Revolutionising career development for new general practitioners

CATALYST researchers working on a whiteboard

The GP workforce in Hull and its surrounding region is facing a crisis, with an increasing number of newly appointed GPs their roles. In response to this urgent issue, the Academy of Primary Care at Hull York Medical School, in collaboration with NHS England, has developed a ground-breaking professional development programme for GPs, called CATALYST.

This innovative two-year programme aims to transform the career development of new GPs, equipping them with advanced generalist skills and empowering them to thrive in the challenging primary care environment. CATALYST is now making a significant difference and revolutionising general practice training.

Dr Myriam Dell’Olio and Professor Joanne Reeve

Dr Myriam Dell’Olio and Professor Joanne Reeve, who are leading change in GP practice through the CATALYST programme

Dr Myriam Dell’Olio and Professor Joanne Reeve, who are leading change in GP practice through the CATALYST programme

The GP workforce in Hull and its surrounding region has become a major concern for healthcare commissioners and researchers. Nationally, there was specific growing worry about the increasing number of newly appointed General Practitioners leaving their roles. NHS England therefore identified Humber as one of two pilot sites to develop new ways of supporting new GPs.

This prompted Professor Joanne Reeve, the Director of the Academy of Primary Care at Hull York Medical School and a GP herself, along with Dr Dan Roper, the then-Chair of the NHS Hull Clinical Commissioning Group, to discuss potential solutions to this crisis in primary care.

Professor Joanne Reeve explained, “Right from the start, Dr Roper and I recognised this would only work through a partnership – bringing together the different expertise across our region to create new solutions. We decided we needed a ‘living lab’ – a space where we could critically and creatively work together to find, try out, and learn from new ways of working.”

The future of general practice

GPs are under enormous pressure and the workforce is in crisis. It’s widely recognised that general practice is overstretched and chronically underfunded. But also, that the job is changing and the support for those new roles – especially the advanced generalist practice needed hasn’t kept up.

Patients in general practice are increasingly living with long term health problems, often complex. Clinicians, including GPs, are needing to adapt how they work/practice to address these changing needs. The service is under resourced but needing to rapidly adapt, resulting in GPs experiencing significant workload and burnout.

The future of GP retention is at stake: and one in five GPs under 30 quit in 2022 (1) and 19,000 further GPs could quit the profession over the next 5 years.(2)

There are many factors behind this worrying trend. But Professor Reeve’s research highlights that some relate to professional/clinical practice – specifically gaps in practising GPs understanding skills and confidence in the practice of advanced generalist medicine.

Key national policy documents have called for a culture shift in healthcare towards greater delivery of whole person, generalist care. So together, Dr Roper and Professor Reeve queried, could we develop an advanced professional development resource that would enhance advanced generalist skills, and so potentially address some of the workforce crisis issues.

In response to this, academics, GPs and GP Fellows in the Academy of Primary Care at Hull York Medical School designed and delivered CATALYST – a two-year, theory informed professional development programme for new to practice GPs that supports GPs to develop skills in addressing everyday primary care challenges, through upskilling them in the knowledge work of advanced generalist practice.

“CATALYST is a novel professional development programme to advance understanding and skills in the knowledge work of advanced clinical practice for primary care"
Professor Joanne Reeve

Knowledge work is about complex problem solving and crucially it means a person who not only knows things about their field of expertise but is also able to apply them in a social, organisational and relational context.

The knowledge needed for this work cannot be defined as simply facts but encompasses what some have called the ‘tacit dimension’ – that is traditions, learned values and judgements, knowledge that we don’t always know we know.(3) But all too often this knowledge work also remains ‘tacit’ or hidden. Making visible the advanced knowledge work of everyday practice is the core goal of the CATALYST programme.

Professor Reeve explained, "CATALYST enables professionals to confidently and appropriately create, use and critique knowledge in context.

"This will help them to work confidently, safely and effectively beyond guidelines and single diseases to deliver whole-person care; enabling and sustaining lifelong professional practice.”

Problems faced by new GPs

 “I was imagining that I was going to feel isolated... and it turns out I was right, it has been quite isolating”
“I wouldn’t say I feel confident [at tailoring explanations to each patient’s circumstances]”
“I feel like quitting my job because it stressed me up so much”
Doctor's desk with medical equipment: stethoscope and clinic tonometer, blood pressure measurement, medication in background

Reclaiming primary care through the knowledge work of modern practice

The researchers behind the CATALYST programme identified three main barriers that new GPs face as they enter into clinical practice: They lacked the confidence in the skills of advanced generalist, tailored care; they experienced exhaustion and limited motivation to keep working as a GP; and they felt isolated with limited access to a community of practice.(4)

Professor Reeve is internationally renowned for her work on advanced generalist practice. She has previously described and defined the core principles and skills of practice in a seminal paper written for the Royal College of General Practitioners.(5) She has also demonstrated through several research studies that people lack the training and confidence to use these skills.

Professor Reeve explained, “We are effectively asking people to work in some of the most complex areas of clinical practice, without the tools and skills they need to do the job. So, Dr Roper and I wondered, if we could address this gap, could it help deliver the culture shift that policy makers were calling for but also help front line GPs cope better with their daily work. From this, CATALYST was born!”

"GPs are overwhelmed and stressed, emotionally and physically, to the point that GPs are one of the groups at highest risk of suicide, along with other mental health conditions"(6)
Dr Myriam Dell’Olio

Dr Myriam Dell’Olio, a Research Fellow at the time of the study and now a Lecturer in the Academy of Primary Care, was the evaluation lead for CATALYST. She said, “General practice and primary care is a resource-limited setting with a lot of demand. Sometimes, many start feeling like they want to leave their job."

Performance monitoring in general practice effectively allows only for small deviations from clinical guidelines, making it difficult for GPs to practice in the holistic, advanced generalist way that they want to do and that evidence and policy recognises is needed.(7) New GPs felt that they lacked the skills necessary to provide personalised treatments to their patients.(7)

Dr Dell’Olio explained, “They don’t feel like they have permission to use their advanced generalist skills because of the way the primary care system and clinical guidelines prioritise a single disease approach. This sometimes clashes with more person-centred, whole-person holistic approaches, so it’s not always best for the patients.”

Empowering new GPs to thrive in a challenging primary care workforce

Launched in 2020, CATALYST welcomed the first cohort of new to practice GPs in the Humber Coast and Vale region.

The evaluation that was part of the programme found that CATALYST had several positive impacts on the GPs that participated in the programme:

  • They experienced an increase in their motivation, professional identity, and sense of meaning and purpose in their work
  • They were able to use their advanced generalist skills and gained confidence in their ability to use them effectively in managing everyday complex problems
  • It helped to reduce isolation and develop a sense of community among the GPs
“My confidence has improved, both clinically and in things like quality improvement work, which means I can take a more active role in practice-based discussions”
CATALYST participant
“Every single doctor is trained to recognise problems, but the major issue is what to do when you spot it. CATALYST allows you to embrace it and deal with it"
CATALYST participant

Dr Dell’Olio commented, “CATALYST provided participating GPs with the scientific evidence, and advanced knowledge work skills on how to use it, which gave GPs the confidence to use them.

"They could tailor a whole-person approach to patient care rather than meeting defined targets set for GPs. CATALYST gave permission and more confidence to the delegates to use this approach, which is more meaningful to them, and to patients.

"So, evidence was important. This affected their pride in their work, and improved the way they see their profession.”

Dr Dell’Olio continued, “CATALYST delegates developed a sense of belonging to a community. Many of their peers share their vision for primary care, so they feel they are moving together in the same direction. They shared experiences and learnt from each other.”

Evidence-based approach

Building on the work established by Professor Reeve over two decades, researchers in the Academy of Primary Care, including Professor Reeve and GP Portfolio Fellows Dr James Bennett and Dr Puja Verma worked to translate theory and evidence into educational delivery.

This started with identifying core concepts which became the building blocks of CATALYST. Based on those foundational concepts, they developed the modules for the programme.

The programme is delivered by GP tutors, and is taught over two years. The programme was released as a one-year pilot, extended to two-years in 2021 following feedback from stakeholders. It was originally intended to be delivered in-person, but became online due to the COVID-19 pandemic.

The first year focuses on the challenges that GPs face, such as over-medicalisation, over-diagnosis, polypharmacy, and imposter syndrome. It also includes a research-informed quality improvement (QI) project, which most GPs have not done in a non-clinical setting before. The development of the QI aspect of CATALYST was led by Dr Clare Fozzard, GP Fellow.

The second year of the program helps GPs consider how they can develop and take the ideas forward into a lifelong professional practice, working on issues that extended beyond daily practice including how we work as teams.

Modules that go in-depth into other challenges of general practice, including climate change, facing the future with artificial intelligence and new technologies, advanced consultation skills, self-care, resilience, and narrative medicine. The programme also includes action learning sets to support GPs develop lifelong support for professional practice.

Currently, the programme is offered to new GPs in the Humber Coast and Vale area.  An NHS England Bursary is provided to cover the delegates’ time away from practice, allowing them to have dedicated time to learning.

CATALYST researchers in discussion around a table

Future outlook for CATALYST

The programme has been so successful, the Academy of Primary Care have been asked by NHS England to develop the programme into an ongoing CPD programme with options to complete an accredited postgraduate level, such as a Diploma or Masters. Their ambition is that this would open up the opportunity to all GPs, regardless of their location – and ultimately to all primary care clinicians.

Dr Dell’Olio said, “CATALYST has had such a positive impact on the general practice workforce locally, it would be fantastic to offer the same opportunity to GPs across the UK or even internationally.

"I think CATALYST could have a very good impact nationally and internationally, so we’re working towards getting our programme accredited to do that.”

CATALYST is just one part of a wider GP Fellowship scheme offered across Yorkshire and the Humber, financially supported by NHS England. The fellowship programme is currently being evaluated to inform future development of these schemes.

“All doctors, including GPs, are usually perceived as individuals with gifted intellect. Let me share my reflection on the ‘just right’ strategies of a Wise GP.”

Dr Rabia Aftab is a GP and palliative care lead in North Lincolnshire. Read their experience of CATALYST in their blog post on BJGP Life.

Dr Dell’Olio also acknowledges that there are GPs at different career stages, who also have their own unique challenges and may not receive adequate support during their career.

She said, “An idea for the future would be to consider developing programmes to GPs at other career stages. We have evaluated CATALYST so that by drawing from CATALYST, we can use our success to inform other programmes with what works."

CATALYST was just the first step in a growing and planned programme of work to tackle the general practice, primary care workforce challenges through strengthening and sustaining the advanced knowledge work of everyday practice.

Work is in progress to develop the new Postgraduate Certificate in Advanced Primary Care Practice. The national WISE GP programme, led by Professor Reeve, recognises a need to champion professional scholarship at the heart of modern General Practice. And researchers in the Academy or Primary Care are delivering online an programme via Future Learn called WISDOM: Supporting Today’s Expert Generalist GP.

Professor Reeve said, “Together these form the foundations for some exciting new developments in general practice. Our research is telling us this can help us achieve the culture changes, and workforce development that we so urgently need.

"We are proud to be doing this work in partnership with Hull York Medical School, Health Education England Yorkshire and the Humber, NHS Health Education England Yorkshire and Humber, and the Royal College of General Practitioners.”

For more information, visit the CATALYST programme page or contact Professor Joanne Reeve, Director of the Academy of Primary Care, or Dr Myriam Dell’Olio.

References

1) Institute for Government - Performance Tracker - General Practice

2) BMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1535 (Published 22 June 2022)

3) Ray, T. (2009). Rethinking Polanyi’s Concept of Tacit Knowledge: From Personal Knowing to Imagined Institutions. Minerva, 47(1), 75–92. https://doi.org/10.1007/s11024-009-9119-1

4) Andah E, Essang B, Friend C, Greenley S, Harvey K, Spears M, Reeve J. Understanding the impact of professional motivation on the workforce crisis in medicine: a rapid review. BJGP Open. 2021 Apr 26;5(2):BJGPO.2021.0005. DOI: 10.3399/BJGPO.2021.0005. PMID: 33653705; PMCID: PMC8170605.

5) Reeve J. Interpretive medicine: Supporting generalism in a changing primary care world. Occas Pap R Coll Gen Pract. 2010 Jan;(88):1-20, v. PMID: 21805819; PMCID: PMC3259801. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259801/

6) Hawton, K., Clements, A., Sakarovitch, C., Simkin, S., & Deeks, J. J. (2001). Suicide in doctors: a study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979–1995. Journal of Epidemiology & Community Health, 55(5), 296-300.

Spiers, J., Buszewicz, M., Chew-Graham, C., Gerada, C., Kessler, D., Leggett, N., ... & Riley, R. (2016). Who cares for the clinicians? The mental health crisis in the GP workforce. British Journal of General Practice, 66(648), 344-345.

7) Reeve J, Fleming J, Britten N, Byng R, Krska J, Heaton J. Identifying enablers and barriers to individually tailored (expert generalist) prescribing: a survey of English health care professionals. BMC Fam Pract. 2018;19(1):17.