A failure to retain GP retention schemes

Nada Khan is an Exeter-based GP and clinical academic, and an Associate Editor at the BJGP.

I wrote here recently in BJGP Life about the key components of the RCGP’s pre-election manifesto and the seven steps raised by the College to ‘save’ general practice.  It is a big blow to these objectives to find out that the New to Practice Fellowship, a national plan providing two years of support to newly qualified GPs and practice nurses in England, has been withdrawn.  This decision by NHS England is pretty much the opposite of what the RCGP has been lobbying for in terms of retention schemes as part of its manifesto and calls for a ‘one-stop-shop’ retention programme, stating that ‘new to practice fellowships must be made more easily accessible for all newly qualified GPs to support them to develop fulfilling and sustainable careers.’¹  It’s worth just reflecting back on what was on offer and why, whether this retention scheme was working, and what future plans NHS England may have to keep GPs in practice.

What was on offer? 

GP retention is a real and imminent concern especially amongst early career GPs, with 2021’s GP Worklife survey indicating that 16% of GPs aged under 50 are thinking of leaving face-to-face practice.  Trainees are equally eyeing up post-CCT life with trepidation.  The King’s Fund runs an annual survey asking GP trainees about their future career plans, and in 2023 the results demonstrate just how concerned the future GP workforce are, with a 10% increase from 2022 in the number of trainees planning not to work clinically at all, or not really sure what they’ll be doing in five years following registration.²  The New to Practice fellowship aimed to ease their transition into practice, reimbursing practices for up to one session per week to free up fellows to attend learning events, complete self-directed learning, take part in peer-support meetings and get mentoring and coaching from seniors.³  The point of the programme was to offer support, learning and development, aiming to provide key mentorship during those key first few years when we know that even these early career GPs are at risk of disillusionment and leaving the profession altogether.³

Do retention schemes work?

Do these types of fellowship schemes actually increase GP retention? The evidence is sparse, but with some of the newer primary care initiatives, including the New to Practice Fellowships, there seems hardly a chance to properly evaluate their effectiveness before the funding is pulled.  In a small study of London-based GPs on a scheme similar to the New to Practice Fellowship, fellows who responded to the study felt supported in their transition to working as a salaried GP, and gained more skills and confidence.  Most also said that the fellowship made them more likely to stay working in general practice, but without any longer term follow-up it’s unclear whether these intentions to stay in practice actually materialised into more feet staying on the ground.⁴  The results of this study mirror other research suggesting that flexible working, peer support and the opportunity for ringfenced portfolio career building and education all help GPs feel supported to stay in work.

Other studies looking more generally at the factors influencing GP retention seem to come to fairly similar conclusions. A systematic review back in 2017 before the introduction of the New to Practice Fellowship identified only a few studies looking at schemes such as golden handshake payments and found little evidence of the positive impact of these, noting that increases in income alone don’t make up for a wider job dissatisfaction or unsustainable workload, and that the priority should refocus on these underlying factors.⁵

A questionnaire study of GPs in the West Midlands suggested that again, factors that influence intention to leave practice include high intensity and volume of workload and job satisfaction.  Respondents also described the emotional impact of these pressures, leading to feelings of stress, disillusionment and burn out.  Interestingly, in this sample, incentives such as the first five programme and the retainer scheme were seen as less important towards retention, but again, this study was conducted before the introduction of the New to Practice Fellowship.  The authors echo the suggestion that the strategies to improve retention need to promote job satisfaction and morale and to address the workload factors that contribute to professional burnout.⁶  A stakeholder panel of experienced GPs came together to build consensus statements on strategies to improve retention and agreed that improving job satisfaction through flexible working, and peer support schemes perhaps similar to the New to Practice Fellowship, would protect against burnout and bolster the workforce.⁷  However, the effectiveness of these interventions are largely untested in research.  And amongst the respondents to the King’s Fund survey of GP trainees, the main priorities to improve retention were better pay, improved workload and longer appointment slots as standard, not mentorship, CPD or additional training.²  Sustainable workload it seems, comes up repeatedly as a main priority for retention across the board, so this may have been a key factor missing from the New to Practice Fellowship. Or, as the King’s Fund survey suggests, are newly qualified GPs choosing to work fewer sessions to better manage their workload and avoid burnout?

The future of retention programmes

So what next?  NHS England has suggested that there will be further investment in GP retention with an update on future initiatives due ‘early’ in 2024.⁸  In the interim, funding for similar schemes could come down, instead, to local decisions at practice or integrated care board (ICB) level, a strategy which could create unwanted variation across different localities.  And it is unclear who would bear the cost of taking these kinds of local schemes forward.  It would be useful at this stage, despite the end of the New to Practice Fellowship as it stands, to try to look at the actual impact of the scheme on retention in order to provide evidence for similar schemes in the future.  We know some of the factors that make GPs leave practice, but it’s time to better understand the factors that make them stay.

References

1. RCGP General Election Manifesto 2023 [Available from: https://www.rcgp.org.uk/representing-you/manifesto.] accessed 25/1/24
2. Young H. Unsustainable workload, part-time working and portfolio careers: results of the GP trainee survey: The King’s Fund; 2023 [Available from: https://www.kingsfund.org.uk/blog/2023/10/unsustainable-workload-part-time-working-portfolio-careers-results-GP-trainee-survey.] accessed 25/1/24
3. General practice fellowship scheme for newly-qualified GPs and nurses, and new to practice nurses – guidance for 2023-24: NHS England; 2023 [Available from: https://www.england.nhs.uk/long-read/general-practice-fellowship-scheme-for-newly-qualified-gps-and-nurses-and-new-to-practice-nurses-guidance/] accessed 25/1/24.
4. Roberts R, DaSilva D. Do fellowships for newly qualified GPs improve retention? Evaluation of London’s SPIN New to Practice Fellowships. Educ Prim Care. 2022;33(6):342-6.
5. Marchand C, Peckham S. Addressing the crisis of GP recruitment and retention: a systematic review. Br J Gen Pract. 2017;67(657):e227-e37.
6. Dale J, Potter R, Owen K, Parsons N, Realpe A, Leach J. Retaining the general practitioner workforce in England: what matters to GPs? A cross-sectional study. BMC Fam Pract. 2015;16:140.
7. Chilvers R, Richards SH, Fletcher E, Aylward A, Dean S, Salisbury C, et al. Identifying policies and strategies for general practitioner retention in direct patient care in the United Kingdom: a RAND/UCLA appropriateness method panel study. BMC Fam Pract. 2019;20(1):130.
8. Colivicchi AF, M. NHS England to end two GP retention schemes: Pulse; 2024 [Available from: https://www.pulsetoday.co.uk/news/workforce/nhs-england-to-end-two-gp-retention-schemes ] accessed 25/1/24

Featured Photo by Ioana Cristiana on Unsplash