Abstract
Training in general practice is a challenging, rewarding and exciting experience. Armed with their Certificate of Completion of Training (CCT) the new GP heads out into the workplace ready for the next steps of their professional development; unfortunately, all is not rosy. It can be difficult to know where to start, how to navigate the myriad of career options and how to develop skills and knowledge. In addition, general practice has a workforce problem (Marchand and Peckham, 2017). There are new and increased challenges in terms of training, recruiting and retaining sufficient numbers of healthcare professionals to work in general practice. More GPs are opting for salaried positions and portfolio careers, leading to many areas considering alternative employment and workforce models (Baird et al., 2016).
The NHS 5-year Forward View envisages a world of closer integration between primary and secondary care, with a focus on proactive care and clinical leadership (NHS England et al., 2014). The recent NHS long term plan goes further, with a focus on community care, population health and collaboration, with a promise of £4.5 billion to fund the expansion of multidisciplinary community teams to work with GPs (NHS, 2019). This imagines an integrated, person-centred service, with joined up care across primary, secondary and mental health services in partnership with local government. Staffing this near-future NHS requires clinicians with skills to lead, transform, and coordinate care across organisational sectors.
Post-CCT Primary Care Fellowships are programmes that provide additional support and development for newly qualified GPs or those in their first few years of practice. Typically a year in length, they were developed by Health Education West Midlands, who established a pilot training programme for post CCT GPs in Urgent & Acute care in 2014. In subsequent cohorts, the scheme was expanded by Health Education England, London & South East with the creation of the Primary Care Fellowship programme. In cooperation with regional providers, this aims to develop a new class of GP and primary healthcare professional, capable of bridging the gap between primary and secondary care, by supporting clinical maturity in general practice, and by extended development in specific clinical areas. The typical post has 2 days in a general practice setting, 2 days in an acute setting, and 1 academic day completing a post-graduate qualification with an affiliated university. The current Fellowship scheme has placements in urgent and acute care, cancer survivorship, and community care of the elderly (frailty). The scheme is not only open to GPs, but also to other professional roles. In the current cohort, there are practice nurses, pharmacists, community matrons and palliative care nurses, as well as GPs. This multidisciplinary professional learning network offers a fantastic opportunity to develop skills beyond a narrow focus of practice.
I am a GP working in Islington, North London, as part of this innovative Primary Care Fellowship coordinated by Health Education England. I am part of the third cohort 2017–18 and my placement is in Frailty. I qualified in 2014 and have worked as a salaried GP, a partner-cover locum and as a Clinical Teaching Fellow with our local medical school. I have also worked in A&E as well as extended and out-of-hours general practice. My interest is in the transitions of clinical care and a particular interest in older adults. I saw the advert for the Fellowship programme through NHS jobs and was really interested by the combination of clinical and academic roles, as well as the attraction of a single contract to cover all jobs. I want to use my experience to showcase how this role might work for the newly qualified GP.
I split my working week between primary and secondary care, working at the interface between the sectors, with an emphasis on improving care for those living with frailty. My role contains an academic component (a PGCert at the University of Christchurch Canterbury), specifically looking at the challenges regarding leadership, innovation and sustainable change in integration of care. In primary care, I work with our local GP Federation, a collaboration of 33 GP practices, who are able to facilitate clinical placements at individual practices to support work on my project. Through partnership working with local health and care organisations, Islington GP Federation is testing new models of integrated care, driving forward a range of pilots for local, population-based, preventative care. In addition to providing commissioned services including community ENT & gynaecology clinics and evening/weekend extended access to core GP services (known as iHub), it is leading a programme of activities to drive increased GP collaboration and at scale working, and to increase GP resilience in practices and across networks of practices. My main role with the Federation has been clinical leadership of a quality improvement (QI) support team) to frame, evaluate and iterate the diverse activities outlined above. I am very proud that this QI team won the national NHS70 Parliamentary Award for Healthier Communities in July 2018.
Within the hospital sector, I work with Whittington Hospital, providing clinical care as part of a Virtual Ward team, visiting patients at home to enhance recovery after a hospital attendance or admission. Our patients tend to be older and frailer, with multiple long term conditions and social challenges contributing to their health challenges. My role as a GP is to provide a holistic assessment and integrate with the existing community services. In addition, I am working with a multidisciplinary team within the hospital to design, develop and improve a pathway for those with frailty attending the emergency department. Similar to other national initiatives, we are using clinical scoring of frailty at the front door to both identify patients and offer a clinical multidisciplinary team approach to support alternatives to admission.
Within the wider health and care context, there is high-level agreement between provider organisations in neighbouring boroughs to work together for the benefit of patients outside the formal regulatory structure of an Accountable Care Organisation (Ham, 2018). Within this partnership is a frailty programme with the ambition to maximise the experience of coordinated and high-quality care. The NHS long term plan (NHS, 2019) makes explicit the need to embed a person-centred approach and challenges the medical profession to adapt to the needs of an ageing population, helping frail and older people stay healthy and independent, preventing avoidable admissions, and integrating health and social care. There are primary-care-led initiatives in these boroughs to improve early identification and proactive care for people who are at rising risk of frailty to reduce crisis and stabilise long term demand. There are also integrated care schemes in place to promote effective joint working across organisations, particularly with a focus on admission avoidance and supporting hospital discharge. Within individual organisations there are plans for improvement in all areas, from adult social care to quality of residential care, memory services and acute frailty pathways. Each of these areas has its own complexity and requirement for system-working. Participation in the Primary Care Fellowship scheme leaves me uniquely positioned to see across the whole system, and to contribute to the strategy for the changes required.
My experience of my Primary Care Fellowship has given me insight into my own leadership capabilities and gives me more confidence in my own ability to participate in this large scale change process. The Fellowship programme has been evaluated (Dale et al., 2017) and has been well received, balancing well the opportunities for skill development, academic advancement and confidence-building. It improves communication and supports integrated care between primary and secondary care settings, challenging some of the misconceptions about general practice and community-based care. After completing the programme, most Fellows utilise the skills gained and can be found working in a variety of primary care / urgent care interface clinical and leadership roles.
In contrast with the well-known GP Academic Clinical Fellowship scheme (Funston et al., 2015), and more recent Global Health Fellow programme (GP National Recruitment Office, 2018) (an early version of which I completed as an Out-of-Programme Experience during my training), these clinical Primary Care Fellowships are aimed at newly qualified GPs who wish to gain extra skills and experience in working in blended roles across organisational boundaries. Fellowship programmes contribute to the transformation of the primary care workforce by supporting both the acquisition of clinical maturity in general practice and extended development in specific clinical or professional areas, furthering both local workforce capability and the career aspirations of the GP Fellows themselves. Primary Care Fellowships are often advertised locally within Clinical Commissioning Groups and nationally on NHS jobs, usually recruiting in time for the new academic year, but there are opportunities to join if there are vacancies in the programme. Further details are available by contacting your local Health Education England lead by using their website (NHS Health Education England).