Co-Production at the Strategic Level: Co-Designing an Integrated Care System with Lay Partners in North West London, England.

In North West London, health and social care leaders decided to design a system of integrated care with the aim of improving the quality of care and supporting people to maintain independence and participation in their community. Patients and carers, known as 'lay partners,' were to be equal partners in co-production of the system. Lay partners were recruited by sending a role profile to health, social care and voluntary organisations and requesting nominations. They formed a Lay Partners Advisory Group from which pairs were allocated to system design workstreams, such as which population to focus on, financial flow, information technology and governance. A larger and more diverse Lay Partners Forum provided feedback on the emerging plans. A key outcome of this approach was the development of an integration toolkit co-designed with lay partners. Lay partners provided challenge, encouraged innovation, improved communication, and held the actions of other partners to account to ensure the vision and aims of the emerging integrated care system were met. Key lessons from the North West London experience for effective co-production include: recruiting patients and carers with experience of strategic work; commitment to the vision; willingness to challenge and to listen; strong connections within the community being served; and enough time to do the work. Including lay partners in co-design from the start, and at every level, was important. Agreeing the principles of working together, providing support and continuously recruiting lay representatives to represent their communities are keys to effective co-production.

Sequential Simulation (SqS): an innovative approach to educating GP receptionists about integrated care via a patient journey--a mixed methods approach.

BACKGROUND: An evaluation of an effective and engaging intervention for educating general practice (GP) receptionists about integrated care and the importance of their role within the whole system was conducted. METHODS: Workshops took place in North West London, one of England's 14 'Integrated Care Pioneers.' Three training days featuring Sequential Simulations (SqS) were held. Forty GP receptionists attended on each day, as well as 5-6 patients and 8-9 healthcare professionals. The SqS developed was from a collection of patient stories, the key scene of which featured a GP receptionist. The scenes were designed to show the consequences for the patient of professionals working in silos. This provided the focus for facilitated table discussions. The discussants suggested ways in which an unfortunate series of events could have been dealt with differently. These suggestions were then incorporated in a re-designed SqS. Evaluation was conducted through questionnaires, field notes and analysis of video material. Descriptive statistics and thematic analysis were applied. RESULTS: Ninety three participants responded to the questionnaire out of 131 attendees. All (93/93) respondents reported that the event was a powerful learning experience and that they had gained confidence in improving patient care. 98 % (91/93) reported that their knowledge of integrated care had improved. The simulation was rated highly as a learning experience [60 % (57/93) - excellent, 39 % (37/93) good]. Further evidence of educational benefit was expressed through comments such as: 'The simulations really got me thinking about the patient as a human with many problems and situations.' CONCLUSION: SqS is an innovative and practical way of presenting current care pathways and health care scenarios in order to create a shared focus, engage the emotions of the participants and bring the principles of integrated care to life. Facilitated table discussions are an opportunity to see events from multiple perspectives, share reactions and ideas, and practise co-producing service reforms with patients. We believe this approach is a useful way of preparing front-line staff to participate in integrated care.

The Academic Backbone: longitudinal continuities in educational achievement from secondary school and medical school to MRCP(UK) and the specialist register in UK medical students and doctors.

BACKGROUND: Selection of medical students in the UK is still largely based on prior academic achievement, although doubts have been expressed as to whether performance in earlier life is predictive of outcomes later in medical school or post-graduate education. This study analyses data from five longitudinal studies of UK medical students and doctors from the early 1970s until the early 2000s. Two of the studies used the AH5, a group test of general intelligence (that is, intellectual aptitude). Sex and ethnic differences were also analyzed in light of the changing demographics of medical students over the past decades. METHODS: Data from five cohort studies were available: the Westminster Study (began clinical studies from 1975 to 1982), the 1980, 1985, and 1990 cohort studies (entered medical school in 1981, 1986, and 1991), and the University College London Medical School (UCLMS) Cohort Study (entered clinical studies in 2005 and 2006). Different studies had different outcome measures, but most had performance on basic medical sciences and clinical examinations at medical school, performance in Membership of the Royal Colleges of Physicians (MRCP(UK)) examinations, and being on the General Medical Council Specialist Register. RESULTS: Correlation matrices and path analyses are presented. There were robust correlations across different years at medical school, and medical school performance also predicted MRCP(UK) performance and being on the GMC Specialist Register. A-levels correlated somewhat less with undergraduate and post-graduate performance, but there was restriction of range in entrants. General Certificate of Secondary Education (GCSE)/O-level results also predicted undergraduate and post-graduate outcomes, but less so than did A-level results, but there may be incremental validity for clinical and post-graduate performance. The AH5 had some significant correlations with outcome, but they were inconsistent. Sex and ethnicity also had predictive effects on measures of educational attainment, undergraduate, and post-graduate performance. Women performed better in assessments but were less likely to be on the Specialist Register. Non-white participants generally underperformed in undergraduate and post-graduate assessments, but were equally likely to be on the Specialist Register. There was a suggestion of smaller ethnicity effects in earlier studies. CONCLUSIONS: The existence of the Academic Backbone concept is strongly supported, with attainment at secondary school predicting performance in undergraduate and post-graduate medical assessments, and the effects spanning many years. The Academic Backbone is conceptualized in terms of the development of more sophisticated underlying structures of knowledge ('cognitive capital' and 'medical capital'). The Academic Backbone provides strong support for using measures of educational attainment, particularly A-levels, in student selection.

The feasibility and acceptability of integrating regular centralised laboratory-based skills training into a surgical training programme.

BACKGROUND: Traditional laboratory-based skills training provides mass training that does not match clinical experience and is not tailored to individual needs. This compromises the transfer and retention of skills into clinical practice. AIM: To demonstrate the feasibility of integrating a centralised programme of laboratory-based surgical skills training into a higher surgical training programme and to evaluate its effectiveness and acceptability to trainees. METHODS: Laboratory-based skills training was provided at a central site, delivered by consultants and tailored to the trainees' level of clinical experience. Each trainee was expected to attend one session a month for 11 months a year. Evaluation was conducted through attendance records, structured evaluations by participants, independent qualitative questionnaires and web interviews. RESULTS: Forty-two specialist surgical trainees in the North West London higher surgical training programme participated in laboratory-based skills sessions delivered by 19 consultants over a period of two years. The average attendance was 70.5% for trainees and 100% for trainers. All sessions were rated by trainees as well-organised and useful with an average score of more than 4 out of 5. Trainees felt that the Skills Programme can complement surgical training by allowing practice under expert supervision in a safe environment. CONCLUSIONS: Centralising laboratory-based skills training and integrating it into a clinical programme is feasible and acceptable and represents a paradigm shift in surgical training. Involvement of trainees in designing the content is valuable.

Educating for integrated care.

In September 2012 the North West London Integrated Care Plot held a conference for clinical educators. The aim was to reach a consensus about what learning clinical staff needed in order to contribute to an integrated care system. The conference was attended by 81 clinical educators from a range of backgrounds. The participants decided that competence in the following three domains was essential: 1. Patient and user engagement and empowerment. 2. Collaboration with other health and social care professionals. 3. Leading improvement in the system of care. Educational interventions to facilitate learning should wherever possible be interprofessional, team based and experiential. The views of patients, carers and users should inform the education. Assessment should take into account real-life performance through multi-source feedback and observed practice. Evaluation of the educational intervention should take into account any impact on the patient and user experience as well as clinical outcome measures.

Engaging patients, users and carers in integrated care.

Engaging patients, users and carers is an important enabler of integrated care. We describe how the Inner North West London Integrated Care Pilot set up a Patients, Users and Carers Committee, found volunteers to join it, and and helped to prepare them for their role. Representatives from the group were included in the membership of the Pilot's management board and committees and took part in several engagement and educational events. Some obstacles and challenges were encountered, including communicating with a large number of patient participation groups across the area, managing the high expectations of the group about how quickly reforms could be achieved, and ensuring that members of other committees understood the role of the representatives. Benefits included easy access to the perspectives of patients, users and carers when developing the strategy, policies and processes of the Pilot. Representatives proved to be eloquent advocates, and played a part in the success of the Pilot in winning some prestigious awards.

Vocation and avocation: leisure activities correlate with professional engagement, but not burnout, in a cross-sectional survey of UK doctors.

BACKGROUND: Sir William Osler suggested in 1899 that avocations (leisure activities) in doctors are related to an increased sense of vocation (professional engagement) and a decreased level of burnout. This study evaluated those claims in a large group of doctors practicing in the UK while taking into account a wide range of background variables. METHODS: A follow-up questionnaire was sent to 4,457 UK-qualified doctors who had been included in four previous studies of medical school selection and training, beginning in 1980, 1985, 1990 and 1989/1991. A total of 2,845 (63.8%) doctors returned the questionnaire. Questions particularly asked about work engagement, satisfaction with medicine as a career, and personal achievement (Vocation/engagement), stress, emotional exhaustion, and depersonalization (BurnedOut), and 29 different leisure activities (Avocation/Leisure), as well as questions on personality, empathy, work experience, and demography. RESULTS: Doctors reporting more Avocation/Leisure activities tended to be women, to have older children, to be less surface-rational, more extravert, more open to experience, less agreeable, and to fantasize more. Doctors who were more BurnedOut tended to be men, to be more sleep-deprived, to report a greater workload and less choice and independence in their work, to have higher neuroticism, lower extraversion and lower agreeableness scores, and to have lower self-esteem. In contrast, doctors with a greater sense of Vocation/engagement, tended to see more patients, to have greater choice and independence at work, to have a deep approach to work, to have a more supportive-receptive work environment, to be more extravert and more conscientious, and to report greater self-esteem.Avocation/Leisure activities correlated significantly with Vocation/engagement, even after taking into account 25 background variables describing demography, work, and personality, whereas BurnedOut showed no significant correlation with Avocation/Leisure activities. Popular Culture and High Culture did not differ in their influence on Vocation/engagement, although there was a suggestion that Depersonalization was correlated with more interest in Popular Culture and less interest in High Culture. CONCLUSION: In this cross-sectional study there is evidence, even after taking into account a wide range of individual difference measures, that doctors with greater Avocation/Leisure activities also have a greater sense of Vocation/Engagement. In contrast, being BurnedOut did not relate to Avocation/Leisure activities (but did relate to many other measures). Osler was probably correct in recommending to doctors that, 'While medicine is to be your vocation, or calling, see to it that you also have an avocation'.

Investing in learning and training refugee doctors.

BACKGROUND: Medically qualified refugees seek to build a new life and return to clinical medicine. The National Health Service (NHS) in the UK needs to develop a workforce to meet the needs of the communities it serves, and refugee doctors have the potential to contribute to the NHS, using their experience and skills to benefit patients. METHODS: Fifty-four per cent of refugee doctors in the UK live in London, so in response, the London Deanery (Postgraduate Department of Medical and Dental Education, London University) has undertaken a series of initiatives over the past 8 years assisting refugee doctors back into medical employment. Clinical attachments, supernumerary 6-month posts and general practitioner (GP) training rotations have been offered. The projects, doctors involved, educational provision and outcomes are reported. The obstacles and barriers to returning to substantive posts in medicine are also discussed. RESULTS: Fifty-six per cent of the refugee doctors were known to be working after the schemes, 52 per cent gained substantive posts and 39 per cent entered training grades. DISCUSSION: Investing in innovative and creative work-based training programmes for refugee doctors is worthwhile, but needs to be adequately resourced if refugee doctors are to bring ultimate benefit to the NHS.

Identification and management of the underperforming surgical trainee.

Most surgical trainee make steady progress, delivering a safe and reliable service at an appropriate level at the same time as they as learn new skills under supervision. Trainees learn at different rates, and progress that is safe and steady although slower than the norm should not be classed as underperformance. Clinical performance issues may arise at any stage of a doctor's cancer, and should be addressed promptly and constructively. Factors that may impact on performance, such as the personality of the trainee, their personal pressures, and the training and working environment, should be considered and where possible mitigated. Enhanced supervision; regular constructive feedback; psychological support; coaching and mentoring may all be required. A change of trainer or working environment may sometimes be necessary, and the duration of training may need to be extended. A supportive working and learning environment with a sound educational framework will help to ensure that trainees in difficulty are identified early and managed supportively and constructively.

A successful initiative for getting refugee doctors back into medical employment: the PRIME project.

Refugee doctors find it difficult to get back to medical work in their new countries. This article describes the setting up and evaluation of the Placing Refugee doctors In Medical Employment (PRIME) project which resulted in 15 out of 25 participants getting substantive jobs in open competition within a year, and suggests this approach should be more widely adopted.

Early signs of the trainee in difficulty.

A series of high-profile medical scandals and tragedies has generated increasing interest in the earlier detection of doctors whose health, conduct or performance may pose a risk to themselves or others. The earliest signs of problems often emerge during the training years, when it may be possible to take remedial action to prevent the doctor derailing. This article describes the early signs that have identified doctors in difficulty in a large postgraduate deanery.

Specialist registrar training: what still needs to be improved?

It is 6 years since specialist training in the UK was radically reformed. Is educational quality still improving or have early improvements slipped as the novelty has worn off? What further improvements are needed to ensure the production of specialists who are properly prepared to be the consultants of the future? The authors address these questions from the perspective of one postgraduate deanery.