Academic GP training: reflections on combining research and clinical roles

Thinking of combining academic and clinical roles?  In this latest APEx blog Academic Clinical Fellow Dr Emily Brown reflects on the benefits and challenges of dual roles. 

 

Photo by Possessed Photography on Unsplash

My academic and clinical roles

As an academic GP trainee, I spend half my week working clinically in general practice and the other half working in research as an Academic Clinical Fellow. This journey started with an undergraduate degree in biochemistry, giving me a strong grounding in basic science and scientific methods. I then reached a fork in the road, applying for both PhDs and medical school. I took the latter path, but my interest in science and evidence-based medicine remained strong. After qualification as a medical doctor, I followed the integrated academic and clinical training route, allowing me to formally combine these roles. This has led to a hugely varied and rewarding job. It is not without challenges, but it is worth it!

 

Benefits of my dual role

I love working clinically in general practice and it is a privilege to work with patients in this context. Nevertheless, I have always had a desire to understand ‘why’ (which I think drove my parents mad!) and I fundamentally believe in evidence-based practice and striving to broaden our understanding of medicine. A career in academic general practice lets me combine these two worlds. It also affords the opportunity to have a broader impact on healthcare, potentially changing the way care is delivered.

I enjoy the diversity of the job. Some days I will be working in a busy general practice, with all the variety and challenge that brings; from reviewing newborns to caring for those who have reached their 90s – and everyone in between. My academic job is equalled varied. I’m involved in research projects relating to shared decision-making in general practice and also antimicrobial resistance in Malawi. The research opportunities in academic primary care are very broad, ranging from disease-specific research to health service delivery to epidemiology. The research is cross-disciplinary, working with and learning from non-clinical colleagues, as well as clinicians in other specialities. I’m also completing a masters in epidemiology, equipping me with skills to hopefully take forwards into a PhD. My academic role has allowed me to publish in peer reviewed journals, present at conferences and teach at the medical school. I have a strong interest in global health and have taken on some related voluntary roles, sitting on the RCGP Junior International Committee and acting as a grant reviewer for MicroResearch, an organisation funding and developing community health research in Africa. Combining roles means I’m rarely bored! The dual training is good for wellbeing; stepping between roles allows you a break from the specific pressures of each role.

My clinical and academic roles are brilliantly complementary, enabling a unique perspective, with an appreciation of both the clinician point of view and the research outlook. This is helpful in generating research ideas – working clinically day to day and interacting with clinicians and patients helps develop understanding of what the important research questions are. For example, I have a particular interest in antimicrobial resistance and antibiotic prescribing. Whilst I can understand the science relating to the transmission and drivers of resistance and recognise the impact that over-prescribing antibiotics has on this, I can also appreciate the real-world challenges of antibiotic prescribing in primary care – including time pressures and clinical uncertainty. This dual perspective helps me to identify interventions that may be of benefit in optimising antibiotic use. I have used this to inform my recent publication on the role of primary care in antimicrobial stewardship (Brown E, 2021.).

 

The challenges

The combined clinical and research training pathway is not without challenges. Both roles are busy, and may often expand beyond their ‘half’ of the time allocation. There may be exams in both roles, which require extra commitment. The need to wear multiple ‘hats’ and freely switch between your ‘GP hat’ and your ‘research hat’ can add an additional complexity. Trying to develop two careers in tandem can sometimes lead to feeling ‘behind’ both your purely clinical and purely academic colleagues. However, the journey is a very enjoyable one, so it’s worth it. The combined training programme also means trying to engineer and integrate two distinct careers and sometimes fitting the pieces of the jigsaw together can be a challenge, although there are plenty of options out there to help make this work.

Emily Brown, ST4 ACF and GP trainee

 

An eye to the future

I’m coming towards the end of my academic GP training programme now. Looking to the future, I hope to continue to combine clinical and academic work, working both as a GP and applying for PhD positions. It’s a privilege to work in these complementary and varied roles and I would wholeheartedly recommend taking this route!

 

Featured Intern Blog – SAPC Annual Scientific Meeting: Di-Facto Presentation

Our Primary Care intern and medical sciences student, Victoria Bak, was invited to attend the 49th Society for Academic Primary Care Annual Scientific Meeting at the end of June 2021, in which the Di-Facto team presented. Victoria wrote a piece about her experiences and reflecting on the event.

SAPC ASM

As part of my internship with the Di-Facto team, I was invited to attend the online 49th Society for Academic Primary Care Annual scientific meeting (SAPC ASM). The topic chosen was ‘Living and Dying Well,’ a primary care focus that has become even more crucial in the light of the pandemic. The ASM was held on an online platform, where you could easily access each presentation through the online programme. Workshops, presentations, networking sessions, and a variety of speakers covered a wide range of problems and solutions related to primary care throughout the two-day event.

On the first day, Professor Gary Abel gave a presentation about one aspect of the Di-Facto project ‘Awareness and use of online services in general practice: analysis of GP Patient Survey data’. The findings of the GP Patient Survey indicated that some patients were less likely to use online services, which will become a disadvantage if primary care services become accessible solely through digital methods. As a result, digital facilitation may be able to make a significant difference.  On the same theme and project, Dr Brandi Leach presented a poster titled ‘What is the potential for digital facilitation to support patient access to online primary care service? A scoping literature review’. The poster depicted the first stage of the Di-Facto project, illustrating what digital facilitation is, how it works, and how to use it effectively. Both Gary Abel’s presentation and the poster emphasise the need for digital facilitation in primary care to minimise inequalities, particularly for disadvantaged populations who may not have easy access to digital services.

The programme covered a wide range of topics in relation to primary care. This year’s Helen Lester Memorial Lecture was delivered by Dr. Wendy Ann Webb, who spoke compassionately about her research about end-of-life care priorities for the homeless population in the UK. Dr. Webb concluded that a new approach for supporting the homeless population at the end of life is needed, one which focuses on hostel services rather than palliative care and typical hospice services. According to the findings of the study, this could be a step forward in ensuring that the homeless population wishes, of remaining in a familiar setting, being remembered and not planning for their end of life care, are met.

Professors Joe Rosenthal, Alex Harding, and Dr. Jane Kirby presented new SAPC innovations in undergraduate teaching, including an online library of recorded GP consultations, a resource that demonstratrd how GPs manage individual consultations and make decisions. As a student, this topic resonated with me as there has been so much change in my online teaching over the past year. I attended several talks which talked about the qualitative data collection through ethnography and interviews, which are techniques also used as part of the Di-Facto project. This was especially eye-opening for me as an intern because during my degree I have only worked with quantitative data. Qualitative data is important for obtaining original insights and can result in new hypotheses being generated.

The event was a great opportunity to learn about and enjoy a wide range of topics, ranging from scientific research to reflective poetry readings, regarding the ASM’s theme. This was my first online scientific conference, and while it’s difficult to truly replace face-to-face interactions with online interaction, there were regular online networking sessions. I would like to thank John Campbell, my supervisor, for inviting me to the event. The event was both informative and enjoyable, and I look forward to exploring certain topics about primary care further.

Di-Facto Intern and Medical Sciences student Vicky Bak

Welcome – Professor Andrew Eynon-Lewis

Andrew Eynon-Lewis has recently been recognised as Honorary Clinical Professor in General Practice and Primary Care. Andrew is Primary Care Dean within Health Education England (South West), and a supporter of many of our educational activities and of APEx colleagues. Andrew’s recognition is thoroughly well deserved, and we look forward to his continuing advice, support, and guidance in respect of APEx activities.

 

Some words from Andrew:

“I am absolutely delighted to have been offered the opportunity to be associated with the department of General Practice and Primary Care in the University of Exeter, and I look forward to working with my colleagues.

Promoting, supporting, and broadening access to primary care research through education and training is something I think is very important. The need to develop thought/research leaders – a primary care workforce equipped to understand the activities of patient care drawing on a research footing, and, where this isn’t evident, have the skills and confidence to create questions and test these out – is needed now as much as in the early days of general practice when one of my predecessors in Dartmouth, Dr RMS McConaghey, became the first editor of the college journal. 

One of the differences now is the need to reach out to the wider primary care workforce and not limit research/academic learning opportunities to those with a medical degree. That is why I am working with colleagues in Exeter to include Professor Alex Harding, who has recently launched a new module on the ‘Principles of Primary Care‘. This module has already secured uptake from GPs and GP Practice Nurses. I am also collaborating with other like-minded colleagues and their organisations to broaden research and learning opportunities for all of the current and future wider primary care health care teams to enrich professional lives and support workforce retention. 

From the welcome I have received over the last couple of weeks, I sense I am being embraced within the Exeter Primary Care Academic community, which ‘feels good’ and I look forward to meeting with you all when COVID-19 permits.”

 

Professor John Campbell said: “We’re delighted to welcome Andrew. Resourcing and ensuring high-quality capacity within the primary care workforce are key considerations for the NHS. Andrew and his colleagues at Health Education England have these considerations as their major concern – supporting both the delivery of innovative clinical service and supporting Higher Education Institutions in their primary care-focused academic activities. Andrew will provide new perspectives and fresh challenges to our APEx activities and we welcome his input and support to our research and education missions”.

Investigating suspected colorectal cancer with faecal immunochemical testing (FIT) in primary care: a review of international guidance

Sarah Bailey, University of Exeter

Colorectal cancer is the third most common cancer worldwide, accounting for around 10% of all new cancers, and is the second most common cause of cancer death (1). As the symptoms of colorectal cancer are often vague and frequently caused by benign conditions, selection for investigation can be difficult. As a result, colorectal cancer is often diagnosed at an advanced stage, leaving few curative options (2). Diagnosing colorectal cancer at an earlier stage results in better treatment options and improved survival (3, 4).

Researchers and clinicians are trying to find ways to diagnose colorectal cancer at an earlier stage; one way to achieve this is to investigate people for possible colorectal cancer when they have low risk symptoms, such as stomach ache. The faecal immunochemical test (FIT) has been developed to triage patient with low risk symptoms of colorectal cancer. Those with a positive FIT go on for further investigation, usually by colonoscopy. A negative FIT means that colorectal cancer is extremely unlikely, and the patient does not need any further investigation, although they are advised to see their GP again if their symptoms persist.

The FIT works by detecting small amounts of haemoglobin in a stool sample. Early stage colorectal cancer can cause bleeding into the gut, and the FIT detects that bleeding. Even if the patient has a positive FIT, it does not mean they definitely have cancer – only around 7% do.

Sarah Bailey and Marije van Melle’s poster presentation for systematic review, now published in Family Practice.

FIT has been rolled out across the UK for testing patients with low risk symptoms of colorectal cancer, but guidance for using the test varies in different countries. In this systematic review, led by Dr Sarah Bailey and Dr Marije van Melle and published in Family Practice (5), we reviewed current worldwide recommendations around the assessment of colorectal cancer symptoms to determine how FIT is used to triage patients with symptoms of possible colorectal cancer in primary care.

We found that worldwide guidance for primary care clinicians on the use of FIT varies greatly, and FIT is only recommended for primary care symptomatic patients in three countries: Australia, Spain, and the UK (excluding Scotland). These recommendations are based on a systematic review of studies that included patients with lower GI symptoms suggestive of colorectal cancer (6). That review reported the sensitivity of FIT as 92.1% – 100% (meaning at least 92% of patient with colorectal cancer are identified as such by the test), and specificity as 76.6% – 85.5% (at least 76% of patients without colorectal cancer are correctly identified). Of the 10 studies included in that systematic review, only one was based in primary care (7), where FIT was still performed at the point of referral, rather than to triage referrals.

The evidence on FIT to date comes from heterogenous populations at different stages of the care pathway, with different thresholds, and different assays used; this heterogeneity adds to the difficulty in making clear recommendations. Future updates to recommendations for investigating possible colorectal cancer may begin to integrate FIT for this low-risk CRC symptoms group as more evidence emerges. There is also a lack of evidence about patient preferences for testing with FIT versus colonoscopy; a gap which must be addressed.

 

 

 

References

  1. International Agency for Research on Cancer. Colorectal cancer-Globocan 2018. The Global Cancer Observatory. 2019
  2. McPhail S, Johnson S, Greenberg D, Peake M, Rous B. Stage at diagnosis and early mortality from cancer in England. Br J Cancer. 2015
  3. Statistics O of N. Cancer survival by stage at diagnosis for England (experimental statistics): Adults diagnosed 2012, 2013 and 2014 and followed up to 2015. Off Natl Stat. 2016
  4. Neal RD, Tharmanathan P, France B, Din NU, Cotton S, Fallon-Ferguson J, et al. Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review. Br J Cancer [Internet]. 2015;112 Suppl:S92-107. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25734382
  5. van Melle M, Yep Manzanob S, Wilson H, Hamilton W, Walter FM, Bailey SER. Faecal immunochemical test to triage patients with abdominal symptoms for suspected colorectal cancer in primary care: review of international use and guidelines. Family Practice. 2020;1-9. Available from: https://pubmed.ncbi.nlm.nih.gov/32377668/
  6. Westwood M, Ramos IC, Lang S, Luyendijk M, Zaim R, Stirk L, et al. Faecal immunochemical tests to triage patients with lower abdominal symptoms for suspected colorectal cancer referrals in primary care: A systematic review and cost-effectiveness analysis. Health Technology Assessment. 2017
  7. Mowat C, Digby J, Strachan JA, Wilson R, Carey FA, Fraser CG, et al. Faecal haemoglobin and faecal calprotectin as indicators of bowel disease in patients presenting to primary care with bowel symptoms. Gut. 2016

Hot air, rubbish and going green: Reflections on chairing a SW Clinical Senate Meeting

by Prof David MG Halpin
Consultant Physician & Honorary Professor of Respiratory Medicine

The Climate Change Act of 2008 introduced an ambitious target of reducing greenhouse gas emissions by 80% by 2050 compared to the 1990 levels. In 2008 the NHS generated around 3% of England’s total carbon dioxide emissions making it the largest public sector contributor to greenhouse gas emissions. It is responsible for a staggering 21.4 million tonnes of CO2 emissions each year, 9.5 billion road miles a year – 5% of all road journeys – and 11,300 tonnes of waste a day, of which 22.7% is plastic. Sir Simon Stevens, the NHS Chief Executive, has said “The climate emergency is a health emergency,” and that “the NHS, as the single biggest organisation across this country is both part of the solution and part of the problem. We are 40% of public sector emissions, and although we have reduced our carbon footprint by around a fifth over the past decade, we’ve got to make major changes if we’re going to help this country become carbon net neutral.”

Late last year I chaired a meeting of the South West Clinical Senate held to develop recommendations on high impact changes that healthcare systems can make as meaningful contributions towards mitigating climate change.

Clinical Senates were established as part of the NHS reorganisation in 2012 to provide a source of strategic, independent advice and leadership on how services should be designed to provide the best overall care and outcomes for patients. I have been a member of the Clinical Senate and on its Council since it was established, and have been vice-chair since 2015.

Sitting on the Council is an interesting and rewarding experience – members come from a wide variety of clinical backgrounds and we have considered topics as disparate as student mental health and suicide, biosimilar monoclonal antibodies, weight loss and smoking cessation criteria to improve surgical outcomes, and NHS workforce challenges. The meetings are run in a similar format to the BBC programme “The Moral Maze”. In the morning we hear evidence from a variety of experts, for example John Campbell contributed to the workforce meeting, discussing his research on the challenges facing primary care. In the afternoon, the evidence is discussed in small groups including the external experts and then the Council Members consider all the points that have been made. Following the meeting, the Senate Management Team magically transform all the flip charts and copious notes into draft recommendations.

Topics as disparate as student mental health and suicide have been considered at Senate Meetings

Being vice-chair brings challenges and rewards. The climate change meeting was a great opportunity to promote awareness of work that is being undertaken across the region and elsewhere to reduce greenhouse gas emissions. As I’ve already mentioned, travel is a large factor in the NHS’s carbon footprint and for this meeting we decided we would link to our speakers from outside the region with teleconferencing. Unfortunately, technology in the NHS is not always up to the task, and making it work caused great angst and required the simultaneous use of multiple mobile phones by our Senate Manager and Project Officer. Not surprisingly, one of our recommendations was that IT systems should upgraded to facilitate virtual meetings !

Addressing climate change made members the Senate think about topics, such as waste management, that perhaps they did not give much consideration to as part of their normal working lives. We heard from the Bristol Trusts who have jointly declared a climate emergency following the examples set by Newcastle and Manchester, from the Royal College of Anaesthetists about reducing anaesthetic gas emissions, which are very potent greenhouse gasses, and I presented on the effect of pressurised metered dose inhalers. Inhaler use accounts for 3.1% of the NHS’s carbon footprint. They cause problems both as a result of the release of their propellants during use, but also because of poor disposal and lack of recycling. Even when “empty”, cannisters still contain significant amounts of propellant and unless they are returned to pharmacies for destruction by incineration, the residual propellant will eventually escape, particularly if the inhalers are simply put in domestic waste and sent to landfill sites. Using propellant free devices, when clinically appropriate, should be considered and prescribing guidance from NICE now encourages this.

Other presenters discussed the health impacts of climate change, how virtual consultations can reduce travel and importantly we considered patients’ views which are collated through the Citizens Assembly – which brings together the chairs of the Healthwatches in the South West. We also heard from the Royal College of General Practitioners representative for Sustainability Climate Change and Green issues who talked about the Green Impact for Health toolkit, which is endorsed by the College and designed to help GP surgeries improve their sustainability and environmental impact. More details are available at https://www.greenimpact.org.uk/giforhealth. As well as topics such as green prescribing, practices are encouraged to take steps such as reducing the use of paper, using energy monitors to establish the energy use of the whole practice, providing feedback to staff on energy use and carbon footprint, having an aspiration to reduce energy consumption year-on-year and having a “green impact” standing agenda item at every practice meeting.

As always, with Council meetings, I learned a lot more about a topic I thought I knew something about. You can read the recommendations we came up with, and see the presentations, on the Senate website (https://www.swsenate.org.uk/senate-council-meeting-reducing-nhs-contribution-to-englands-total-carbon-emmisions/2871/).

 

The NHS have reduced their carbon footprint by around 1/5 over the past 10 years.

Making a meal of it: How I sank my teeth into a Cochrane systematic review

Dr Jo Butterworth, GP and NIHR Doctoral Research Fellow.

 

 

 

 

“How are you 300 ahead of me?!” said my colleague, arriving at her desk to start a new day’s work. “Sorry?” I said, finishing off a mouthful of breakfast bar. I already knew what she meant. We’d been ‘competing’ like this for a few days now, egging each other on to maintain our momentum and get through the work on schedule. “Titles and abstracts! You’ve screened 300 overnight!” My mind went back to yesterday evening, sitting in the kitchen watching the potato wedges turn crispy in the oven whilst I flicked through “just a few more” articles on my mobile screening app. I guess that’s the way with screening isn’t it? At the start it’s like being confronted with a gigantic raw potato but once you’ve peeled the skin, gotten rid of a few knobbly bits, you just keep chipping away…

“… if we’d had all of the ingredients to make a shepherd’s pie then we would’ve made a shepherd’s pie, so next time we’re in the kitchen we might think about peeling a few more potatoes.”

In the case of our review of interventions, the evidence was fairly small fry and study authors had chosen different outcomes resulting in a lack of data which could be combined in our analysis. We reached the nevertheless important conclusion that further research was warranted and we made suggestions as to how research teams might go about this.

I never set out to lead on a Cochrane review; my funders thought it might be more than I could chew. However, when both I and the team from Manchester applied to update an existing review, Cochrane served up a sharing platter and suggested that we start with a clean slate. Now, when you’re posing your question and designing your search strategy, you’re just at the tip of the iceberg, with little real idea about where this might lead in terms of the workload ahead.  Well, I can tell you now that there is nothing bite-sized about a Cochrane review.

Serving up and submitting a Cochrane review is what I imagine being a contestant on a well-known television cooking show might be like. You know you won’t get through to the next round if it doesn’t look, smell and taste just as the judges expect. However, there is plenty of guidance available to authors to ensure that their writing is up to standard.

There is also a lot of suggested text, which must not be left out, even if it does not seem applicable. For example, you’re expected to say something like, “if we’d had all of the ingredients to make a shepherd’s pie then we would’ve made a shepherd’s pie, so next time we’re in the kitchen we might think about peeling a few more potatoes”.

Carrying out a Cochrane review is, all-in-all, a highly valuable learning experience and it is the gold standard approach to a systematic review. I am grateful that I have been through the process and for the more sophisticated research palate that I have undoubtedly acquired along the way.

 

Reference:

Butterworth_JE, Hays_R, McDonagh_STJ, Richards_SH, Bower_P, Campbell_J. Interventions for involving older patients with multi-morbidity in decision-making during primary care consultations. Cochrane Database of Systematic Reviews 2019, Issue 10. Art. No.: CD013124. DOI: 10.1002/14651858.CD013124.pub2 .

Society for Academic Primary Care ASM 2019 Exeter – in tweets

All of us here in the Primary Care Research Group really enjoyed hosting the Annual Scientific Meeting (ASM) of the Society for Academic Primary Care (SAPC) 3-5th July 2019 at the fabulous Forum on the University of Exeter’s Streatham Campus. Three days of excellent quality primary care research, catching up with colleagues and friends, forging new connections and collaborations, fun sporting events, a scrumptious conference dinner and above all, beautiful weather!

We would like to share this link with you so that you might see a Twitter snapshot of this great meeting – see if you can spot your Twitter contributions and photographs!

SAPC ASM 2019 Exeter – in tweets – best tried in desktop rather than mobile.

Many thanks to all who attended and all who helped organise this conference, we are still buzzing and very proud to have hosted you all in Exeter this year and are already looking forward to SAPC ASM in Leeds 2020.

Enjoy!

National trainee research collaboratives – Time for general practice to join the party.

Dr Sam Merriel

A career in general practice provides a myriad of opportunities for young and aspiring GPs. The core work as a generalist of providing holistic, patient-centred care to our patients ‘from the cradle to the grave’ and establishing continuity of care with our patients over a long period of time is truly rewarding. GPs can also lend their unique skill sets to other elements of primary care to improve the health of our patients and our community. Developing and building a GP practice or practices through partnership, commissioning NHS services as part of a CCG, and teaching the next generation of GPs are all possibilities open to early career GPs. Academic general practice, contributing to the improvement of primary care through research, is another vital area that GPs can turn their hand to.

But where to start? And how?

First5 GPs and GP trainees are busy people. As GPs we are trained to be lifelong learners, and there is a steep learning curve to begin with in transferring from hospital to community care. Newly qualified GPs need time to find their feet. Some opportunities exist for formal academic training through academic foundation posts in primary care departments, academic clinical fellowships for trainees, and in-practice fellowships for GPs, but these posts are very competitive and require commitment to an academic career. Opportunities to ‘dip one’s toe in the water’ in primary care research are harder to find.

Trainee research collaboratives

A successful model for trainee-led research, audit and quality improvement that has been used by other medical specialties in recent years is that of trainee research collaboratives. These local, regional and national groups exploit the networks of hospital specialty trainees across multiple sites to conduct research and audit projects. The advantages of this approach are that patients can be recruited and data can be quickly and cheaply collected across a number of centres(1). For doctors involved, they can engage in the process on many levels, from identifying patients or collecting data at their local site right through to developing and proposing new ideas for research, audit or quality improvement projects. They can also develop their teamwork, leadership and communication skills(2). Medics without any research experience have the opportunity to gain an insight into how studies are conducted, and their eyes may just be opened to the world of academia.

Trainee research collaboratives in the UK have rapidly expanded in some disciplines in the last 10-15 years. Surgery and anaesthetics in particular have a number of established regional research collaboratives and networks, including the Severn and Peninsula Audit and Research Collaborative for Surgeons (SPARCS) and the South West Anaesthesia Research Matrix (SWARM) in the south west of England. Between 2012 and 2016, the proportion of general surgery units across the UK which participated in at least one study run by trainee research collaboratives grew from 44% to 99%(3). Numerous randomised controlled trials and national audits have been delivered by these collaboratives, resulting in truly impactful research that is improving patient care(4).

PACT – Primary care Academic Collaborative for Trainees

General practice is ideally placed to take full advantage of the trainee research collaborative model. GP trainees are embedded in GP surgeries in all parts of the UK and cover all sections of the population. Electronic medical records can easily be searched for patients who meet inclusion criteria for research and audit, and the general practice model means changes arising from quality improvement projects can more easily be implemented at a local level. General practice in the UK is moving towards networks and federations of practices, making engagement in a collaborative a great opportunity for GP trainees and First5 GPs to experience working with colleagues across multiple GP surgeries towards a common goal.

The Primary care Academic Collaborative for Trainees (PACT) was launched by its chair, Dr Polly Duncan from the Centre for Academic Primary Care in Bristol, at the recent National GP ACF and early career researcher conference in Manchester. We have established a core committee of GP trainees and First5 GPs from right across the UK, and we will be coming to the 48th SAPC Annual Scientific Meeting in Exeter in July to deliver a workshop to develop the very first collaborative project PACT will undertake. PACT will generate numerous opportunities for GP trainees and First5 GPs to bring forward their ideas, and will seek to support them in delivering these projects to improve care for our patients across the UK.

Dr Sam Merriel GP and Clinical Senior Research Fellow, University of Exeter
Vice chair, PACT – Primary care Academic Collaborative for Trainees
@sammerriel

References

  1. Kasivisvanathan V, Kutikov A, Manning TG, McGrath J, Resnick MJ, Sedelaar JPM, et al. Safeguarding the Future of Urological Research and Delivery of Clinical Excellence by Harnessing the Power of Youth to Spearhead Urological Research. Eur Urol [Internet]. 2018;73(5):645–7. Available from: https://doi.org/10.1016/j.eururo.2017.10.026
  2. Kasivisvanathan V, Ahmed H, Cashman S, Challacombe B, Emberton M, Gao C, et al. The British Urology Researchers in Surgical Training (BURST) Research Collaborative: an alternative research model for carrying out large scale multi-centre urological studies. BJU Int. 2018;121(1):6–11.
  3. Nepogodiev D, Chapman SJ, Kolias AG, Fitzgerald JE, Lee M, Blencowe NS. The effect of trainee research collaboratives in the UK. Lancet Gastroenterol Hepatol. 2017;2(4):247–8.
  4. Jamjoom AAB, Phan PNH, Hutchinson PJ, Kolias AG. Surgical trainee research collaboratives in the UK: An observational study of research activity and publication productivity. BMJ Open. 2016;6:e010374.

 

Overseas GP recruitment to bolster the UK GP workforce – how can we maintain registration standards and patient safety?

In the context of our department’s GP workforce research and in light of reports today that GP numbers are showing a sustained drop, Emily Fletcher introduces the ‘GMAP’ project which aims to support the UK’s ambitions to recruit GPs from overseas.

Key points:

  • Across the UK, the number of GPs relative to the size of the population show a sustained drop. GPs are leaving or decreasing their hours in large numbers. Our own survey of GPs indicated that even in South West England, 37% were likely to quit patient care within five years. Some of our work highlights the many reasons for this.
  • The Nuffield Trust reports today that the fall in GPs per person reflects “insufficient numbers previously being trained and going on to join the NHS; more practitioners leaving for early retirement; and failure to recruit enough from abroad”.
  • On the subject of recruiting from abroad, ‘GMAP’ is a research project commissioned by NHS England and the Royal College of General Practitioners in late 2017 to compare the training and experience of overseas GPs to support the UK’s international recruitment ambitions.

International referencing and mapping of UK GP training curricula (GMAP)

Addressing a knowledge and information gap identified by NHS England, and working in collaboration with the Royal College of General Practitioners (RCGP), the GMAP project aimed to develop and pilot a method for mapping GP training and other relevant healthcare system contextual data from an overseas country to the UK, to inform future consideration of streamlined processes for overseas doctors joining the UK GP register.

Professor John Campbell leads the research team, with expert medical education input from Professor Adrian Freeman, international expertise from Dr Emma Pitchforth, project management and data collection overseen by Emily Fletcher and data collection support by Dr Leon Poltawski and Dr Jeffrey Lambert.

Background Over the last six years, the UK has experienced a worsening GP shortage in relation to recruitment and retention. Amongst a number of responses, the UK government and NHS England have sought to develop opportunities for doctors who are suitably qualified as GPs overseas to be attracted to work in the UK. In this context, for doctors outside of the European Economic Area (EEA), there is a need to ensure that their training and experience is appropriate to support them working in UK primary care.

Between the RCGP and the General Medical Council, the ‘Certificate of Eligibility for GP Registration’ (CEGPR) process examines whether doctors have equivalent experience to UK-trained GPs. However, CEGPR is cumbersome, and NHS England commissioned GMAP to develop a method for determining whether a streamlined process for assessing doctors from certain countries was possible.

Method Developing the method involved a number of stages. Our final approach to comparing training and experience of GPs who have trained outside of the UK involved mapping five specific domains: (i) the healthcare context, (ii) the GP training pathway, (iii) the GP curriculum, (iv) Assessment processes, and (v) ongoing continuing professional development and revalidation.

Pilot We published a paper in the BJGP Open in April which outlines the development of the method and its application to a pilot case study site: Australia. We concluded that implementing this systematic method for mapping GP training between countries may support the UK’s ambitions to recruit more GPs and alleviate current GP workforce pressures.

Application Since developing the method, we have gone on to apply the mapping to more countries (South Africa, Canada, and the United States of America) to further support NHS England’s overseas recruitment programme. We are also currently applying the mapping process to GP training in New Zealand.

Mapping these additional countries will inform further considerations of the CEGPR process by the RCGP and GMC as to whether streamlining can be introduced for GPs/family physicians from these countries wishing to enter UK general practice.

My reflections

Whilst GMAP is very different to other research undertaken by our department, it has been hugely interesting and challenging to undertake, and with the added bonus of being of immediate use to NHS England, the RCGP and the GMC. Sadly (for me) no field trips have been required (!) but in writing up the findings for each country I have been fortunate to speak to contacts in each setting who have been generous in giving their time to help refine our interpretations.

Overseas recruitment is hardly the wholesale answer to the UK GP workforce crisis. However, it is important to draw the various strings of our GP workforce research together, and overseas recruitment is one of the many approaches to alleviating the pressure.

Emily Fletcher

Research Fellow

e.fletcher@exeter.ac.uk, @emilyfletcher1

References

  1. Palmer B. Is the number of GPs falling across the UK? Nuffield Trust; 2019. URL: https://www.nuffieldtrust.org.uk/news-item/is-the-number-of-gps-falling-across-the-uk
  2. Baird B, Charles A, Honeyman M, Maguire D, Das P. Understanding pressures in general practice: King’s Fund; 2016.
  3. Fletcher E, Abel GA, Anderson R, Richards SH, Salisbury C, Dean SG, et al. Quitting patient care and career break intentions among general practitioners in South West England: findings of a census survey of general practitioners. BMJ Open 2017;7:e015853. http://dx.doi.org/10.1136/bmjopen-2017-015853
  4. Sansom A, Terry R, Fletcher E, Salisbury C, Long L, Richards SH, et al. Why do GPs leave direct patient care and what might help to retain them? A qualitative study of GPs in South West England. BMJ Open 2018;8:e019849. http://dx.doi.org/10.1136/bmjopen-2017-019849
  5. Spooner S, Fletcher E, Anderson C, Campbell JL. The GP workforce pipeline: increasing the flow and plugging the leaks. British Journal of General Practice 2018;68:245. http://dx.doi.org/10.3399/bjgp18X696125
  6. Campbell JL, Fletcher E, Abel G, Anderson R, Chilvers R, Dean SG, et al. Policies and strategies to retain and support the return of experienced GPs in direct patient care: the ReGROUP mixed-methods study. 2019;7:14. http://dx.doi.org/10.3310/hsdr07140
  7. Fletcher E, Sansom A, Pitchforth E, Curnow G, Freeman A, Hawthorne K, et al. Overseas GP recruitment: comparing international GP training with the UK and ensuring that registration standards and patient safety are maintained. BJGP Open 2019; http://dx.doi.org/10.3399/bjgpopen18X101640
  8. NHS England. International GP Recruitment Programme. NHS England. URL: https://www.england.nhs.uk/gp/gpfv/workforce/building-the-general-practice-workforce/international-gp-recruitment/
  9. Fletcher E. Moving into the GP workforce? In: University of Exeter Collaboration for Primary Care (APEx). Exeter; 2019. https://blogs.exeter.ac.uk/apex/blog/2018/10/17/moving-into-the-gp-workforce/

Don’t throw the baby out with the bathwater – asking the right questions when evaluating computerised CBT for depression in primary care

Over a third of all patient visits with a general practitioner are estimated to involve a mental health component, and 90% of these patients are primarily managed in primary

Picture By Jim Wileman – Medical School portraits.

care [1]. Due to this high demand, National Institute of Health and Care Excellence (NICE) guidelines recommend the provision of computerised CBT as an initial lower intensity treatment for depression in primary care [2]. Computerised CBT is more accessible, scalable and cheaper than face-to-face CBT and has the potential to reduce the burden of depression in primary care significantly.

Systematic reviews have confirmed the effectiveness of computerised CBT [3]. However, a randomised controlled trial published in the British Medical Journal in 2015 reported that supported computerised CBT did not improve depression outcomes compared with usual GP care alone [4]. On the back of this, the authors suggested that the routine promotion and commissioning of computerised CBT be reconsidered. I would caution against this for the following reasons:

  • First, it is unlikely that computerised CBT will reduce depression if patients do not adequately use the platform or actively engage with the cognitive and behavioural techniques offline in their day-to-day lives. The median number of online sessions completed by patients in the study by Gilbody et al. ranged from 1–2, and no data were reported concerning offline engagement. Were the negative findings due to an ineffective intervention or the lack of engagement?
  • Second, a large proportion of participants across all arms of the trial were using antidepressants (81%). It is therefore unsurprising that the trial failed to find a positive effect. The argument for computerised CBT is not that is will be more effective than usual care, but that it offers a viable alternative that takes the pressure off general practice and offers patients another treatment option that is less resource intensive.

The issues in the study by Gilbody et al. are by no means unique and are indeed prevalent across the field of computerised interventions for mental health. However, resolving these issues are fundamental to ensure we don’t prematurely reject interventions with the capacity to transform healthcare. As highlighted by the NHS -term plan, harnessing the power of technology and empowering people to take responsibility for managing their own health is vital to meet the increasing demand on healthcare services. This is well within our grasp, but we need to be asking the right questions!

Dr Jeff LambertPostdoctoral Research Associate in Primary Care, UEMS

References

  1. Ferenchick EK, Ramanuj P, Pincus HA. Depression in primary care : part 1 — screening and diagnosis. Br Med J. 2019;
  2. National Institute for Health and Clinical Excellence. Depression in adults: recognition and management. 2018.
  3. Karyotaki E, Riper H, Twisk J, Hoogendoorn A, Kleiboer A, Mira A, et al. Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms: A Meta-analysis of Individual Participant Data. JAMA Psychiatry. 2017;74(4):351–9.
  4. Gilbody S, Littlewood E, Hewitt C, Brierley G, Tharmanathan P, Araya R, et al. Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ. 2015; 1–13.