ObjectivesThis study draws on an in-depth investigation of factors that influenced the career decisions of junior doctors.SettingJunior doctors in the UK can choose to enter specialty training (ST) programmes within 2 years of becoming doctors. Their specialty choices contribute to shaping the balance of the future medical workforce, with views on general practice (GP) careers of particular interest because of current recruitment difficulties. This paper examines how experiences of medical work and perceptions about specialty training shape junior doctors’ career decisions.ParticipantsTwenty doctors in the second year of a Foundation Training Programme in England were recruited. Purposive sampling was used to achieve a diverse sample from respondents to an online survey.ResultsNarrative interviewing techniques encouraged doctors to reflect on how experiences during medical school and in medical workplaces had influenced their preferences and perceptions of different specialties. They also spoke about personal aspirations, work priorities and their wider future.Junior doctors’ decisions were informed by knowledge about the requirements of ST programmes and direct observation of the pressures under which ST doctors worked. When they encountered negative attitudes towards a specialty they had intended to choose, some became defensive while others kept silent. Achievement of an acceptable work-life balance was a central objective that could override other preferences.Events linked with specific specialties influenced doctors’ attitudes towards them. For example, findings confirmed that while early, positive experiences of GP work could increase its attractiveness, negative experiences in GP settings had the opposite effect.ConclusionsJunior doctors’ preferences and perceptions about medical work are influenced by multiple intrinsic and extrinsic factors and experiences. This paper highlights the importance of understanding how perceptions are formed and preferences are developed, as a basis for generating learning and working environments that nurture students and motivate their professional careers.

Background General practices have had difficulty recruiting and retaining enough general practitioners to keep up with increasing demand for primary health care in recent years. Proposals to increase workforce capacity include a policy-driven strategy to employ additional numbers and a wider range of health professionals. Objectives Our objective was to conduct a comprehensive study of the scale, scope and impact of changing patterns of practitioner employment in general practice in England. This included an analysis of employment trends, motivations behind employment decisions, staff and patient experiences, and how skill mix changes are associated with outcome measures and costs. Design NHS Digital workforce data (2015–19) were used to analyse employment changes and to look at their association with outcomes data, such as the General Practitioner Patient Survey, General Practitioner Worklife Survey, prescribing data, Hospital Episode Statistics, Quality and Outcomes Framework and NHS payments to practices. A practice manager survey (August–December 2019) explored factors motivating general practices’ employment decisions. An in-depth case study of five general practices in England (August–December 2019) examined how a broader range of practitioners is experienced by practice staff and patients. Results We found a 2.84% increase in reported full-time equivalent per 1000 patients across all practitioners during the study period. The full-time equivalent of general practitioner partners decreased, while the full-time equivalent of salaried general practitioners, advanced nurse practitioners, clinical pharmacists, physiotherapists, physician associates and paramedics increased. General practitioners and practice managers reported different motivating factors regarding skill mix employment. General practitioners saw skill mix employment as a strategy to cope with a general practitioner shortage, whereas managers prioritised potential cost-efficiencies. Case studies demonstrated the importance of matching patients’ problems with practitioners’ competencies and ensuring flexibility for practitioners to obtain advice when perfect matching was not achieved. Senior clinicians provided additional support and had supervisory and other responsibilities, and analysis of the General Practitioner Worklife Survey data suggested that general practitioners’ job satisfaction may not increase with skill mix changes. Patients lacked information about newer practitioners, but felt reassured by the accessibility of expert advice. However, General Practitioner Patient Survey data indicated that higher patient satisfaction was associated with a higher general practitioner full-time equivalent. Quality and Outcomes Framework achievement was higher when more practitioners were employed (i.e. full-time equivalent per 1000 patients). Higher clinical pharmacist full-time equivalents per 1000 patients were associated with higher quality and lower cost prescribing. Associations between skill mix and hospital activity were mixed. Our analysis of payments to practices and prescribing costs suggested that NHS expenditure may not decrease with increasing skill mix employment. Limitations These findings may reflect turbulence during a period of rapid skill mix change in general practice. The current policy of employing staff through primary care networks is likely to accelerate workforce change and generate additional challenges. Conclusions Skill mix implementation is challenging because of the inherent complexity of general practice caseloads; it is associated with a mix of positive and negative outcome measures. Future work Findings from this study will inform future funding applications for projects that seek to examine the nature and impact of evolving multiprofessional teams in primary care. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 9. See the NIHR Journals Library website for further project information.

ObjectivesTo examine the extent, and nature, of impact on junior doctors' career decisions, of a proposed new contract and the uncertainty surrounding it.DesignMixed 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.SettingDoctors (F2s) in second year of Foundation School (FS) Programmes in England.ParticipantsInvitations 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 measuresProportions 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.ResultsAmong 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.ConclusionsDoctors 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.

ObjectiveTo quantify general practitioners’ (GPs’) turnover in England between 2007 and 2019, describe trends over time, regional differences and associations with social deprivation or other practice characteristics.DesignA retrospective study of annual cross-sectional data.SettingAll general practices in England (8085 in 2007, 6598 in 2019).MethodsWe calculated turnover rates, defined as the proportion of GPs leaving a practice. Rates and their median, 25th and 75th percentiles were calculated by year and region. The proportion of practices with persistent high turnover (>10%) over consecutive years were also calculated. A negative binomial regression model assessed the association between turnover and social deprivation or other practice characteristics.ResultsTurnover rates increased over time. The 75th percentile in 2009 was 11%, but increased to 14% in 2019. The highest turnover rate was observed in 2013–2014, corresponding to the 75th percentile of 18.2%. Over time, regions experienced increases in turnover rates, although it varied across English regions. The proportion of practices with high (10% to 40%) turnover within a year almost doubled from 14% in 2009 to 27% in 2019. A rise in the number of practices with persistent high turnover (>10%) for at least three consecutive years was also observed, from 2.7% (2.3%–3.1%) in 2007 to 6.3% (5.7%–6.9%) in 2017. The statistical analyses revealed that practice-area deprivation was moderately associated with turnover rate, with practices in the most deprived area having higher turnover rates compared with practices in the least deprived areas (incidence rate ratios 1.09; 95% CI 1.06 to 1.13).ConclusionsGP turnover has increased in the last decade nationally, with regional variability. Greater attention to GP turnover is needed, in the most deprived areas in particular, where GPs often need to deal with more complex health needs. There is a large cost associated with GP turnover and practices with very high persistent turnover need to be further researched, and the causes behind this identified, to allow support strategies and policies to be developed.

BackgroundThe capacity of the UK GP workforce has not kept pace with increasing primary care workloads. Although many doctors successfully complete GP specialty training programmes, some do not progress to work in NHS general practice.AimThis article explores the training experiences and perceptions of newly qualified GPs to understand how their education, training, and early experiences of work influence their career plans.Design and settingA qualitative study of doctors in their final year of GP training (ST3) and within 5 years of completion of GP training (F5).MethodParticipants across England were recruited through training programmes, First5 groups, and publicity using social media and networks. Open narrative interviews were conducted with individuals and focus groups. Audiorecorded interviews were transcribed, and a thematic analysis was supported by NVivo and situational analysis mapping techniques.ResultsFifteen participants engaged in individual interviews and 10 focus groups were carried out with a total of 63 participants. Most doctors reported that training programmes had prepared them to deal confidently with most aspects of routine clinical GP work. However, they felt underprepared for the additional roles of running a practice and in their understanding of wider NHS organisational structures. Doctors wished to avoid unacceptably heavy workloads and voiced concerns about the longer-term sustainability of general practice.ConclusionStrategies to attract and retain enough GPs to support delivery of comprehensive primary care should consider how doctors’ early career experiences influence their career intentions. A coherent plan is needed to improve their preparation and increase confidence that they can achieve a professionally satisfying, effective, and sustainable career in NHS general practice.

Background: 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 in England in 2019. Method: Multivariable regression analysis relating numbers of staff in four groups (GPs; Nurses; Health Professionals; and Health Associate Professionals) to patient access and satisfaction, quality of clinical care and prescribing, use of hospital services, GP working conditions, and costs to National Health Service. Results: More GPs were associated with higher satisfaction for patients and GPs, More workers of other types had opposite associations with these outcomes. More Nurses and Health Associate Professionals were associated with lower cost per prescription but more prescribing activity. More GPs were associated with higher costs per prescription and lower use of narrow-spectrum antibiotics. Except for Health Associate Professionals, more staff were associated with more hospital activity. Higher NHS costs were associated most with more Nurses and least with more Health Professionals. The effects of different staff types on outcomes were largely independent. Conclusion: Professional, population and system outcomes show a variety of associations with primary care workforce composition. More Nurses are associated with lower quality in some aspects and higher costs and activity. More Health Professionals and Health Associate Professionals associates less than additional GPs with higher costs, but is associated with lower patient and GP satisfaction.

ObjectiveEnglish primary care faces significant challenges, including ‘persistent high turnover’ of general practitioners (GPs) in some partnerships. It is unknown whether there are specific predictors of persistent high turnover and whether it is associated with poorer population health outcomes.DesignA retrospective observational study.MethodsWe linked workforce data on individual GPs to practice-level data from Hospital Episode Statistics and the GP Patient Survey (2007–2019). We classified practices as experiencing persistent high turnover if more than 10% of GPs changed in at least 3 consecutive years. We used multivariable logistic or linear regression models for panel data with random effects to identify practice characteristics that predicted persistent high turnover and associations of practice outcomes (higher emergency hospital use and patient experience of continuity of care, access to care and overall patient satisfaction) with persistent high turnover.ResultsEach year, 6% of English practices experienced persistent high turnover, with a maximum of 9% (688/7619) in 2014. Larger practices, in more deprived areas and with a higher morbidity burden were more likely to experience persistent high turnover. Persistent high turnover was associated with 1.8 (95% CI 1.5 to 2.1) more emergency hospital attendances per 100 patients, 0.1 (95% CI 0.1 to 0.2) more admissions per 100 patients, 5.2% (95% CI −5.6% to −4.9%) fewer people seeing their preferred doctor, 10.6% (95% CI−11.4% to −9.8%) fewer people reporting obtaining an appointment on the same day and 1.3% (95% CI −1.6% to −1.1%) lower overall satisfaction with the practice.ConclusionsPersistent high turnover is independently linked to indicators of poorer service and health outcomes. Although causality needs to be further investigated, strategies and policies may be needed to both reduce high turnover and support practices facing challenges with high GP turnover when it occurs.

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