Extended training to prepare GPs for future workforce needs: a qualitative investigation of a 1-year fellowship in urgent care

Evaluation of different models of general practitioners working in or alongside emergency departments: a mixed-methods realist evaluation

Background

Emergency healthcare services are under intense pressure to meet increasing patient demands. Many patients presenting to emergency departments could be managed by general practitioners in general practitioner-emergency department service models.

Objectives

To evaluate the effectiveness, safety, patient experience and system implications of the different general practitioner-emergency department models.

Design

Mixed-methods realist evaluation.

Methods

Phase 1 (2017-8), to understand current practice: rapid realist literature review, national survey and follow-up key informant interviews, national stakeholder event and safety data analysis. Phase 2 (2018-21), to collect and analyse qualitative (observations, interviews) and quantitative data (time series analysis); cost-consequences analysis of routine data; and case site data for 'marker condition' analysis from a purposive sample of 13 case sites in England and Wales. Phase 3 (2021-2), to conduct mixed-methods analysis for programme theory and toolkit development.

Results

General practitioners commonly work in emergency departments, but delivery models vary widely in terms of the scope of the general practitioner role and the scale of the general practitioner service. We developed a taxonomy to describe general practitioner-emergency department service models (Integrated with the emergency department service, Parallel within the emergency department, Outside the emergency department on the hospital site) and present a programme theory as principal output of the study to describe how these service models were observed to operate. Routine data were of variable quality, limiting our analysis. Time series analysis demonstrated trends across intervention sites for: increased time spent in the emergency department; increased emergency department attendances and reattendances; and mixed results for hospital admissions. Evidence on patient experience was limited but broadly supportive; we identified department-level processes to optimise the safety of general practitioner-emergency department models.

Limitations

The quality, heterogeneity and extent of routine emergency department data collection during the study period limited the conclusions. Recruitment was limited by criteria for case sites (time series requirements) and individual patients (with 'marker conditions'). Pandemic and other pressures limited data collection for marker condition analysis. Data collected and analysed were pre pandemic; new approaches such as 'telephone first' and their relevance to our findings remains unexplored.

Conclusion

Findings suggest that general practitioner-emergency department service models do not meet the aim of reducing the overall emergency department waiting times and improving patient flow with limited evidence of cost savings. Qualitative data indicated that general practitioners were often valued as members of the wider emergency department team. We have developed a toolkit, based on our findings, to provide guidance for implementing and delivering general practitioner-emergency department services.

Future work

The emergency care data set has since been introduced across England to help standardise data collection to facilitate further research. We would advocate the systematic capture of patient experience measures and patient-reported outcome measures as part of routine care. More could be done to support the development of the general practitioner in emergency department role, including a core set of competencies and governance structure, to reflect the different general practitioner-emergency department models and to evaluate the effectiveness and cost effectiveness to guide future policy.

Study registration

This study is registered as PROSPERO CRD42017069741.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/145/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 10. See the NIHR Funding and Awards website for further award information.

An International Competency Framework for High-Quality Workforce Development in Integrated Care (IC): A Modified Delphi Study Among Global Participants

Introduction

There have been increasing calls in the literature recommending training in integrated care (IC) for health and social care professionals. Although studies have focused on different stakeholders' perceptions of education and training, there is no consistent definition of the key competencies or approach to implementing these competencies among health and social care providers. This study used a modified Delphi consensus-building method with global panellists with experience in delivering and designing training in IC to ascertain which competencies are important in an international framework guiding workforce development in IC.

Methods

A four-step methodological process was used. First, a scoping review identified a potential list of competencies and features of education and training in IC. Second, predefined criteria were used to identify global panellists with IC education experience. Third, two anonymous iterative Delphi rounds were conducted to (1) reach a consensus on the level of importance of the competencies and key themes to be included and (2) identify existing models of training in IC. This was followed by the analysis of the Delphi study and presentation of the results.

Results

A list of eight domains and 40 competencies was generated. Twenty-one panellists reviewed the competencies in the first and second round. The highest importance rankings were allocated to person-centred care, interprofessional teamwork and care coordination. The lower-ranking domains focused on professional workforce attributes.

Discussion and conclusion

The study provides a global consensus on the competencies required for workforce training and development in IC and offers recommendations on how these competencies can be implemented in higher education and vocational institutions and workplace settings. The results will be useful for developing policy and curriculum by health and education providers and accreditation bodies.

Strength in the gap: A rapid review of principles and practices for urgent care centres

Responding to a provincial government decision to develop two Urgent Care Centres (UCCs) in Saskatchewan, we undertook a rapid review of published literature with the objective of determining best practices for their creation and functioning. Two English-limited PubMed database searches combining "after-hours care," "ambulatory care," "emergency medicine," "urgent care," "minor emergency," "walk-in," and "Canada" over the past 10 years were the sources of articles for our review. Articles were independently reviewed by two authors and synthesized collaboratively. From 833 articles, 44 were utilized in the review. Six considerations in the following areas were subsequently outlined: expected impact, preferred location, healthcare services collaboration, available services, staffing priorities, and community partnerships. These principles were considered against the backdrop of currently successful Canadian UCCs. This review indicates that general principles for the successful development of UCCs exist; these may guide the establishment and functioning of UCCs both in Saskatchewan and elsewhere.

Applicant Selection for Anesthesiology Residency Programs in Saudi Arabia

Background

Anesthesiology is a medical specialty that involves pre, intra, and postoperative surgical and medical procedures; it is a profession shaped by the clinician’s medical knowledge and manual dexterity. To date, very few studies have addressed the selection criteria and factors associated with the applicant selection process for anesthesia residency programs in Saudi Arabia.

Objectives

We aimed to define the criteria, factors, and guidelines for candidate selection in anesthesia residency programs in Saudi Arabia.

Methodology

This was a cross-sectional study conducted using electronic questionnaires that were distributed to anesthesiology program directors in Saudi Arabia via email. The questionnaire was divided into six sections, and each section included various parameters such as demographic data, cognitive/academic activities, non-cognitive/non-academic activities, individual qualities, and red flags or negative factors of the individual. The participants rated each parameter, and the collected data were analyzed for statistical significance (p≤0.05).

Results

A total of 28 programs were included in this survey. All 14 parameters associated with individual qualities were found to be significantly important for applicant selection (p≤0.05). Except for delayed entry into residency after graduation, all 12 parameters associated with red flags or negative characteristics of individuals were significant for candidate selection (p≤0.05).

Conclusion

The results showed that academic/cognitive factors and non-academic/non-cognitive factors, along with the individual characteristics of the applicant, were given priority when selecting candidates for anesthesiology residency programs in Saudi Arabia.

Workforce Development in Integrated Care: A Scoping Review

Introduction

Integrated care aims to improve access, quality and continuity of services for ageing populations and people experiencing chronic conditions. However, the health and social care workforce is ill equipped to address complex patient care needs due to working and training in silos. This paper describes the extent and nature of the evidence on workforce development in integrated care to inform future research, policy and practice.

Methods

A scoping review was conducted to map the key concepts and available evidence related to workforce development in integrated care.

Results

Sixty-two published studies were included. Essential skills and competencies included enhancing workforce understanding across the health and social care systems, developing a deeper relationship with and empowering patients and their carers, understanding community needs, patient-centeredness, health promotion, disease prevention, interprofessional training and teamwork and being a role model. The paper also identified training models and barriers/challenges to workforce development in integrated care.

Discussion and Conclusion

Good-quality research on workforce development in integrated care is scarce. The literature overwhelmingly recognises that integrated care training and workforce development is required, and emerging frameworks and competencies have been developed. More knowledge is needed to implement and evaluate these frameworks, including the broader health and social care workforces within a global context. Further research needs to focus on the most effective methods for implementing these competencies.

Factors impacting anesthesiology residents in Saudi Arabia when they are planning their future

Purpose:

This study is undertaken to examine the factors that influence Saudi Board anesthesia residents' preferences in terms of future practice location, fellowship training, and research.

Methods:

A cross-sectional study was conducted. Data on fellowship training, research, and future practice location preferences, as well as demographics, were collected using surveys distributed to all anesthesia residents enrolled at Saudi anesthesiology residency program (N = 302).

Results:

A total of 117 residents (38.7%) responded to the survey. Of those 88.5% of residents planned on further subspecializing. The most highly sought fellowships were acute and chronic pain, regional anesthesia, simulation, and pediatric anesthesia. Residents pursuing fellowship training were mostly affected by personal interest, improving employment prospects, and future income. Only 11.5% of residents intended to incorporate research into their next practice—personal interest, employability, and lifestyle were the most influential in their decision.

Conclusion:

Most anesthesia residents training in Saudi Arabia choose to pursue fellowship training. However, less than one-fifth have an interest in incorporating research into their future careers.

The impact of general practitioners working in or alongside emergency departments: a rapid realist review

OBJECTIVES

Worldwide, emergency healthcare systems are under intense pressure from ever-increasing demand and evidence is urgently needed to understand how this can be safely managed. An estimated 10%-43% of emergency department patients could be treated by primary care services. In England, this has led to a policy proposal and £100 million of funding (US$130 million), for emergency departments to stream appropriate patients to a co-located primary care facility so they are 'free to care for the sickest patients'. However, the research evidence to support this initiative is weak.

DESIGN

Rapid realist literature review.

SETTING

Emergency departments.

INCLUSION CRITERIA

Articles describing general practitioners working in or alongside emergency departments.

AIM

To develop context-specific theories that explain how and why general practitioners working in or alongside emergency departments affect: patient flow; patient experience; patient safety and the wider healthcare system.

RESULTS

Ninety-six articles contributed data to theory development sourced from earlier systematic reviews, updated database searches (Medline, Embase, CINAHL, Cochrane DSR & CRCT, DARE, HTA Database, BSC, PsycINFO and SCOPUS) and citation tracking. We developed theories to explain: how staff interpret the streaming system; different roles general practitioners adopt in the emergency department setting (traditional, extended, gatekeeper or emergency clinician) and how these factors influence patient (experience and safety) and organisational (demand and cost-effectiveness) outcomes.

CONCLUSIONS

Multiple factors influence the effectiveness of emergency department streaming to general practitioners; caution is needed in embedding the policy until further research and evaluation are available. Service models that encourage the traditional general practitioner approach may have shorter process times for non-urgent patients; however, there is little evidence that this frees up emergency department staff to care for the sickest patients. Distinct primary care services offering increased patient choice may result in provider-induced demand. Economic evaluation and safety requires further research.

PROSPERO REGISTRATION NUMBER

CRD42017069741.

Learning from the transfer of a fellowship programme to support primary care workforce needs in the UK: a qualitative study

OBJECTIVES

Service redesign, including workforce development, is being championed by UK health service policy. It is allowing new opportunities to enhance the roles of staff and encourage multiprofessional portfolio working. New models of working are emerging, but there has been little research into how innovative programmes are transferred to and taken up by different areas. This study investigates the transferability of a 1-year post-Certification of Completion of Training fellowship in urgent and acute care from a pilot in the West Midlands region of England to London and the South East.

DESIGN

A qualitative study using semistructured interviews supplemented by observational data of fellows' clinical and academic activities. Data were analysed using a thematic framework approach.

SETTING AND PARTICIPANTS

Two cohorts of fellows (15 in total) along with key stakeholders, mentors, tutors and host organisations in London and the South East (LaSE). Fellows had placements in primary and secondary care settings (general practice, emergency department, ambulatory care, urgent care and rapid response teams), together with academic training.

RESULTS

Seventy-six interviews were completed with 50 participants, with observations in eight clinical placements and two academic sessions. The overall structure of the West Midlands programme was retained and the core learning outcomes adopted in LaSE. Three fundamental adaptations were evident: broadening the programme to include multiprofessional fellows, changes to the funding model and the impact that had on clinical placements. These were felt to be key to its adoption and longer-term sustainability.

CONCLUSION

The evaluation demonstrates a model of training that is adaptable and transferable between National Health Service regions, taking account of changing national and regional circumstances, and has the potential to be rolled out widely.