All seven fellows participated in the evaluation, giving 24 interviews in total. The overarching themes related to fellows’ expectations; experience of professional development, academic training, and service improvement and integration; and subsequent career activity. With few exceptions, fellows’ views about the scheme were very positive and remained unchanged across the two interview points during the fellowship year.
Expectations of the scheme
All participants described having been attracted to the fellowship scheme as an early career opportunity to gain experience and skills that went beyond those obtained in vocational training, particularly in relation to understanding the roles and expertise of primary care professionals working across the urgent and emergency care system. Generally, this reflected personal ambitions to develop a portfolio career within which urgent care would be a key aspect. The elements of the programme were viewed as being varied and well balanced in terms of developing a breadth of competence and self-confidence:
‘… potentially open up another scope of practice to me, to try and improve the chances of working in an acute and urgent care environment.’
(1)
‘I have never worked with a paramedic before … I wanted to find out what they do and what barriers they have, what is their role, and see what I can do to make things better.’
(5)
Experience of the professional development and service improvement activities
Service improvement and integration
The fellows felt that they were benefiting patient care and contributing to service improvement and integration in several ways: through the impact of their clinical work, the varied interaction with colleagues in urgent/emergency care and primary care settings, and by undertaking service improvement projects. They felt that the fellowship was changing the way that they worked, their understanding of the healthcare system, and in particular their capacity to help patients receive care in the community and avoid hospital admission:
‘It has had a huge impact on my practice. You see the total care. If you are just working in isolation you don’t see it. [As a result of the fellowship] you get a better perspective on the services and the care, and what you can do.’
(4)
‘The impact was more on my own learning … and it has made a difference to my practice in the community. An example of this is the way I see elderly patients in nursing homes and look after the step-down patients just out of hospital — so the experience is helping to manage those patients.’
(7)
‘I don’t have the data but my admission rate is lowest. It is quite a lot less than the other GPs who work in the system who have not done the fellowship … I think this is because we have more of a 360 degree perspective of working in medicine, A&E, and the community.’
(6)
This fellow went on to explain that:
‘… it is completely different working as a GP in A&E to working as a trainee in A&E, it is completely different, and I think getting that experience on the ground is invaluable really … understanding the way that services are set up really helped me moving forward with the things I am doing because now I have that understanding.’
(6)
They also had greater awareness of the barriers to delivering integrated care. For example, with the requirement to treat patients within designated time frames, some fellows experienced organisational barriers in emergency departments when trying to implement alternatives to patient admission:
‘In terms of the 4-hour target … they are more focused on that and they don’t see anything outside that. So there were barriers … me saying, “You know if you don’t do this, if you don’t admit this patient, then the NHS has saved, what, £1000 per night per patient, so why don’t you send them home?”’
(5)
There were numerous examples of how the programme was felt to be helping patients to access community-based and specialist services more efficiently, and avoid attendance at emergency departments or unplanned admissions, particularly when they were working with the ambulance service or out of hours:
‘Last night as an out-of-hours GP I had a confused old lady, lives on her own, no family around, and a GP’s mind is, “Oh, we’ve got no choice, we’ve got to admit the patient.” But having gone through the fellowship, it made me think laterally and, with access to all this knowledge, I was able to get an emergency social worker, speak to the community emergency response team, we were able to keep the patient at home.’
(3)
The opportunity to facilitate more integrated care by applying their knowledge about community resources, and encouraging communication and working relationships across organisational and professional boundaries, was viewed as a significant benefit. It was observed on several occasions that medical staff in urgent care environments approached fellows for advice about community and primary care:
‘I just say “pick up the phone”. They say “the named GP is almost never there” and I was saying “don’t worry about their named GP, [the other GPs at the practice] will have access to the same information”.’
(6)
Professional development and academic training
The weekly academic days were felt to complement the clinical skills development and were valued as providing practical, evidence-based learning opportunities and peer support. They provided an opportunity to consolidate on experiences and build confidence. For some, the prospect of Masters-level academic training was a distinct attraction of the fellowship:
‘You cannot pinpoint it to one thing, especially when comparing the academic with the clinical days. It is a combination of both for success, as you learn on the academic day what you try to apply in your clinical and vice versa.’
(6)
‘ [The taught days] afforded us a lot more knowledge of how to manage subacute and acute cases in the community. So we had teaching about diabetes, heart failure, acute MIs, orthopaedics, musculoskeletal, which could sometimes present as an acute condition.’
(3)
For some participants, there were gaps where it was felt more professional development would have been of value, as reflected in the following comment:
‘What I think it lacks a little bit is the paediatric side of things when you are talking about urgent care and I think that could be incorporated possibly a bit more.’
(4)
Working towards a Masters-level award, writing assignments, and making presentations about their service improvement projects were among the most demanding aspects of the programme. The projects enabled the fellows to explore how to meet patients’ needs more effectively and efficiently, and potentially contribute to longer-term service improvement. They covered issues such as triaging patients, patients’ attendance at emergency departments during surgery hours, and the impact of advanced care plans for nursing home residents on reducing emergency ambulance calls. One project involved writing new guidelines for reviewing pregnant women who attend emergency departments; this has now been implemented in the hospital. Another involved the fellow creating a community resource pathway booklet for the hospital; this has been made available on its intranet.
Although most participants appeared to thrive on this, some found it difficult to balance within the context of the clinical activities:
‘Doing a sort of degree and doing the work, it’s just balancing that out, because it can take over your life.’
(5)
‘I’d not done academic writing before. It was quite a steep learning curve for me … It was another challenge and opportunity. I don’t think I would have been able to do that doing a regular job.’
(2)
The Postgraduate Certificate in Urgent and Acute Care was valued as an important element of the scheme that demonstrated the application of reflective clinical, strategic, and operational thinking:
‘The critical appraisal of things, which is one of the skills we learn as well … this is what this evidence says but is this really relevant in our setting? Having that perception shift — that has been really useful in the academic days.’
(5)
Challenging negative attitudes
Challenging the negative attitudes about general practice that are held in secondary care was viewed as an unanticipated benefit of the scheme. The leadership training was felt to prepare them for this, and their presence in acute care settings had led to secondary care colleagues becoming more appreciative of the skillset of general practice:
‘Everybody is working in silos and we are actually just trying to bridge that gap … you need people to act as the ambassadors of each side to go to them and say, “Well, this is what we do, do you want to know more? We don’t bite, you can come and ask us questions, you know.”’
(5)
‘I think changing attitudes was probably the biggest achievement for me of the fellowship, and I think that was the case in every placement that we had.’
(4)
‘It was up to me to assert myself. Learning leadership helped. Being clear in your head what your role is and conveying that clearly.’
(3)
However, there were examples of acute clinical teams who were less receptive to the aims of the fellowship scheme, sometimes seeing the GP as just ‘another pair of clinical hands’, and on reflection all fellows felt this needed further attention:
‘She took me round and introduced me and said “this is our new GP”, but that was it because she didn’t really understand … “What are they going to do?” and “Why are they here?” was missing … I think they really struggled with the concept of who we are.’
(4)
As the fellowship became more established, measures were introduced to address this issue, including a programme manual for all individuals who have responsibility for implementing the fellowship within each clinical setting.
In addition, the regional leads of the programme meet regularly with all sites to facilitate the smooth running of the placements.
Impact on career opportunities and the GP workforce
Career opportunities
The fellows described how their employment since completing the fellowship had been supported by the knowledge, skills, and experience gained from the training.
They believed their skillset was highly valued by potential employers. Three were now working part-time as GPs in emergency department roles in addition to working sessions in general practice, one was appointed urgent and acute clinical lead for a clinical commissioning group (CCG) and clinical lead for an ambulance service physician response unit, and three were working in urgent care and walk-in services:
‘The fellowship has opened up different horizons and opportunities … the guy who hired me knew about the fellowship, so he approached me because I was on the fellowship, it was definitely an advantage.’
(2)
‘I am still in touch with many of the people that I worked with at the hospital. So even a few weeks ago somebody e-mailed me about a vacancy that they had and that they were considering a GP for and whether I knew somebody from the fellowship who would be interested in it.’
(4)
‘I was approached by various headhunters and locum agencies for salaried posts. I had quite a few interviews as a result and my current post was offered to me based on the experience gained during the fellowship.’
(5)
There were examples of how the fellows had already taken on leadership roles in relation to clinical practice, commissioning, and service development:
‘In my current role, [I am] lead clinician with a team of ANPs [advanced nurse practitioners], trainee ANPs, shop floor nurses, HCAs [healthcare assistants] in a minor injury unit/A&E.’
(7)
‘I have taken the lead on the urgent care side in the practice, working with [CCG] looking at developing things in different areas. I use a lot of what I have learnt and picked up whilst on the fellowship. I have been working with the CCG on their urgent care schemes … it’s amazing how natural it feels now.’
(4)
Another fellow had taken on a lead role at CCG level:
‘I provide clinical oversight for the urgent care work that is done within [CCG] … The fellowship helped, very much so. It gave me a good insight into the organisational structures within acute care and the ambulance service. I certainly wouldn’t be doing this job had I not done the fellowship.’
(1)
Two of the cohort had decided to continue their academic development, with one working towards a Masters degree with the aim of becoming an educational lead and the other doing a postgraduate diploma in diabetes in order to strengthen the delivery of diabetes care in the community:
‘I am doing a negotiated learning for 40 credits towards a Masters looking at care of marginalised groups. That’s building on the whole service enhancement theme that there was within the fellowship.’
(4)
‘You see a lot of diabetes cases in A&E and in the community, and they do contribute to a lot of admissions. This is something that can be managed in the community very well, so that is what led to my interest in it.’
(6)
Impact on the GP workforce
The fellows described numerous ways in which they had found that the programme was attracting interest from those undertaking vocational training:
‘We went there [Vocational Training Services (VTS) training days] and did a talk about clinical teachings and all that and there were so many ST1s and ST2s who said they were interested in it and they said “This is new, this is so interesting, I would like to do that, it is exciting!”’
(6)
‘I have found it very positive and everyone who I have spoken to — whether that is potential future employers, whether that is colleagues, even friends who I have been telling what I have been doing — have all found it really interesting and I have lots of interest. My inbox has been inundated with, “When is the new one going to start?”’
(4)
It was felt that the opportunity of undertaking extended training may influence medical students and recently qualified doctors to consider GP vocational training by highlighting new career opportunities associated with working at care interfaces:
‘ [Those who] like acute care … might then choose to do GP training whilst they keep their feet in acute care. It will be more attractive because it is giving an extra option to people.’
(2)
‘So when you think general practice, you think of a Monday to Friday job sitting in a surgery, but the urgent care fellowship is a whole way of thinking, not just as a GP, but as a doctor that’s an interface position, working both primary and secondary care … It breaks all boundaries, it breaks all limitations, the world is your oyster.’
(3)
The experience of being an independent GP before embarking on the fellowship was felt to be important, particularly in terms of the value and impact of having a GP working within acute clinical settings.
Hence, some felt that the fellowship objectives would be compromised if it was embedded into vocational training:
‘I would not have preferred it as another 1 year in GP training. I think it would make a big difference being in the roles that we were, as a fully qualified GP compared to GP in additional training.’
(7)
