility for his or her own state of health. In order to maximise the effectiveness of such cam paigns two components are essential: the targeting of specific at-risk groups; and an improved under standing of how the attitudes to general health issues within these groups are structured. If these two objectives can be achieved, then the chances of attitude change are improved. However, there remains the problem of altering an individuals behaviour to accord with a more positive outlook to health. Existing studies suggest that a correspond ing change in behaviour to match an attitude is far from automatic. These issues are discussed in the light of relevant findings.

Survey evaluation of the National Patient Safety Agency’s Root Cause Analysis training programme in England and Wales: knowledge, beliefs and reported practices

Background: Root Cause Analysis (RCA) is a systematic approach to investigations, and is applied in many healthcare settings within comprehensive patient safety systems. The National Patient Safety Agency (NPSA) in England and Wales commissioned a survey evaluation of its national training programme which consisted of 3-day workshops and internet support materials. Methods: Anonymous survey of 374 health professionals immediately after they attended the programme (T1), and a further 350 participants 6 months after the programme (T 2), who had attended courses in England and Wales in 2005. Results: T1 knowledge tests showed a greater understanding of the frameworks and techniques of RCA but with less accuracy in application to scenarios. Personal beliefs about conducting RCAs were consistently positive at both times, but many participants experienced personal barriers to conducting RCA in their current role and trust context, and some felt low confidence in undertaking cascade training of other staff in their trust. There was also low confidence in implementing RCA as standard practice at both times. At T2, 76.7% were confident the outcomes from their RCA had been implemented, but only 12.1% were aware if improvements had been shared outside the local organisation. Barriers to RCA at both times most often concerned time and resources to apply RCA. At T1, there was particular concern for personal development, at T2 greater concern for organisational impediments. Conclusions: The RCA programme enhanced knowledge of RCA, and participants valued the programme, but further personal development and organisational support are required to achieve continued improvement in practice and sustained organisational learning.

The new GMS contract: impact and implications for managing the changes

Background: In February 2003, a new General Practitioner (GP) contract was agreed between the professions leaders and the government, which was later accepted following a national ballot of GPs. However, the ballot simply required respondents to vote for or against the proposal; it did not provide any opportunity to identify which aspects of the new contract were more or less acceptable. Since the proposed changes were far reaching, the implications of implementing and managing these were considerable. Consequently, some information about how GPs viewed various components of the new contract would enable a more targeted and effective management strategy to be developed that would facilitate the introduction of all aspects of the contract. Objectives: To survey GPs working within the West Midlands region regarding their opinions on each of the key features of the new contract. Method: A postal survey of 360 GPs was undertaken, using a specially devised questionnaire. Results: Four factors emerged as the most acceptable aspects of the contract: option to opt out of out-of-hours work, flexibility in the services provided, prediction of future income levels and linking practice to performance targets. Least acceptable were: performance monitoring systems, the new financial formula for calculating income, greater patient involvement in service development and 24/48 hour access. With regard to potential outcomes of the contract, the most positive were considered to be increased proportion of salaried GPs, increased salaries, appropriate quality standards for care, earlier retirement; the factors least likely to be of potential benefit were: reduction in occupational stress, simplification of the regulatory framework, improved equity of workload and improved staff retention. Further analysis of the results using inferential statistics revealed a range of subgroup differences in reaction to the contract. Conclusion: Overall, those aspects of the new contract that are perceived to reduce workload and enhance salary were supported, while those that increase targets and bureaucracy were not. Generally, there was only moderate support for the changes, which could be explained by a general scepticism about any top-down modifications, the practicality and power of the changes to impact upon practice and/or a genuine belief that the modifications are unacceptable. Taken together, these results provide an indicative focus for managing the implementation of the new contract, especially with regard to its least acceptable components and the emerging differences between subgroups of GPs.

Counselling in primary care: A study of the psychological impact and cost benefits for four chronic conditions

Primary care counselling services have expanded rapidly over the last twenty years. Their principal focus has been to manage the demands placed on general practitioners by high service users, such as frequent attenders and patients with mental health problems. To date, very little research has been conducted to ascertain the impact of counselling for other patient groups in terms either of psychological outcomes or of cost-benefits. This study looked at the effect of short-term counselling on both the uptake of health services and the psychological states of four patient groups – frequent attenders and patients with diabetes, hypertension and asthma. All patients on the chronic disease register for these conditions and all patients who had made at least eight GP appointments over the previous twelve months were invited to take part in the study. The participants received eight 90-minute small-group counselling sessions, conducted by trained counsellors. The counselling followed a cognitive behavioural therapy (CBT) approach, with an emphasis on developing personal responsibility. Psychological outcomes were assessed using three proprietary measures (SF 36, HADS and CORE) immediately following counselling and at six months post-intervention. Health service uptake was assessed for each group over the twelve months post-intervention, using number of GP consultations, home visits, hospital referrals and test/investigations requested as outcome indicators. These data were compared with those for comparable control groups for each condition. The results suggested that, overall, all patient groups showed a significant improvement in psychological well-being, and that these gains were maintained for the six-month study period. The intervention groups also significantly reduced their uptake of primary and secondary care services, by comparison with their comparable control groups. The results suggest that the psychological and fiscal benefits of counselling provision within a primary care setting can extend to other patient categories.

The quality of working life: occupational stress, job-satisfaction and well-being at work

The quality of working life is a topic that has been discussed in many different guises by a range of experts from a variety of disciplines. Those with an interest in management theory, sociology, industrial relations and organizational behaviour have often debated the ways in which our working lives are structured and the influences upon us at the organizational and societal levels.

Organisational change through clinical governance: the West Midlands three years on

Clinical governance is an organisational approach to improving the quality of clinical services. A survey was conducted of 33/40 NHS trusts 2.5 to three years after a baseline survey of the 46 trusts was conducted in the West Midlands region. Reported outcomes were achieved more often than expected at baseline. Patient outcomes and documented changes in clinical behaviour were both expected and reported in over three quarters at both periods. A more open culture was expected in 65 per cent at baseline and achieved in 84 per cent at time 2. Strategies for change continued to rely on both periods in optional, educative, audit and protocol procedures. The new approaches of critical incident review and consultant appraisal were welcomed. External review and league tables had adverse impacts where results were poor, but minimal impact if results were positive. Conclusions are drawn about more effective means of catalysing change.

Personal responsibility, empowerment and medical utilization: a theoretical framework for considering counselling and offset costs

The problem of effectively managing patients with functional somatic symptoms remains huge in both primary and hospital care, although the potential benefits of mental health interventions such as counselling or psychotherapy are still not widely accepted. Unfortunately, the cost-effective evaluation of counselling has been beset by methodological problems, which stem from attempting to make comparisons between counsellors with different types of training, therapeutic approach and case mix. Since these real-world variations in counselling practice are likely to remain, it is proposed that a different approach to the evaluation of cost-effectiveness should be adopted in the hope of accelerating acceptance of the value of psychological interventions for the army of patients who are currently labelled as ‘difficult’ or ‘heartsink’ and who do not receive the treatment they deserve from the health-care services. It is proposed that, since the common aim of almost all mental health interventions is to engender or enhance a sense of ‘personal responsibility’ in patients/clients, this core objective should form an agreed ‘yardstick’ against which to evaluate the impact of various mental health interventions. Furthermore, since personal responsibility and future health-care utilization (and associated costs) can be assumed to be directly causally related, it is proposed that offset costs should form the basis for future cost-effectiveness evaluations.