Gillian Vance’s research while affiliated with Newcastle University and other places

Background NHS dentistry is experiencing significant recruitment and retention challenges, particularly in rural, coastal, and deprived urban areas. Issues have been exacerbated by the Covid-19 pandemic, leading to unequal distribution of dental professionals across UK geographies. Despite workforce policy initiatives, issues persist. This study explores factors influencing workforce sustainability in the North East of England – an under-served region of the UK. Methods Forty-six participants, including 30 dentists, 3 dental care professionals, and 13 managers, contributed to this study. Four focus groups were held at two events in July 2023 – one in the north of the region, and one in the south to enable broad stakeholder engagement and reflect the different geographies within the region. These groups generated qualitative data to elaborate on the factors influencing workforce sustainability and ideas for change. Analysis involved a codebook approach to thematic analysis. Results Thematic analysis identified four key factors influencing workforce sustainability: careers, collaboration, costs, and contentment. Career development in a supportive learning environment was essential for professional growth and retention, yet systemic barriers hindered progression. Collaboration, both within dental teams and across regulatory bodies, played a vital role in improving job satisfaction and service delivery, but fragmented communication remained a challenge. Financial pressures, particularly rigid NHS contracts and inadequate remuneration, emerged as significant concerns impacting recruitment and retention. Contentment was shaped by work-life balance, professional recognition, and the ability to provide high-quality care without excessive bureaucracy. These systemic challenges collectively contribute to workforce instability, particularly in the North East. Conclusion Findings highlight critical systemic barriers that threaten workforce sustainability in NHS dentistry. Addressing career progression pathways, improving collaboration, reforming contracts, and enhancing professional support systems are essential for sector stability. Without coordinated action from employers and policymakers, NHS dentistry will remain unsustainable, necessitating urgent interventions to support workforce retention and service provision.

Objectives Explore what is known about the impact of changes made at a national level to UK postgraduate medical education during COVID-19. Design A scoping review, following Arksey and O’Malley’s framework, reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews Checklist. Data sources Ovid MEDLINE, Ovid Embase and ERIC were searched for peer-reviewed literature, and grey literature was searched via DuckDuckGo. The initial search was conducted on 17 January 2023 and updated on 5 June 2024. Forward citation tracking was performed. Eligibility criteria English-language studies of any design examining national-level adaptations to postgraduate medical education (eg, curricula, examinations and Annual Review of Competency Panels (ARCPs)) within the UK during the COVID-19 pandemic. Studies were excluded, which focused solely on undergraduate education, international settings, grassroots-level changes (eg, to individual teaching sessions), or where full text was unobtainable. Data extraction and synthesis Data were extracted using a piloted charting form and analysed thematically to identify recurring patterns across studies. Basic numerical data were collected to describe study characteristics. Results Of 1067 records screened, 30 studies met inclusion criteria. Most were cross-sectional surveys, with a strong representation from surgical and craft specialties. Four themes were identified: (1) impact on career development (including concerns about career delays and shifts in aspirations); (2) impact on trainee progression (highlighting delays due to ARCP outcomes 10.1/10.2 and reduced procedure accreditation); (3) changes in teaching and learning (such as a shift to online learning and cancelled rotations) and (4) supervision and support (revealing mixed experiences, with reports of burnout and inadequate organisational guidance). The systemic impact was uneven across specialties and training stages. Conclusions National-level changes mitigated immediate educational disruptions but are beginning to reveal long-term consequences for career development, workforce planning and trainee well-being, highlighting the need for resilient and equitable future frameworks.

Background The healthcare workforce is in crisis. Despite a competitive selection process, a substantial number of doctors leave specialty training (ST) programmes prematurely. This attrition causes increased costs for the National Health Service, exacerbates workforce shortages and threatens quality and safety of care. It also increases pressure on trainees who remain, further compounding the risk of attrition. There is an urgent need to understand why doctors leave ST in order to find ways to maintain the training pipeline from ST to consultant. Objectives We aimed to understand what is known about why doctors choose to leave ST programmes in secondary care, to map current knowledge and identify avenues for future research. Eligibility criteria All studies which investigated why doctors leave ST programmes in secondary care were included. Sources of evidence Ovid Medline, Web of Science, SCOPUS and EMBASE were searched until January 2024. Descriptive codes were assigned to the findings of each study. These descriptive codes were reviewed and grouped together in broader categories. Charting methods Data was extracted and charted, and a qualitative content approach was used to synthesise data. Results A total of 6079 potentially relevant abstracts were retrieved, of which 23 were included in the final analysis. This included the experience of 1896 doctors who have left training and 454 programme directors. Doctors chose to leave training programmes because (1) they felt unsupported and underappreciated, (2) training was associated with unacceptable personal costs and (3) career prospects were unattractive. Conclusion There is a mismatch between trainees’ expectations of ST and the reality of being a trainee in ST. Understanding the issues which drive attrition and developing evidence-based solutions, has the potential to both reduce attrition, and improve the training experience for doctors in training more widely.

Background Patient contact is integral to undergraduate medical training. While political strategies emphasise the ‘patient’s voice’ in medical education, the literature on how to enhance the active involvement of real-time patients is sparse. Increased demands for real-time patient interactions in primary care poses a challenge for educators to provide adequate opportunities for students to learn. Evidence on how students may benefit from patients’ active involvement may inform the design and construction of teaching/learning encounters to optimise the educational value while maintaining positive patient experiences. This study aimed to identify how the involvement of real-time patients in medical education might be enhanced. It examined two research questions: •How does enhanced patient involvement support student learning in different areas of practice? • What can be done to enhance patients’ active involvement in medical students’ training to support those learning benefits? Methods We conducted focus groups with patients, workshops and interviews with medical students and analysed the data using codebook thematic analysis. Results Patient contact helped students develop their knowledge, clinical and interpersonal skills, professional values, confidence and sense of identity. Students learn by practising the role of a doctor, observing clinicians and reflecting on their experiences. Real-time patients provided experience of diversity, real-life stories and contextual variations that promoted learning. Patients would like to perform active roles, such as shaping encounters and providing explanations, feedback and emotional support to students. While such active involvement may provide learning opportunities for students, many patients were unable to perform active roles during their previous interactions with students. Patients’ active involvement may be facilitated by ensuring adequate introductions, good relationships and an explicit invitation. Conclusion The resulting model may form the basis for future research and interventions that encourage and support patients to actively participate in teaching consultations. [293 words]

Background: Global and United Kingdom (UK) primary care face significant General Practitioner (GP) workforce shortages. Worldwide strategies to address this issue include the introduction of additional healthcare professionals and increasing technology utilisation, to reduce GP workload. However, whether these strategies can sustain the GP workforce remains unclear. Our review examines the factors that sustain and enable GPs to flourish. Aim: To examine how general practice work and healthcare systems support GP workforce sustainability and effective and equitable patient care. Design & setting: A realist review of existing empirical and grey literature. The search strategy encompassed six electronic databases. Method: Realist synthesis involved (1) finding existing theories, (2) searching for evidence, (3) selecting articles, (4) extracting data, and (5) synthesising evidence/drawing conclusions. Context-Mechanism-Outcome Configurations were developed using extracted data and patient and public involvement/stakeholder suggestions to refine our programme theory. Results: 168 documents were included. Findings underscore the importance of meaningful work and engagement; relationships across individuals, organisations, and communities; and learning and development. We emphasise the need for congruence between GPs` core values and their work; cumulative-knowledge building; system agility; psychological safety; and direct human connections. Conclusion: General practice structures, policies, and practices, and the interactions they facilitate, are crucial for the sustainability of the workforce. Collaboration among GPs, the public, and national policymakers is essential for implementing the principles from this review. Future systems should enable personalised care; sustain meaningful work and relationships; facilitate meaning-making; and promote agency, agility, and flexibility to enable GPs to utilise, adapt, and cultivate expertise.

Context The COVID-19 pandemic led to an increase in numbers of patients dying at home in the UK, meaning that general practitioners (GPs) were exposed to more patient death than would be pre-COVID. This project aimed to gain insight into GP trainees’ experiences of patient death between March and July 2020. This insight can inform support for GPs, leading to improved wellbeing, workforce retention and ultimately, better patient-centred care. Methods Interpretative Phenomenological Analysis (IPA) of semi-structured interviews was used to explore GP trainees’ experiences of patient death in one region of England. Results Seven trainees, two male and five female, participated. They were working in both rural and urban community settings and were at different stages of GP training. Group experiential themes related to heightened emotional responses to patient death, managing uncertainty and the increased salience of relationships. Most appreciated positive teamworking and solidarity, though some had felt isolated within their surgery and wider community. There were some unforeseen positive experiences of individual and organisational healthcare changes, including a perceived new appreciation for the NHS workforce equality, diversity and inclusion (EDI) by actions to identify and reduce occupational hazards to at-risk healthcare staff. There were potential effects on career choice with participants feeling that changes during COVID-19 offered new flexibility in working arrangements and opportunity to sub-specialise within GP. Conclusion More support to help navigate the amplified emotional responses to managing dying and death in the community is needed. Some experiences, particularly around managing uncertainty, can cause moral injury if not managed in a safe and supportive environment.

Objectives This study addressed two research questions: What factors do doctors in training describe as influencing their choices to apply (or not apply) for specialty training during their Foundation Year 2? Which of these factors are specific to the context of the COVID-19 pandemic, and the unique experiences of the cohort of doctors who qualified early during the pandemic? Design Sequential explanatory mixed methods study: Quantitative survey. Qualitative semistructured interviews. Quantitative data were analysed with logistic regression. Qualitative data were analysed using reflexive thematic analysis. Setting UK-wide. Participants Junior doctors who graduated medical school in 2020. Survey: 320 participants (22% of those contacted). 68% (n=219) were female, 60% (n=192) under 25 and 35% (n=112) 25–30. 72% (n=230) were white, 18% (n=58) Asian and 3% (n=10) black. Interviews: 20 participants, 10 had applied for specialty training, 10 had not. Results A minority of respondents had applied for specialty training to start in 2022 (114, 36%). While burnout varied, with 15% indicating high burnout, this was not associated with the decision to apply. This decision was predicted by having taken time off due to work-related stress. Those who had not taken time off were 2.4 times more likely to have applied for specialty training (OR=2.43, 95% CI 1.20 to 5.34). Interviews found reasons for not applying included wanting to ‘step off the treadmill’ of training; perceptions of training pathways as inflexible, impacting well-being; and disillusionment with the community and vocation of healthcare, based, in part, on their experiences working through COVID-19. Conclusions Participants infrequently cited factors specific to the pandemic had impacted their decision-making but spoke more broadly about challenges associated with increasing pressure on the health service and an eroded sense of vocation and community.

Background UK general practice has been described as being in crisis. A shortage and exodus of GPs is an urgent and challenging problem, attracting significant media attention, widespread public debate, and policy action. Aim Our review aims to examine which aspects of the healthcare system affect GP workforce sustainability, how, why, and for whom. Method A realist review is an interpretive, theory-driven approach to evidence synthesis, that brings together data from quantitative, qualitative, mixed methods research, and the wider grey literature (e.g., policy documentation). Using this data allows us to examine a diverse range of evidence with a clear focus on understanding factors which support (or hinder) GP workforce sustainability, how these are shaped by contexts, and the mechanisms that underpin them. We identify important individual and system-level contexts that may be amenable to change. Results We present our emerging findings in the form of a programme theory which explores human connection with patients, colleagues, and across organisations, gaining intellectual enrichment and learning systems comprising socially-situated knowledge. Relational continuity is key across these, supporting GP workforce sustainability. Challenges include standardisation, alienation and professional loneliness, inflexible organisation, and restrictive technologies. Conclusion Our research generates new knowledge about the interdependencies between contexts, mechanisms, and outcomes. The findings can inform strategies and interventions intended to support, facilitate, and assist the GP workforce in delivering equitable and effective patient care. We identify critical gaps in knowledge and prioritise the expectations for scope and nature of future GP work and retention strategies.