INCREASING JOB DEMANDS FOR GPs
Recent major structural and policy developments in the UK health services have significantly impacted on the primary role of the GP as a generalist clinician; there is increasing emphasis on their capabilities as team leaders, care coordinators, educators, and commissioners.1 Sir Bruce Keogh, the NHS Medical Director in England, is exploring issues of demand for services and the need to ensure people with long-term conditions are better looked after outside the hospital system, thus reducing their need for emergency care services. The Health Secretary for England, Jeremy Hunt, is calling for better integration between the health and social care systems, which implies a significantly revised model for the delivery of primary care. NHS England launched ‘Call to Action’2 to stimulate debate in communities and enable GPs to play a stronger role in delivery of out-of-hospital integrated services for an improved patient experience, personalised care, with more effective and efficient use of the resources. In the devolved administrations there are similar policy directives reflecting the wish to increase care in the community in the future.3–5 Consequently, there are significantly increasing job demands, not least from patients, for GPs to be better prepared to manage increasingly complex long-term conditions. To what extent do the current curriculum, the training provision, and the licensure assessments accommodate these changes?
EVIDENCE FOR NEW COMPETENCIES REQUIRED IN A BROADER GP JOB ROLE
New evidence from a multi-source, multi-method job analysis study6 (involving interviews, focus groups, observations of GPs at work, a survey; n = >1400) identifies a framework of eleven competency domains including:
Empathy and perspective-taking
Communications skills
Clinical expertise
Conceptual thinking and problem-solving
Organisation and management of resources
Professional integrity
Coping with pressure
Effective teamworking
Respect for diversity and the law
Learning and development of self and others
Leading for continuing improvement.
GPs are required to consider how their work impacts on communities: both to address the health of the population they serve, and how this is managed within the wider health service, with new competencies now required (such as Leading for continuing improvement) compared to an original job analysis conducted over 10 years ago.7
Research evidence is sparse regarding the skills and attributes required by community generalists to be effective as their role expands outside of the consulting room, especially relating to planning services for population-based healthcare and proactive preventative care for those at risk.6
IMPLICATIONS FOR WORK DESIGN AND TRAINING VALIDITY
Research evidence highlights three core themes arising that have significant implications for work design in general practice, including increased role breadth, increased potential for role conflict, and concerns around the level of preparedness for practice after training.6
Regarding an increased role breadth, results show an enhanced emphasis for GPs to consider multiple agendas beyond the patient and their practice in future. GPs are required to focus on balancing individual (local) needs versus their registered population’s health (such as ‘bigger-picture’ thinking), and to take on multiple complex roles in future. However, there is increased potential for conflict in relation to ethical values. GPs are required to demonstrate commitment to patient care and maintain patient trust, which may at times conflict with managing limited resources. Increasingly, GPs need to resolve these significant competing tensions to be effective in their role. For individuals, there is a potential ethical conflict between these tensions, which may be at odds with their identity as a clinician. Research in work design implies this will increase the risks of experiencing work-related stress, reduced job satisfaction, and burnout.8 With competing job demands for individuals, to remain effective, trainees will require specific support to deal with these conflicts and significant changes in work design.
There are identified concerns regarding the level of trainee preparedness for practice given these new job demands. For example, there are gaps in training provision relating to dealing with challenging psychosocial issues and complex long-term health conditions facing patients. Several new domains relate to an increasingly broad range of non-clinical activities such as leading for innovation, business acumen, adopting collaborative approaches when working in expanded multiprofessional teams6 (in addition to managing healthcare pathways effectively), which are not currently assessed in training or tested directly by the current MRCGP licensure exams.
To what extent do trainees feel confident that they are able to carry out a broader and more proactive role? Self-efficacy is an important motivational dimension to consider in future education and training activities as it influences individual goals, emotional reactions, effort, coping, and wellbeing.
This proposition is consistent with survey data from recently qualified GPs now reporting significantly higher levels of stress than their counterparts,9 and with evidence showing a significantly increased number of GPs intending to quit.10 There is also a risk that perceived stress in the profession will affect recruitment in future; at a time when the number of GPs needs to expand.
THE CASE FOR TRAINING TO BE RECONFIGURED?
Given the extensive range of responsibilities and capabilities required, this work supports the case for enhancement of the current training provision to ensure it reflects the role changes and the greater breadth of competencies now needed by GPs. To ensure validity, further work is required to define the optimal content and construction of training to support the career pathway (and, by extension, patient care) appropriately in future.
The educational value of reconfiguring GP training by the RCGP to encompass these and other new domains has been widely recognised by health departments. Inevitably, there will be differences in the role of GPs in the health systems across the UK, but it is essential that there is a single set of national training standards that are fit for purpose.
Much of the training should now take place in posts that provide services in community settings, with a focus on GPs leading the response to population health issues, developing generalist competencies and working collaboratively in multiprofessional teams to develop expertise together to tackle the increasing complex profile of patients with long-term conditions. Such posts should play a key role in facilitating the shift of patient care into the community, supporting new models of emergency care, and contributing to the development of in- and out-of-hours services.11 Flexibility in the nature of these posts at a local level is important to ensure the provision of the highest quality training environments, and provide for a cost-effective method of delivery. All programmes will need to follow a well-defined curriculum setting out new competencies that can be acquired in a wide variety of training environments; service delivery should be an important component, as will working in multiprofessional teams, supported by high quality mentoring and support systems for future GP trainees.
Given that the first cohort of trainees recruited into new educationally approved extended programmes are unlikely to reach the start of their fourth year until 2018, there is time to plan the essential changes in service delivery and to revise aspects of the curriculum, while also providing the new community-based training posts in a cost-effective manner. The result will be a better trained, confident, and capable GP workforce, educated in an environment that delivers new models of high quality patient care. By ensuring that the education and training provided is fit for purpose, newly-qualified GPs will be fit for practice, in an increasingly challenging workplace.
Notes
Provenance
Commissioned; not externally peer reviewed.
- © British Journal of General Practice 2013