Hello and welcome to BJGP Interviews.

My name is Nada Khan and I'm one of the Associate editors of the bjgp.

Thanks for joining us here to listen to this podcast today.

In today's episode, we're speaking to Dr. Laura Jefferson, who is a senior research fellow based at the University of Manchester.

We're here to discuss her paper, recently published here in the journal, titled Understanding Persistent GP Turnover Using Work and Personal A Retrospective Observational Study.

So, hi, Laura, it's really nice to see you again and to talk about this research and I suppose I really just wanted to frame our discussion here today by saying that there's been a lot of talk recently about the retention crisis in UK general practice, but I wonder, could you just talk us through how big is the scale of the problem that we're dealing with here?

Yeah, thank you.

Yeah, well, thank you for inviting me to talk to you today as well.

I think it's interesting, we hear a lot of discussion in the media and in our research evidence as well, recently about an increase in GP turnover.

In the past sort of decade, there's been a gradual increase, so that's in terms of GPs leaving medicine, but also moving across practices.

And it's good to see a kind of change in policy focus from historically, a lot of policies focused on recruitment of GPS.

So, you know, we've had like, pledges to have 6,000 GPS that have not been met and it's often kind of criticized as filling a leaky bucket.

So if we try and obviously pay a lot.

So I think it's approximately half a million pounds to train a gp, but actually to replace the GP is really expensive as well.

So it's about £300,000 to replace the GP.

And so, yeah, so there's a positive focus to thinking about retention, but actually it's about how can we do that effectively and understanding that the sort of one size fits all approach doesn't necessarily work and that there's different gps with different needs.

And this was a study where you were looking at the association between high practice turnover of GPs and GP job satisfaction.

And what you did was you linked data from different general practice practices and GP workforce surveys.

But the first thing I wanted to really look into was that you identified these high turnover practices.

What exactly did this mean?

Yeah, so there's been previous research that's done this before, so it's using.

We're really fortunate in the UK that we've got really good workforce data compared to a lot of other countries.

So we have longitudinal data going back a long way that we can use for research purposes to try and understand more about these trends.

So colleagues of mine at Manchester have previously used this data from NHS Digital, which is now NHS England, linking with data on gps by General Practice, which is has got data on their kind of start and leave dates in a practice.

And that allows us to track where gps are moving out of a practice and how long they've stayed there for.

So they've previously looked at sort of persistent turnover as being categorized as a practice where they have consistently, for three years running, had a 10% turnover of GPS.

So this is where it seems to be a more worrying turnover figure.

I think it's expected that there's going to be some level of turnover and some level of turnover that might be a useful thing.

But those kind of practices where you think, oh, what's going on there?

And particularly then within our research, looking at what are the striking differences in those practices, both in terms of the sort of workplace characteristics that GPs are experiencing?

So can we use that data to explore strategies that could be used to actually support gps in those practices?

So trying to understand, really, what does it feel like for a GP in these practices with persistent turnover, so that then, hopefully, through this sort of research, is kind of like the first step in a puzzle to try and determine strategies to support them.

Yeah, fair enough.

And then thinking a bit more about what you found here.

So you looked, as you said, at some of the characteristics of the GPs who worked in these high turnover practices, and you found some really interesting differences that related to gender, age and experience.

So can you talk us through that?

Yeah.

So this was the first time that these large data sets have been used to look at GP characteristics that might not necessarily predict turnover, but might be associated with turnover.

So difficult to make predictions using the approaches that we've used, but we were able to, within our analysis, adjust for things like age, experience, gender, looking at GP partners and salaried GPs to try and draw out, are there any differences?

And we did find a gender difference.

So women were more likely to be in practices with persistent high turnover.

But because of the analytical approach that we've used, it's really difficult for us to unpick.

What does that actually mean?

Does that mean that are they driving turnover or do they actually become stuck in these practices?

So there's a lot of research literature that suggests that women may be less mobile in the workplace for a number of societal reasons.

So it could be that that's a factor explaining the gender difference that we found.

But this is a really important first step for us to then develop the strateg thinking about what different groups need.

Only included a smaller proportion of salaried GPs, so we weren't able to look so well at partners versus salaried.

And also looking at ethnic diversity and variations, particularly important given that there's a large proportion of international medical graduates now as GP registrars.

So this is a kind of first step and there's going to be future research, which we've been commissioned now to do this research in a larger sample of gps, looking at a longer time frame as well, which will be really nice to be able to look after.

Covid.

Brilliant.

That sounds really exciting.

And I think what's really interesting here is how satisfied GPs were with different aspects of their work.

What did the gps rate as low satisfaction in their job role and how did this impact on turnover?

Yeah, so what we did is we used a theoretical framework to guide our analysis.

So within the Work Life Survey, there's a number of different kind of components that gps can rate in terms of their satisfaction with their working lives.

But that would be quite a messy analysis.

So to try and break this down, we used the ABC of Doctors Needs, which is a framework which talks about the importance of autonomy, belonging and competence for doctors to feel that they're happy and well within their work and that impacts on retention.

So, yeah, so we looked at those components and within each of those we used questions from the survey that spoke to those theoretical domains.

So, for example, autonomy looked at sort of, there was an item around freedom to choose the methods that they're working with.

Also items around paperwork, variety of work and hours of work, belonging looked at particularly around sort of relationships and feeling connected to and valued in the workplace.

There's questions in the survey about strained relationships at work and also about recognition, so feeling like they're valued for delivering a good job.

And then the third domain that we created around competence, speaks to gps, sort of perceived ability within their role.

So I think gps know how to do their job well, but it's actually like their perception as to how well they're able to do that within the constraints of the working environment.

So that related to questions on the survey to do with complaints from patients feeling like they didn't have sufficient time to do a good job and also workload issues.

And when we came to do the analysis, we found that in those practices with persistent high turnover across three years, all of those domains were significantly related to turnover.

So all of those factors are important and it is very Intuitive really, isn't it?

But this is the first kind of step in terms of research evidence in a decent sample to show us that these factors are what we should be prioritising for future intervention development.

Sure.

And one thing that came out really clearly here was the association between that autonomy domain and turnover.

Can you talk us through this and why you think it's so important?

Yeah.

So there's been previous work looking at retention in other fields where autonomy has been really valued.

And so this is about.

About sort of having flexibility to work, how it's kind of suitable for them in their sort of work life and balancing work life, but also crafting the job to suit their own interests and needs.

And this is really interesting, I think, as well, in terms of thinking about the gender differences, I know you're familiar with the other research that I'm involved in about supporting women GPs to thrive in their roles, and that research has shown that there's differences in terms of how patients are allocated to gps according to gender.

And so it's really about prioritising fair distribution of work, but also distribution according to doctors interests.

So that, that also then speaks to this feeling of competence and being valued.

But one of the areas actually that had the highest difference between persistent high turnover practices and the other practices was around competence.

And that was really striking, I thought, in terms of those issues around concerns about complaints not having sufficient time were some of the largest differences in practices with high turnover.

And I mean, this work is really important because it has shown that clear link between gps having, for instance, a sense of autonomy and belonging at work.

But do you or your team have any ideas about how we could use these findings to improve GP retention and reduce turnover?

Yeah, I think, I mean, one of the key findings that would be easily implementable for practices would be about supporting team cultures.

So there's been a lot of work that's looked at that, but it's.

And I know it's often challenging within the sort of workload environments that gps are working in, particularly across fast teams and other roles in general practice as well.

But having a sense of belonging within a team and trying to challenge where there are strained relationships would potentially be a kind of first step.

I think I've spoken to a number of GPs in my research and in planning future projects where there's just actually no kind of sense of like line management, particularly if you're a GP partner, the kind of.

Of getting on with things and not necessarily having that sort of strategic approach to workload management and allocation of work so perhaps a more supportive hierarchy in terms of line management.

I know that's, for example, part of the GP retainer scheme, but that's a end of the line approach, you know, and it's also quite short term, so it doesn't necessarily solve the problems that a number of GPs are experiencing.

I think also in terms of potentially making the role more rewarding for gps.

So I think that they're feeling more distanced from patients, probably, particularly as there's been movements to online consultations and extensive roles in triaging and moving care to other parts of the team, perhaps not necessarily getting that feedback from patients that they're being valued, valued.

And obviously there's quite a negative media narrative which drives that as well.

And that's a lot of clear messages for practice based working.

So, you know, fostering a team environment and trying to think about how to maintain that doctor patient relationship.

But if you had a clear message to send to policymakers, what would that be?

I think it needs to be grounded in evidence.

So we see a lot of policy changes, particularly, you know, in the past year where we don't have an evidence base to support these decisions.

And so the work that I'm doing with colleagues at Manchester is.

So we've got six years of funding to look at developing retention strategies for GPs that is going to be grounded within the evidence base and developed with gps so that they can be solutions that can be adapted to suit different workforce needs and not this one size fits all approach.

So strategies, women GPs, salary GPs, locum GPs and also different area needs so that hopefully then that can develop policy in future, guided by the evidence base.

That sounds really exciting, Laura.

So, yeah, we'll look forward to hearing more about that big program of research in this area.

So, great, great to hear about that, but I think that's probably a great place to wrap things up.

But I just wanted to say thank you very much for your time here.

Thanks.

Nada.

And thank you all very much for your time here and for listening to this BJGP podcast.

Laura's original research article can be found on bjgp.

Org and the show notes and podcast audio can be found at bjgplife.

Com.

Thanks again for listening and bye.