HEE SW Pan-STP UEC Workforce Programme Developing Salaried Portfolio GP Roles

1. HEE SW Pan-STP UEC Workforce Programme Developing Salaried Portfolio GP Roles Dr. Justin Geddes CEO, Devon Doctors Liz Edwards-Smith Director of Organisational Development, Evalesco Consulting

2. Background to Project and Case for Change

3. Why this project? • We recognised there are workforce challenges in urgent care • We want to offer something different to attract and retain GPs in urgent care • We recognise that GPs want the opportunity to do different things • Research suggests that more GPs want a portfolio approach to work • Patients want high quality care to be joined up and available when they need it • Policymakers want healthcare to be integrated and see GPs as vital to this

4. What do we want to achieve? • Develop a role that increases the workforce resilience of Integrated Urgent Care Services • Develop a role in which the GP can interface between urgent and acute healthcare services across health settings for the benefit of patients and the health system • Enhance the function of the GP within urgent and acute secondary care teams such as ED, Frailty and Paediatrics • Raise GP interest in urgent care and emergency medicine career paths • Enhancing the general wellbeing in particular the mental health of GPs • Design an attractive job role that will support urgent and emergency care system-wide recruitment and retention.

5. The aspiration…… • Develop a new Salaried Portfolio GP role working across General Practice, the Integrated Urgent Care Service (IUCS) and secondary care with protected support time • Over time, to offer 10-15 new posts.

6. Case for Change – attitudes and intentions • From the BMA 2016 Survey (of all GPs) • 5,025 responses • 34% of GP Partners think their role and responsibilities are too onerous such that they wish to explore alternative working options • 30% of respondents would like to work as a portfolio GP • Three in ten GPs described being a salaried GP as a positive career choice. • From the BMA 2017 Sessional GP Survey • 2,079 responses • Looking forward over five years, most respondents preferred career option would to be work as a portfolio GP.

7. Case for Change – attitudes and intentions • From the Kings Fund GP Trainee Survey (2017) • 729 respondents • 21.7% planned to work in full-time clinical general practice one year after qualifying. This fell to 5.4% planning to do so ten years after qualifying • 9% (in the first year post-qualifying) intended to work part-time as a GP, with many wanting to undertake other responsibilities and have ‘portfolio’ careers, with this option becoming increasingly popular the longer they had qualified • 52% chose other clinical NHS work’ as the preferred option for work alongside their NHS general practice commitments. ‘Medical education’ was also a popular choice (39 per cent of respondents) • most commonly cited reason for not undertaking full-time NHS general practice work, irrespective of gender, was ‘intensity of working day’

8. Case for Change – attitudes and intentions • From the University of Exeter Medical School 2017: Quitting patient care and career break intentions among GPs in the South West of England; findings from a census survey of GPs • 20% of GPs reported a high likelihood of quitting direct patient care within 2 years • 37% of GPs reported a high likelihood of quitting direct patient care within 5 years • 70% of GPs reported a career intention that, if implemented, would negatively impact GP workforce capacity and availability in the next 5 years • 57% of GPs reported they are likely or very likely to reduce working hours.

10. Case for Change – close to home • GP numbers are declining nationally (2.2% decline in FTE GPs in 2017) and locally • More GPs are leaving than entering the profession • 20% of the GP workforce eligible to retire in the next 5 years in Devon • Over 200 GPs in Somerset are 50+ - their working intentions are largely unknown

11. Case for Change – attitudes and intentions • From the University of Exeter Medical School 2016: Understanding quit decisions in primary care: a qualitative study of older GPs (50-60 yrs old) • Key factors to take into account when trying to retain GPs in direct patient care include: • making the GP workload more manageable • managing change sympathetically • paying attention to GPs’ own health • improving confidence in the future of general practice; and improving GP morale.

12. Links to surveys and research papers British Medical Association Survey of GPs in England, ICM Unlimited, 2016 British Medical Association, Sessional GP Survey, BMA, 2017 Kings Fund Trainee Survey, 2017 University of Exeter Medical School: Quitting patient care and career break intentions among GPs in the South West of England: findings of a census survey of GPs, BMJ Open, 2017 University of Exeter Medical School: Understanding quit decisions in primary care: a qualitative study of older GPs, BMJ Open, 2016

13. Any questions?

14. Current state analysis and models

15. Current state analysis – portfolio roles All fixed term posts for 12 months

16. Current state analysis – lessons learned • Role definition – clarity on the remit and level/grade of the role within each healthcare setting • Employment model – early agreement on salary and how cross-charging for clinical time will work; prime employer model with honorary contracts including indemnity cover within secondary care setting • Communication – promote a wide understanding of the role within the settings the GP will work in; make clear the benefits of working with a colleague who is sighted on patient pathways across health care settings

17. Current state analysis – lessons learned • Clinical supervision – acknowledgement that this will be necessary for GPs working within secondary care; early agreement as to how this will be provided and funded • Education – provision of funded post-graduate education aligned to clinical interest • Reflection/Wellbeing/emotional support – build in time for reflection and peer support; use of action learning sets to work through challenges

18. Early design and test of role

19. Early design and test of role • Simple demand data analysis showed IUCS key patient cohorts to be paediatrics and frail elderly • Early design of role to include 3 healthcare settings • IUCS • In Hours GP Surgery • Acute Trust (Paediatrics, Frailty or ED) • Early engagement with Royal Devon and Exeter to test idea in principle • Medical Director • Paediatrician (Associate Medical Director) • Consultant Physician (Deputy Medical Director) • Senior HR Manager * Also engaged UHP NHS Trust – they are using outputs from this project to mirror approach.

20. VTS Focus Group - Exeter • The focus group explored factors that make portfolio working attractive with common themes emerging across the group: • Flexibility of sessions (not one group member expected to work full time hours) • Variety of work and opportunity • Choice of where and how to work as a GP (in-hours General Practice, out of hours, expedition doctor, prison doctor, acute setting) • Good salary and earning potential • Autonomous role / independent decision making • The ability to intercept health problems at an early stage • The opportunity to develop a special interest, do research, teach • Salaried portfolio role sounds like an easy option • Salary expectation between £60,000-£70,000 • Helpful to have mentoring, peer support, formal CPD arrangements

21. ST3 Online Survey – Exeter and Plymouth • The online survey achieved a 38% response rate (25 individual responses). The survey was designed to understand attitudes and preferences in relation to GP portfolio working. • Key findings: • 92% stated that portfolio work would be of interest • The top three factors that make portfolio working attractive are variety of work and opportunity (87%), work life balance (78%) and flexibility (74%) • Elements of a portfolio role – 74% stated developing a special interest, 57% stated out of hours work • Other types of work that would be of interest within a portfolio role were education / teaching (52%), being a GP Trainer (43%) and working in an acute setting (39%). • Most frequently cited specialties to develop a special interest in were ‘care of the elderly’, ‘paediatrics’ and ‘acute medicine’.

22. ST3 Online Survey – Exeter and Plymouth • Key findings (cont’d): • 96% would be interested in a ‘salaried’ portfolio role that combined general practice, out of hours and some acute based work • 83% favoured a substantive, salaried role with a main employer that provides a portfolio of work • 65% stated they would prefer their first role on qualifying to be between 4 and 6 sessions, 26% would prefer to work between 7 and 9 sessions • 64% of respondents expect a first salary post qualification for a portfolio role to be up to £75,000

23. Clear indications that….. • The future career intentions of GPs (if followed through) will negatively impact GP capacity • GPs are looking for different professional opportunities and portfolio working is one such opportunity • A ‘salaried’ portfolio role that provides the opportunity to work within General Practice, the out-of-hours service and within an acute setting is an attractive proposition.

24. Any questions?

25. The offer

26. The offer

27. Job plan 1 Two job plans will be offered based on the feedback from the focus group and online survey. There is flexibility to change these based on individual candidate preference. Job Plan 1 Sessions: 8 sessions per week / 30.5 hours (Mon-Sun) / plus protected learning time *Sessional breakdown: 3 sessions in Acute Trust (Healthcare of Older People) 3 sessions General Practice (in hours) **1 session Integrated Urgent Care Service (OOH) 1 session protected learning time  * Session length is dependent on health care setting: Acute Trust session 4hrs, General Practice (in hours) session 4.5hrs, IUCS (OOH) session 5hrs, Protected Learning Time session 4hrs ** opportunity for additional OOH sessions if desired.

28. Job plan 2 Two job plans will be offered based on the feedback from the focus group and online survey. There is flexibility to change these based on individual candidate preference. Job Plan 2 Sessions: 6 sessions per week / 26 hours (Mon-Sun) / plus protected learning time *Sessional breakdown: 3 sessions in Acute Trust (Healthcare of Older People) 2 sessions General Practice (in hours) **1 session Integrated Urgent Care Service (OOH) (with 2 sessions per month protected learning time)  * Session length is dependent on health care setting: Acute Trust session 4hrs, General Practice (in hours) session 4.5hrs, IUCS (OOH) session 5hrs, Protected Learning Time session 4hrs ** opportunity for additional OOH sessions if desired.

29. Job descriptions

30. Support for GPs • The portfolio role includes a package designed to offer both professional and personal support and development: • Onboarding and induction • A clear programme of induction across each healthcare setting • Tailored to the experience of the GP • Clinical Supervision • Named Clinical Supervisor in each healthcare setting • Streamlined process to provide clear picture of performance and easy access to support • Peer Support • Externally facilitated, off-site, clinical peer support group • Protected Learning Time

31. Salary • Two approaches were considered: • Spot salary divided equally by number of sessions to provide parity across all healthcare settings (e.g. £75,000 divided by 8 sessions = £9,375 per session plus on-costs) • OR • Assign different sessional values based on healthcare setting to provide parity among peers within each healthcare setting (e.g. use of SAS scale for acute based sessions, GP sessional rates for General Practice and OOH)

32. Salary • Principles that guided salary conversations: • The salary is comparable to equivalent experienced peers in same healthcare setting • It recognises that when working in a Trust a GP will be developing competences • It reflects the difference in skill set and the value that brings to the MDT in different healthcare settings • It reflects the level of investment in personal development, education and support • It acknowledges that an inflated salary may have unintended consequences within primary care

33. Salary • A simple salary building model was developed: • Direct costs for annual leave and sickness will be covered pro rata by each organisation • Equal shared cost for protected learning time • A value of £9,375 assigned to in-hours General Practice session • A value of £5,089 assigned to Acute Trust session (based on SAS/Specialty Dr scale) • A value of £60ph for weekday OOH session • £68,409 for 8 session job plan role • £46,276 for 6 session job plan role.

34. Salary A simple salary building model was developed:

35. Funding of posts • Devon Doctors Group will invest in the portfolio roles • Acute Trusts are looking at existing budgets to fund portfolio posts • Local General Practitioners Retention Fund • a key focus on supporting general practitioners (GPs) who are at risk of leaving general practice, or who have already left • funding principles include supporting GPs who are newly qualified or within the first five years post-CCT by offering a flexible career alternative to provide them with greater exposure to different models of practice to inform their long-term career decisions – such as portfolio working.

36. Next steps • Finalise funding for posts within RD&E and Plymouth • Finalise HR processes to support the portfolio roles • Advertise and recruit to posts (Paediatrics and Healthcare for Older People) • Engage ED to develop portfolio role

37. Any questions? Thank you Dr. Justin Geddes CEO, Devon Doctors Liz Edwards-Smith Director of Organisational Development, Evalesco Consulting